Emergency Obstetric and newborn care

Background and Definitions History

Historically, many safe motherhood programs that emphasized identifying high risk

pregnancies and training traditional birth attendants have achieved limited success. This has caused the global community to develop a new focus on the management of complications and emergencies.

Preventive interventions (e.g., active management of the third stage of labor, intermittent preventive treatment for malaria, prevention of mother-to-child transmission of HIV, and birth planning) are essential to reduce maternal and newborn mortality. But safe motherhood programs must also ensure that complications are rapidly detected and that emergency obstetric and newborn care is accessible to women and newborns when and where it is needed.

Highlights Rather than investing in predicting which women or newborns will have life-threatening complications, maternal mortality reduction programs should recognize the principle that every pregnant woman and newborn baby is at risk for life-threatening emergencies.

The Place of EmONC Within Essential Obstetric and Newborn Care

As shown in the graphic above, essential obstetric and newborn care (EONC) encompasses all care that is provided during pregnancy, labor, childbirth, and the postpartum period to prevent and manage complications.

Comprehensive emergency obstetric and newborn care (CEmONC) encompasses all of the basic care for maternal and newborn emergencies as well as cesarean section surgery, blood transfusion, and umbilical vein insertion and intubation of the newborn.

Did you know?

In general, BEmONC is provided at the primary health care level by skilled birth attendants of any cadre.

CEmONC is usually provided at the referral hospital level, either by physicians, non-physician clinicians (e.g., physician assistants), or specially trained midwives.

Maternal and Newborn Mortality

The tragic loss of life in the developing world dictates that measures that reduce the risk of death for mothers and newborns must be a global priority. As the table above shows, death is a frequent visitor to mothers and newborns in much of the world.

Did you know?

It is estimated that 15% of women will develop a potentially life-threatening complication during pregnancy or childbirth.

Causes of Maternal Mortality

According to an analysis of the causes of maternal mortality by WHO in 2006 approximately 70% to 80% of maternal deaths are due to direct obstetric complications, primarily hemorrhage, sepsis, complications of abortion, eclampsia, and obstructed labor. Basic and comprehensive emergency obstetric and newborn care addresses the main causes of maternal and newborn mortality.

Footnote to the chart above: Other direct causes of maternal mortality include embolism, ectopic pregnancy, and those that are anesthesia-related. Indirect causes include malaria and heart disease.

Glossary Term: Eclampsia Embolism Ectopic pregnancy Did you know?

99% of maternal mortality occurs in the developing world.

Causes of Newborn Mortality The main causes of newborn deaths are severe infections (including sepsis/pneumonia, tetanus, and diarrhea), preterm birth, and complications of asphyxia. More than 50% of newborn deaths are caused by infections and asphyxia, two emergency conditions for which effective preventive and treatment measures exist.

Of newborn deaths, 99% arise in low- and middle-income countries, and about half occur at home.

Source: Lawn, Cousens, and Zupan 2005 Congenital = pertaining to a condition present at birth

Glossary Term: Sepsis_2 Asphyxia Highlights Of all under-five deaths, 40% occur in the newborn period.

Source: Bhutta et al. 2005

Highlights Three-quarters of neonatal deaths occur in the first week of life.

Sources: Lawn Cousens, and Zupin 2005; Zupan and Aahman 2005.

EmONC Addresses Causes of Mortality

See page one of Session Two of this course for a listing of signal EmONC functions (i.e., key interventions to treat/manage key causes of maternal and newborn mortality).

Highlights Basic and comprehensive emergency obstetric and newborn care (EmONC)addresses the main causes of maternal and newborn mortality.

Putting the Newborn in EmONC The tragedy of an estimated two million newborns dying each year had to

receive attention.

Historically, both maternal mortality and newborn mortality have been neglected. And although emergency obstetric care (EmOC) focused on the mother, by the late 1990s, the global community was coming to acknowledge the reality that the mother and her newborn are a dyad, a single entity that needs to be cared for as a unit rather than as separate entities.

The impossibility of separating efforts to reduce newborn mortality from efforts to reduce maternal mortality became more real with the growing realization that the majority of neonatal mortality could be addressed through quality antenatal, intrapartum, and postpartum care. Thus the "obstetric" in emergency obstetric care had to be paired with emergency newborn care.

In fact, many programs and much training, as you will see in case studies and illustrations in this course, that are called "emergency obstetric care" programs, already included the newborn. Newborn resuscitation has long been an assumed part of emergency care.

Glossary Term: Emergency obstetric care (EmOC) Highlights Although antenatal and childbirth care are sometimes considered to be care of the mother, tetanus toxoid vaccination, HIV/AIDS detection and management, iron/folate supplementation, intermittent preventive therapy (IPT) for malaria, the use of insecticide-treated bednets, the reduction of prolonged labor, and avoidance of early artificial rupture of the membranes all help prevent a portion of neonatal mortality.

Did you know?

A study in Bangladesh showed that complications during labor and birth increased the risk of perinatal death fivefold and accounted for 30% of perinatal mortality.

Source: Kusiako, Ronsmans, and Van der Paal 2000

Basic and Comprehensive EmONC The Basic and Comprehensive Functions Basic emergency obstetric and newborn care (BEmONC) includes the following signal functions (i.e., key interventions to treat/manage key causes of maternal and newborn mortality): ●

●

●

●

●

●

●

●

●

Administration of parenteral (intravenous or intramuscular) antibiotics Administration of a parenteral uterotonic Administration of a parenteral anticonvulsant Manual removal of the placenta Removal of retained products of conception (e.g., manual vacuum aspiration) Assisted vaginal birth (e.g., with vacuum or forceps) Newborn resuscitation Care of the low-birth-weight (LBW) newborn Administration of a parenteral antibiotic to the newborn

Comprehensive emergency obstetric and newborn care (CEmONC) includes all of the BEmONC functions PLUS: ●

●

Performing a cesarean section (c-section) Administration of blood

Glossary Term: Placenta

Key Functions Necessary to Save Lives EmONC does not require that all babies be born in hospitals or that all births be attended by a doctor. Regardless of the place of birth or the distribution of tasks among staff, EmONC focuses on the interventions that save the lives of mothers and newborns.

Everyone who attends a birth needs to have BEmONC skills, equipment, drugs, and infrastructure to provide - or provide access to - BEmONC. Without immediate access to emergency obstetric and newborn care, when a potentially fatal complication arises, the woman and/or her newborn may die.

Where the EmONC necessary to treat complications is universally accessible and appropriately utilized, maternal mortality rates (MMRs) and newborn mortality rates (NMRs) are quite low.

Highlights All skilled birth attendants (competent midwives, nurses, or doctors) should be skilled in providing all BEmONC functions.

Administration of Antibiotics to the Mother Sepsis may account for an estimated 11% of maternal mortality. Prevention of maternal mortality from sepsis includes early diagnosis and treatment. Sepsis should be suspected when a woman has a temperature of 38° C or more.

Infection/sepsis can happen during pregnancy or labor, or after childbirth.

Postpartum (puerperal) infection of the uterus accounts for more deaths than any other postpartum infection.

Diagnosis is made by evaluating the patient for accompanying signs or symptoms: ●

●

Foul-smelling discharge Tender uterus

Recommended antibiotic treatment (Cochrane review and WHO's Managing Complications in Pregnancy and Childbirth): ●

●

●

Combination antibiotics for metritis (infection of the uterus) A penicillin (ampicillin) every six hours, an aminoglycoside (gentamycin) every 24 hours, and clindamycin/metronidazole every eight hours Continued oral antibiotics after clinical improvement is not necessary in cases of uncomplicated endometritis. They add expense but no benefit.

Glossary Term: Sepsis Endometritis Did you know?

Postpartum Sepsis Risk Factors: Frequent vaginal examinations, prolonged and obstructed labor - length of labor, prelabor rupture of membranes (ROM) - length of ROM, cesarean section (odds ratio [OR] at least 2.0) Contributing Factors: Preterm birth, episiotomies, vacuum extractions, forceps delivery, any procedure involving the uterus, poor maternal hygiene, maternal anemia, micronutrient deficiencies, sexually transmitted infections

Administration of Uterotonics A uterotonic is a drug that causes contraction of the uterus.

The leading cause of maternal death is postpartum hemorrhage and 80% of primary postpartum hemorrhage (i.e., hemorrhage occurring in the first 24 hours after birth) is caused by uterine atony (failure of the uterine muscles to contract.)

Besides the use of oxytocin for active management of the third stage of labor to prevent postpartum hemorrhage, uterotonics such as oxytocin, ergometrine, syntometrine, prostin E2 (dinoprostone), misoprostol, or prostaglandin F2 alpha are life-saving drugs for the management of postpartum hemorrhage resulting from an atonic uterus. These drugs cause continuous or sustained contractions of the uterine muscles, so that local blood vessels are compressed, bleeding at the placental site is controlled, and a clot forms.

Preferred routes of administration: ●

●

●

Oxytocin - intramuscularly or in an intravenous infusion Ergometrine - intramuscularly Misoprostol - orally (ICM/FIGO Joint Statement)

Did you know?

The most common uterotonic drugs available in primary health care facilities in resource-limited settings are oxytocin, ergometrine, or syntometrine.

Highlights Ergometrine should NEVER be given to a woman with elevated blood pressure because it can precipitate an eclamptic seizure/convulsion.

Anticonvulsants An estimated 10% of maternal mortality results from hypertensive disorder of pregnancy, with eclampsia (hypertension with convulsions/seizures) being one of the main causes of mortality from hypertensive disorder.

A three-year magnesium sulfate for prevention of eclampsia (MAGPIE) study carried out in 33 countries, showed that magnesium sulfate, an inexpensive drug, can drastically reduce eclampsia. Ideally, magnesium sulfate should be administered intravenously, but if this is impossible, it may be given into the muscle.

The administration of this drug to treat pre-eclampsia and prevent or treat eclampsia is a key component of emergency obstetric and newborn care (EmONC). (Duley and Henderson-Smart 2003).

If magnesium sulfate is not available, diazepam (Valium) may be used. However, magnesium sulfate is substantially more effective in preventing convulsions and mortality, and diazepam carries a greater risk of neonatal respiratory depression. Therefore, diazepam is not the drug of choice.

Glossary Term: Hypertensive disorder Highlights ALL cases of severe pre-eclampsia (diastolic blood pressure more than 110 mm Hg) or eclampsia (hypertension plus convulsions/ seizures) should be managed actively and rapidly.

In eclampsia, delivery must occur within 12 hours of onset of convulsions/ seizures.

Manual Removal of the Placenta

Another cause of postpartum hemorrhage is retained placenta. This occurs when the baby is born but the placenta fails to separate and expel within 30 minutes of the birth of the baby.

When a placenta is retained, oxytocin may be administered and controlled cord traction may be attempted to deliver the placenta. However, if the placenta still is not delivered, it must be manually removed.

During manual removal of the placenta, infection prevention practices for sterility must be observed. As soon as the placenta is extracted in the hand of the clinician, an oxytocic is administered to cause the uterus to contract.

Did you know?

Prophylactic antibiotics should be given to a woman who is having a placenta removed manually.

Removal of Retained Products of Conception Following a Miscarriage or Abortion Unsafe abortions account for an estimated 5% of maternal mortality. Also,

an incomplete spontaneous abortion (miscarriage) can result in fatal hemorrhage.

Removal of the retained products of conception following a miscarriage or abortion is facilitated with a manual vacuum aspirator or dilatation & curettage (D&C). A manual vacuum aspiration (MVA) is less traumatic, less painful, and less likely to perforate the uterus.

MVA is a procedure performed using a manual suction syringe that is attached to a cannula (a flexible tube) inserted into the uterus to remove the retained products of conception by suction. A curettage is a procedure in which a metal "spoon-shaped" instrument is inserted into the uterus to scrape the inside wall of the uterus and remove any retained products.

Ideas in action Promising studies in South Africa and Kenya have found that incomplete abortion or miscarriage may also be treated with oral misoprostol, a uterotonic.

Did you know?

An essential element of postabortion care services is providing the woman with a family planning method before she leaves the facility.

Assisted Vaginal Birth with Vacuum Extractor or Forceps

An estimated 7% of maternal mortality globally is attributed to obstructed labor. Although completely obstructed labor requires a c-section for delivery, a significant number of relatively obstructed births are possible vaginally with the assistance of a vacuum extractor or forceps.

Skills to use a vacuum extractor are often more easily taught than are the skills to use forceps. Using a vacuum extractor, a suction "cup" is placed on the baby's head and gentle traction applied during a contraction to assist the descent and birth of the head. Forceps are two metal tongs/spoons that are applied to either side of the baby's head to faciliatate the birth of the head.

If the attempt with vacuum or forceps fails, a c-section must be performed.

Did you know?

Use of a vacuum extractor is only possible if the baby is descending head-first.

Did you know?

A Cochrane Review found that use of the vacuum extractor rather than forceps for assisted vaginal delivery appears to reduce maternal morbidity. However, the reduction in cephalhematoma (benign bleeding beneath the outer layer of the skull) and retinal hemorrhage (bleeding in the eye) seen with forceps may be an advantage.

Source: Johanson and Menon 1999

Newborn Resuscitation: The Need About 5% to 10% of all newborns need resuscitation at birth. Nearly one million babies die each year because they do not breathe normally at birth. (Saugstad 1998; WHO 1995) "Asphyxia" is the term applied to the condition when a baby does not breathe or continue adequate breathing. There are many reasons that a baby may not breathe at birth, but most of the time, asphyxia is the result of a decreased oxygen supply to the baby during pregnancy, labor and/or birth. Maternal conditions such as high blood pressure, diabetes or infection, or conditions during birth such as prolonged or obstructed labor, preterm birth, or cord or placenta problems can contribute to hypoxia (inadequate oxygen in the blood).

The person attending a birth should always be ready to resuscitate a newborn at every birth because there is no reliable way to predict which baby will fail to breathe.

Newborn Resuscitation Using an Ambu Bag and Room Air

Globally, an estimated 23% of newborn mortality has been attributed to asphyxia. A simple and effective treatment for asphyxia is resuscitation using a self-inflating bag and mask (Ambu bag) and room air. A reduction in neonatal mortality or morbidity/mortality of 6% to 42% may be obtained through effective resuscitation of the newborn.

A meta-analysis of four human studies showed a reduction in mortality and no evidence of harm in newborns resuscitated with room air compared to 100% oxygen. (Tan et al. 2005) Health care workers should be made aware that oxygen is not necessary for successful resuscitation of asphyxiated newborns.

Glossary Term:

Meta-analysis APGAR Did you know?

A 2006 study reported in the British Journal of Obstetrics and Gynaecology showed that emergency obstetrics training that included neonatal resuscitation was associated with a clinically important, and sustained, improvement in perinatal outcomes.

The introduction of this training was associated with significant reduction in low five-minute APGARs and hypoxic-ischemic encephalopathy (a type of brain damage due to lack of oxygen).

Source: Draycott et al. 2006

Care of the Low-Birth-Weight and Premature Newborn A baby who weighs less than 2500 grams at birth is considered low birth weight (LBW). Most LBW newborns in developing countries are term or near term. However, a baby born prematurely (before 37 weeks gestation) may also be LBW. A LBW newborn has increased risk of hypothermia (low body temperature), hypoglycemia (low blood sugar), and poor growth. A premature baby has additional problems with feeding, respiration, bleeding in the brain, and jaundice.

The stable LBW and premature newborn needs: ●

●

●

●

Kangaroo care Early and exclusive breastfeeding on demand (facilitated by kangaroo care) Warmth (facilitated by kangaroo care) Protection from infection

Did you know?

Kangaroo care is early, prolonged, and continuous skin-to-skin contact between a mother and her LBW newborn. The naked newborn is secured between the mother's breasts, against the mother's skin.

Kangaroo care can begin in the facility or after early discharge and continue at home.

Administration of Antibiotics to the Newborn Sepsis in the newborn, especially lung infection (pneumonia,) is a leading cause of newborn death. Unless the mother has a history suggestive of sepsis, most newborn sepsis does not appear until after day three.

It is estimated that 15% to 30% of neonatal mortality could be eliminated if lung infection were treated rapidly and effectively with antibiotics. This case management of pneumonia in the newborn should occur across the continuum, in the home-community, through outreach and primary health care services, and in the referral facility.

Community-based treatment of pneumonia could result in a 27% reduction in neonatal mortality in resource-constrained countries. (Darmstadt et al. 2005) Glossary Term: SEARCH Ideas in action Programs such as SEARCH in India have demonstrated that trained community workers (non-professionals) can effectively identify and treat newborn lung infections in the home.

Did you know?

Besides being given antibiotics by injection, the newborn with an infection should be kept hydrated by frequent breastfeeding.

Comprehensive EmONC (CEmONC)

CEmONC is typically delivered by a doctor, clinical officer, or other trained

provider, and includes the basic EmONC functions plus c-section and safe blood transfusion.

Labor that is truly obstructed requires delivery by c-section to save the life of the mother and newborn. Surgical capability to perform a c-section may also be accompanied by the capability to perform other emergency obstetric surgery (e.g., repair of a ruptured [torn] uterus). The ability to given anesthesia is also necessary because anesthesia is used when performing a c-section, and might also be used when correcting a uterine inversion or performing a laparotomy.

Likewise, a safe blood supply is essential to saving the lives of women who have suffered hemorrhage. Some women may already be in shock when they arrive at the hospital; others may suffer severe hemorrhage after arrival.

Regardless of the cause of the hemorrhage, replacement of volume and of red cell mass is life-saving.

Insertion of an umbilical vein catheter or intubation of a newborn might be considered CEmONC functions for the newborn.

Glossary Term: Uterine inversion Laparotomy Did you know?

In contrast to BEmONC functions, CEmONC functions are usually performed at the district or tertiery hospital level rather than at the primary health care level.

Implementation of EmONC Services Met Need: The Strategic Role of Basic Emergency Obstetric and Newborn Care Existing evidence suggests a tendency to opt for care at a referral level center rather than at a primary health care level. This may be due to availability of services rather than to women's preferences. â—?

â—?

Data from fourteen countries in the Averting Maternal Death and Disability (AMDD) program show serious under-investment in basic emergency obstetric care (EmOC) facilities (AMDD Working Group on Indicators 2002a; 2002b; 2003a; 2003b; 2004 in Stanton et al. 2007) Nine of fourteen countries report on study sites where the availability of basic EmOC is 50% or less of levels recommended by United Nations agencies. In contrast, all but two study sites (Than Hoah, Vietnam, and Rajastan, India) report comprehensive EmOC is between 100% and 400% of recommended levels.

Thus, expanding access to basic EmOC by upgrading existing lower level facilities, increasing availability of those facilities, and improving referral systems may be more cost-effective in achieving widespread coverage than focusing on increasing hospital-based births. (Stanton et al. 2007) Close-to-client care for normal birth and complications has been proposed as the most effective and cost-effective strategy for reaching the most women with life-saving care (Campbell and Graham 2006). Thus, basic emergency obstetric and newborn care (BEmONC) at health centers would help ensure that the needed care is accessible to the

woman or newborn who needs emergency care.

Glossary Term: Emergency obstetric care (EmOC) Highlights The success of emergency obstetric and newborn care (EmONC) is dependent on the distribution of facilities that enables women and newborns with complications to access the necessary care - ideally within a couple of hours.

Source: Campbell and Graham 2006 Did you know?

United Nations Recommendations for Every 500,000 Population At least four facilities providing basic EmONC At least one facility providing comprehensive EmONC

Unmet Need for Emergency Obstetric Care Services A recent review of availability of basic EmOC services in 13 developing countries found that uterotonics and antibiotics are the most likely EmOC key functions to be available in primary health care units. Assisted vaginal delivery is the least likely key function to be available. (Bailey et al. 2006) A survey conducted in Uganda by the AMDD program reported in 2006 that although 553 health units surveyed were expected to offer basic EmOC services, 97.2% were not offering all six. Similarly, 92.5% of facilities that were expected to offer comprehensive EmOC services were not even able to offer basic EmOC services. (Mbonye et al. 2007) Glossary Term: Uterotonic Highlights The cited study in Uganda found that assisted vaginal delivery was the basic EmOC function that was most likely to be missing from basic EmOC services. The comprehensive EmOC service most often missing was blood transfusion.

Source: Mbonye et al. 2007

A Supportive Health System Functional EmONC services require a supportive health system. This does not mean that a high-tech hospital is necessary, but rather that facilities capable of providing the basic and comprehensive signal functions are accessible to women. Such a functioning health system will require: ●

●

●

●

Health care workers with necessary competencies to provide emergency obstetric and newborn care (EmONC) A physical infrastructure appropriately and adequately equipped and supplied A referral network including transportation A management and supervision system that facilitates a continuum of care for women and newborns

Initiatives intended to bypass health systems and deliver interventions directly to people may sound efficient and empowering, but tend to weaken the health system as well as complicate and overburden administrative structures.

Evidence shows that such programs have some impact on newborn mortality, virtually no impact on maternal mortality, and are not sustainable in the long term. (Freedman et al. 2003) Glossary Term: Signal EmONC functions

Supportive Policy Various policy issues can hinder the implementation of EmONC services. ●

●

●

●

Policies may require that primary care facilities refer all emergencies and only perform normal antenatal care (ANC), labor and birth, and postpartum care (PPC) -as in Honduras. (Bailey et al. 2006) Even when basic facilities are upgraded to provide BEmONC services, they need policy to allow this function.

Lack of certain life-saving drugs on the government's essential drug list. The World Health Organization (WHO) recently reported that magnesium sulfate was not on the national essential drug list of half the countries it reviewed. (de Bernis 2003) Regulatory guidelines for blood banks can inadvertently limit the facilities that can provide blood. Likewise, a shortage of laboratories or reagents may limit the ability to test and screen blood for transfusion.

Budgets must be sufficient to pay staff; obtain drugs, equipment, and supplies; and operate the facilities.

Glossary Term: Stock-out Signal EmONC functions Did you know?

Access Barriers Besides "stock-outs" . . .

Regulations may also prevent drug use by certain levels of providers (e.g., nurses or midwives) who may be the only providers at peripheral (basic) facilities.

In some countries, midwives are not allowed to administer uterotonics (a signal function of EmONC).

Human Capacity To be able to perform EmONC procedures, health care workers should be: ●

●

●

●

Sufficient in numbers to provide coverage 24 hours a day and seven days a week. Coverage by skilled birth attendants can be extended by using assistants and providers with less sophisticated skills.

Trained to competence through pre-service and in-service training. Few in-service or pre-service curricula/programs include all the skills for performing the signal functions of EmONC. And few are truly competency-based. See a learning resource package for teaching these skills.

Legally supported in performing these procedures through updated national standards and guidelines, regulations, and delegation of authority. Job descriptions must allow the most peripherally located health care worker to provide the highest level of health care they can safely provide. This means that tasks previously reserved for physicians (e.g., use of uterotonics, assisted vaginal deliveries, manual removal of the placenta, and manual vacuum aspiration) may be shifted to skilled midwives and nurses. And c-sections may be shifted to general practitioners or other providers functioning at the district hospital level. Anesthesia may be delivered by a properly trained nurse or general doctor rather than only by an anesthesiologist.

Strengthened with ongoing, day-to-day management and supportive supervision, adequate compensation, and recognition.

A tool for assessing the readiness of a facility is provided in a room-by-room 'walk-through' tool. (Gill et al. 2005) Glossary Term: undefined Ideas in action In Mozambique, assistant medical officers are being trained to perform emergency obstetric services, including cesarean deliveries. These non-physicians now perform most emergency obstetric surgery in rural hospitals.

Likewise, in Tanzania and Malawi a similar approach is being implemented.

Source: Rosenfield, Min, and Freedman 2007

Facilities Facilities at each level of the health care system must have: ●

●

Necessary space and areas for privacy during patient care (If a partition cannot be built, a moveable screen can be used.)

A regular supply of equipment, supplies, and drugs, including: Systems to prevent the "stock-out" of a particular drug (e.g., magnesium sulfate), which frequently occurs Necessary equipment and supplies that are accessible (not locked away in a cupboard with no key available to the care provider) National level oversight to develop, fund, and regulate local supervision as a component of a quality assurance system. (Gill and Ahmed 2004) ❍

●

●

An Effective Referral System Once an emergency is recognized, another key to timely life-saving care is an effective referral system. This requires adequate information and skill at each level of the system, and implies an adequate transportation system. In a functional referral system, patients are treated at the level in the system that is most appropriate for their condition.

Requirements of an effective referral system are: ●

●

●

●

●

●

●

●

Personnel who are skilled in managing complications Equipment and supplies for providing BEmONC care at the primary level(s) and CEmONC at referral levels Communications and feedback systems Reliable transport Protocols for identifying complications at each level of the system Communication between referral levels A record system that allows effective flow of information between levels Mechanisms to prevent patients from bypassing a level of the system (good patient information, clear criteria for treatment at each level, an equitable fee structure)

Source: Murray et al. 2001 in Freedman et al. 2003.

Did you know?

To significantly reduce deaths, an EmONC referral system and its referral centers must function 24 hours a day, and seven days a week.

Community Education and Mobilization Even widely available EmONC facilities that are well equipped and functioning with

competent staff are not sufficient to reduce maternal mortality unless women and families are using them.

Communities should not accept the inevitability of maternal and newborn mortality, but should grow to expect survival of mothers and newborns.

Once a complication arises one key to saving a woman's or newborn's life is to get adequate care in time. Preparing for a possible complication should begin at the first ANC visit, and be reinforced with each visit.

The first step in complication readiness is recognition of danger signs and what to do if one is recognized. Community education by community health workers as well as health education in the clinic teach women and communities when

they need to find immediate help and where to find it. Complication readiness also helps facilitate access to care by ensuring that a source of emergency transportation and emergency funds are immediately accessible.

Highlights A maternal morbidity and mortality study in Nepal (MOH 1998) found that only 48.5% of families where a maternal death occurred even recognized there was a problem. Several women with convulsions were kept at home two to nine days before being referred.

In a number of cultures, convulsions are not considered a problem that requires medical attention but rather a problem that needs a religious or spiritual intervention.

In many cultures, vaginal bleeding after birth is desired and considered a sign of good health.

Care for the Mother and Newborn Who Has No Complication EmONC deals with the management of complications. ANC and PPC deal with health promotion and self-care that help prevent complications and also deal with the early detection of problems.

During normal ANC, women are taught to recognize problems and to be prepared to seek help immediately.

Infectious diseases (e.g., malaria and tuberculosis) as well as conditions (e.g., severe anemia) are prevented or treated during routine care, so that complications are less likely to be life-threatening.

During labor and birth, prevention of prolonged labor and active management of the third stage of labor, are practiced to prevent life-threatening complications for the mother and newborn.

During postpartum care, the mother is taught healthy self-care and care for her newborn, including the early detection of problems in either.

Postpartum family planning counseling and care are integrated into normal ANC, labor and birth, and PPC. Glossary Term: Anemia/Severe Anemia

Monitoring and Evaluation United Nations Process Indicators: Are There Sufficient Emergency Obstetric and Newborn Care (EmONC) Facilities?

The World Health Organization (WHO), together with other United Nations (UN)

agencies, established a minimum standard for the number of EmONC facilities.

For every 500,000 population: â—?

â—?

At least four facilities should be providing basic EmONC (BEmONC) At least one facility should be providing comprehensive EmONC (CEmONC)

Are they well distributed? ●

Geographic distribution - 100% of sub-national areas (provinces, states, districts) should have the minimum acceptable numbers of basic and comprehensive EmONC facilities

Sources: Wardlaw and Maine 1999; Meyers, Lobis, and Dakkak 2004

UN Process Indicators: Are the Quantities of EmONC Services Sufficient? Is the Quality Adequate?

Are sufficient quantities of critical services being provided?

The quantity of critical services is reflected through: ●

Cesarean section rate - Not less than 5% and not more than 15%, as a proportion of all births in the population, are by cesarean section.

Is the quality of the services adequate?

The quality of care is reflected through: ●

Case fatality rate - Not more than 1% of all women with obstetric complications who are admitted to comprehensive EmOC facilities die.

Source: Wardlaw and Maine 1999

Calculations of UN Process Indicators of EMOC: Amount, Distribution, and Utilization How to determine the AMOUNT OF EmOC* SERVICES AVAILABLE TO THE POPULATION ●

●

●

●

●

Use local demographic data.

Use the most recent census to determine the population size in a given area.

Calculate the number of EmOC facilities through direct observation, interviews with staff, or record review.

Divide the region's population (numerator) by 500,000 (denominator).

To qualify: For BEmOC, all six BEmOC functions* must have been performed in the previous three months.

For CEmOC, all six BEmOC functions* plus surgery and blood transfusion must have been performed in the previous three months. ❍

❍

How to determine the GEOGRAPHICAL DISTRIBUTION OF EmOC FACILITIES ●

●

Use a local map and local demographic data.

Simply look at the geographic distribution of facilities on a map. If facilities are all in the main cities, rural women may have no access.

*Only six functions were described in the UN Guidelines because only the mother, not the newborn, was included in EMOC. With the addition of newborn care, (the "N" in EmONC) three basic functions were added.

Source: AMDD/Columbia University 2003 Highlights Does the area have one CEmONC facility for each 500,000 population and four BEmONC facilities for each 500,000 population?

Calculations of UN Process Indicators of EMOC: Utilization How to determine the PROPORTION OF ALL BIRTHS IN EmOC FACILITIES (utilization of services). ●

●

●

Calculate by dividing the number of women giving birth in EmOC facilities during a specific time period (numerator) by the number of expected births in the population during that time (denominator).

Obtain the numerator from hospital record/register review.

Obtain the denominator by multiplying the population (from census or government statistics) by the crude birth rate (available from health authorities).

How to determine the MET NEED FOR EmOC SERVICES (another aspect of utilization) ●

●

●

Calculate by dividing the number of women with complications treated in a facility or facilities in a region (numerator) by the number of complications you would expect to occur in that population (denominator).

Obtain the numerator by reviewing hospital records.

The denominator is estimated as 15% of expected births in the population. As noted above, the expected births in a population is calculated by multiplying the population (from census or government statistics) by the crude birth rate (available from health authorities).

Source: AMDD/Columbia University 2003 Did you know?

Although the calculation for met need for EmOC services as described at the left determines the "women treated," a clinical audit or another in-depth method is required to determine whether the treatment received was adequate or "to standard."

Ideas in action Calculating the Proportion of Births in EmONC Facilities IF The population is 500,000 AND The crude birth rate is 40 (or 40/1000) THEN 500,000 x 0.04 = 20,000 annual births

Calculations of UN Process Indicators of EMOC: Quality How to calculate CESAREAN SECTIONS AS A PERCENTAGE OF ALL BIRTHS (shows what proportion of women giving birth in the population gave birth by c-section) ●

●

●

Divide the number of c-sections (numerator) by the expected births in the population (denominator). As noted previously, the expected births in a population is calculated by multiplying the population (from census or government statistics) by the crude birth rate (available from health authorities).

Obtain the numerator from operating theatre registers.

Obtain the denominator from hospital records. (The denominator is not the number of births in a facility but the expected births in the population.)

How to calculate the CASE FATALITY RATE (an indicator of the quality of care women receive in a facility) ●

Divide the number of direct obstetric deaths in EmOC facilities (numerator) by the number of cases of key

complications* seen in EmOC facilities (denominator).

Obtain data from hospital records (for both numerator and denominator). *Key complications might be postpartum hemorrhage, obstructed labor, pregnancy-induced hypertension, or other direct causes of obstetric deaths.

Highlights An appropriate level of cesarean sections is considered to be 5% to 15%, but it is recognized that the wrong women may receive c-sections and those who need them may not receive them.

Highlights According to WHO guidelines recommendations, the maximum acceptable case fatality rate is 1%.

Summary: UN Process Indicators for EmONC

Tools for Assessing Quality of Service The only UN indicator that addresses quality is the case fatality rate. Other tools for assessing quality of care may be: ●

●

●

Focus groups Client/patient exit interviews In-depth interviews of staff, patients, and the community

In addition, useful tools may be: ●

●

●

Standards-based Management and Recognition (SBM-R) - A Field Guide: A Practical Approach for Improving the Performance and Quality of Health Services at the JHPIEGO Web site A WHO publication, Beyond the Numbers: Reviewing Maternal Deaths and Complications to Make Pregnancy Safer Also, three documents available at the AMDD Web site Improving Emergency Obstetric Care Through Criterion-based Audit Quality Improvement for Emergency Obstetric Care: Leadership Manual and Toolbook AMDD Workbook: Using the UN Process Indicators of Emergency Obstetric Services: Questions and Answers UNFPA has a Monitoring and Evaluation Toolkit for EmOC (See Tool Number 6: Progamme Indicators, Part II: Indicators for Reducing Maternal Mortality.) ❍

❍

❍

●

Did you know?

Although "clinical audit" is not a specific "method," it is another useful tool for assessing quality.

"Clinical audit" may consist of several methods (e.g., record review, supply and equipment audit, and/or structured clinical observation).

Usefulness of Indicators at the Facility Level A review of the data that are applicable at the facility level will help gauge the progress made towards improved quality and utilization. A graph may be used to show whether the numbers of complications treated or the numbers of c-sections is increasing over time. Likewise, you would want to see the numbers of maternal deaths decreasing over time.

An audit or case review may be needed to determine the cause of trends noted.

Population data may not be available for the catchment area of a particular facility. So, trends in absolute numbers may be the most useful data to study.

If the number of complications seen in a facility is very low, then it is not useful to calculate case fatality rate. Also, if women are arriving in a very weakened condition that causes them to die soon after arrival, the case fatality rate may not be useful. Likewise, if all severely ill women are referred, the case fatality rate will be low.

Quality of care can be traced by looking at the numbers of maternal deaths in the facility and the time of death in relation to time of arrival at the facility.

Ideas in action At the facility level, if the number of complications treated or the number of c-sections suddenly flattens out, you may examine whether, during that time, the surgeon or the anesthetist was absent or a vital piece of equipment was broken.

Did you know?

Simple Indicators Utilization can be monitored by looking for an increase in the number of births and in the number of complications treated in the facility.

You want to see an increase in c-sections. But if the rate is >20%, unnecessary procedures are perhaps being performed.

Usefulness of Indicators at the National Level Planners, program managers, and policy makers need to know whether their efforts to improve the quality and coverage of emergency obstetric and newborn services are making a difference for women and newborns who experience life-threatening complications.

Usefulness at the national level for: â—?

â—?

Baseline assessment - Indicators can be used in a baseline needs assessment, and also in program design.

Monitoring, program development, and policy making - As programs and national plans are implemented, decision makers need to know whether the interventions are proving effective and whether there are gaps and needs that should be addressed. These data help governments allocate budgets appropriately, and help policy makers identify problems and prioritize solutions.

Monitoring the performance of the emergency obstetric and neonatal care functions provides a picture of the capacity of the health system to provide key interventions when obstetric and neonatal emergencies occur.

Highlights Even more valuable information will be obtained if there is an effort to match these process indicators with outcome indicators (e.g., maternal and perinatal mortality and incidence of complications).

Did you know?

DHS data can be an additional useful source of data to supplement EmONC indicator data that may be

available.

Case Studies: Mozambique and Bangladesh UNFPA/Averting Maternal Death and Disability (AMDD) in Mozambique Background ●

●

●

●

In 1995, the maternal mortality rate (MMR) in Mozambique was estimated to be 980 (380-2000) per 100,000 live births.

Only 48% of births were attended by a skilled birth attendant.

In the 1997 Demographic and Health Survey (DHS), approximately 72% of women reported at least one prenatal visit.

In 2000, there were only 25 Mozambican ob/gyns and nurses: the population ratio was 1:5000.

Objective: Increase the access and availabilty of emergency obstetric care (EmOC) and increase the quality and utilization of this care.

Target area: The entire project covered two sites in the capital city, one covering a large district, and one covering an entire province, Sofala, with a population of 1.5 million. Different interventions were used in each of four different areas. This case study covers interventions in Sofala province - which contains the second largest urban center in Mozambique, is very poor with 70% unemployment, and whose health system has been destroyed by civil war.

Source: Jamisse et al. 2004 Glossary Term: Emergency obstetric care (EmOC) Sepsis Did you know?

In 2000, the Ministry of Health in Mozambique approved a MMR reduction strategy and conducted a needs assessment that found that sepsis, postpartum hemorrhage (PPH), and uterine rupture were leading causes of maternal mortality, and that significant shortcomings existed in hospitals.

UNFPA/AMDD in Mozambique Project Activities

Project activities, based on a baseline survey, included:

1. Made capital improvements to EmOC facilities (including electricity, water and sanitation, roofs, windows).

2. Provided essential equipment and made essential supplies available in the facilities. Until then manual vacuum aspiration (MVA) equipment, vacuum extractors, and magnesium sulfate had not been routinely available.

3. Conducted basic EmOC training (one week theory and three weeks practical) for staff in basic facilities and comprehensive EmOC training (one month theory and two months hands-on) for physicians in referral hospitals.

No one entered the comprehensive EmOC course without surgical experience.

4. Established a system of radio communication and rapid transport of patients requiring comprehensive EmOC. 5. Developed clinical and training guidelines in collaboration with other agencies.

6. Instituted provincial level maternal mortality committees.

During the first year, the project targeted eight rural and the largest urban health facilities. During the second year, eight more distant facilities were added. In the third year, seven even more distant facilities were added.

Source: Jamisse et al. 2004 Did you know?

The main obstacle to implementing the interventions was identifying appropriate candidates for training and personnel who could substitute for them while they were at training.

Accomplishments and Results in Sofala Province, Mozambique EmOC facilities increased - By the end of the project, the number of comprehensive EmOC facilities remained at four and those providing basic EmOC increased from one to five.

Utilization increased - Utilization (met need) among women with complications increased from 6.3% in 2000 to 11.2% in 2002.

Deliveries in facilities increased - The proportion of deliveries in EmOC facilities increased from 12% in 2000 to 25% of all births in the first six months of 2002.

Case fatality rate decreased - The aggregate case fatality rate in basic EmOC facilities decreased from 4.7 in 2000 to 2.4 in first six months of 2002. And during the same period, the case fatality rate in comprehensive EmOC facilities fell from 4.1% to 3.1%.

Scale-up - With some adaptations, the Ministry of Health has implemented much of the Sofala model in the other nine provinces in Mozambique.

Source: Jamisse et al. 2004 Glossary Term: Sea change Highlights The "interventions" in Sofala were not seen as a transient project, but rather as a sea change in the health system's approach to normal delivery and the management of obstetric emergencies.

Did you know?

Even though the case fatality rate in hospitals providing comprehensive EmOC decreased, it still remained well above the UN target of 1.0%.

Lessons Learned in Mozambique Human Resources Program success requires policy, training, and supervision. â—?

Policy Support - To train mid-level providers and non-specialists, and to pay staff

●

Training Should involve the provincial health directorate and other provinical managers and supervisors as well as health personnel Should include - besides EmOC skills - infection prevention, equipment maintenance and repairs, monitoring and evaluation (M&E), quality improvement, and supervision Supervision - Supportive supervision and frequent supervisory visits are essential to promote continuous training and quality improvment. ❍

❍

●

Facilities - Basic infrastructure must be in place, and basic equipment and supplies must be continuously available.

Emergency response system - A functioning and reliable referral and transport system is critical to saving lives.

Measurement - To reduce maternal mortality, programs must: ●

●

●

Determine causality of mortality (by means of maternity registers, maternal mortality committees, and maternal death audits) Determine quantifiable contributions of each intervention Measure program impact (MMR estimates)

A well-developed data collection system and M&E capability should be in place to allow staff to use results to question why outcomes did not develop as expected.

Community mobilization - Demand generation and more accountability to underserved rural women is needed to meet the need for EmOC care among the population.

Source: Santos et al. 2006 Highlights Maternal mortality committee meetings included non-punitive discussion on: Progress on indicators of EmOC signal functions Problems with care and referral Lessons learned in achieving progress

CARE in Bangladesh

Background: The Dinajpur Safe Motherhood Initiative (DSI) was a three-year project

developed in 1998 by CARE in collaboration with UNICEF and the government of Bangladesh.

In 1995, MMR in Bangladesh was 600/100,000. Of deliveries, 96% occurred at home.

Target area: The project areas were Dinajpur and Panchagarh, two districts in the northwestern region, plus a comparison and control area. The intervention area was Birampur (153,000 population). The comparison area was Bochaganj (164,000 population). The control area was Debiganj (183,000 population).

Objective: To test the impact of several interventions on the use of obstetric services in government health facilities in northwestern Bangladesh.

Source: Hossain and Ross 2006

Project Interventions in the DSI Initiative in Bangladesh In both intervention and comparison areas: Facilities were refurbished and equipment and supplies were provided for delivering basic EmOC services.

In intervention areas (but NOT in control areas): In facilities ●

●

●

●

●

Staffing - The number of staff was increased; staff were trained in EmOC skills; job aids were developed; and team building was conducted among providers.

Ongoing supervision and quality assurance - Supportive supervision included monthly visits, clinical care observation, and on-the-job training as needed.

Management information systems - A system was introduced to register all patients, capture statistics, record training, and analyze obstetric emergencies.

Stakeholders committee - A committee was established to solicit community opinions regarding the design and delivery of health care services.

Health system linkages - To facilitate referral, close links were maintained between higher and lower facilities.

In the community ●

●

●

Birth planning - Messages and learning aids were developed; traditional birth attendants (TBAs) and other key community members were trained in disseminating messages.

Community support sytem - Communities were mobilized around the recognition of danger signs and the provision of timely referral (transport, funding, blood transfusion).

Facility-community linkages - Regular discussions were held between facility and community committees.

Source: Hossain and Ross 2006 Highlights As illustrated by the DSI project, reducing maternal mortality requires a broad range of interventions in facilities and in communities.

Accomplishments and Results of the DSI Project in Bangladesh The intervention area achieved: ●

●

●

●

A statistically significant increase in the percentage of women delivering in facilities - a 119% increase (compared to the control area) A threefold increase in comprehensive EmOC facilities per 500,000 A twofold increase in utilization of EmOC services for pregnancy complications and c-sections A greater knowledge of obstetric complications (44% of women knew three or more of five danger signs) compared to 4% in the comparison area and 6% in the control area

Other positive intervention outcomes that were not quantifiable, yet are important: ●

●

●

The regular use of data in facilities, including death and "near miss" reviews, increased service providers' understanding of patient needs and the importance of providing timely and quality care.

The government has visited the site and is planning scale-up activities.

Staff in facilities are engaging in team-building activities.

Source: Hossain and Ross 2006

Did you know?

Community activities (e.g., birth planning) allowed women and their families to recognize danger signs and to seek care appropriately.

Lessons Learned in Bangladesh ●

●

●

●

●

Increased utilization rates in both the intervention and comparison areas may indicate that improvement of facilites/services affects utilization rates.

Use of data and team building among staff in facilities enabled staff to understand the importance of providing quality care, and empowered lower level staff.

Stepwise implementation of stakeholder committees sensitized facility staff to community needs and enabled the community to participate in decision making.

The government of Bangladesh asked CARE to replicate the DSI model in sixteen sub-districts of the Sylhet division, where met need increased from 12% to 48%.

Sustaining staff morale and commitment amid difficult working conditions is not easy, but it is essential.

Source: Hossain and Ross 2006

Case Studies: India and Francophone Africa Federation of Obstetrics and Gynecological Societies in India (FOGSI) in India

Background

●

●

●

●

●

In India,100,000 maternal deaths occur per year (20% of global maternal deaths).

The nation is plagued by a high maternal mortality rate (MMR) and inadequate medical facilities.

The current curricula of most medical colleges are geared toward hospital-oriented services rather than toward primary or rural health services.

In rural areas, the population is served by non-specialists. At the beginning of the project in rural areas of India, there were 20,000 non-specialist doctors, but only 700 obstetrician/gynecologists.

To bridge the gap, FOGSI planned to prepare non-specialist doctors in comprehensive emergency obstetric care (CEmOC) for rural India.

Objective To develop: ●

●

The capacity of doctors in India to provide high quality emergency obstetric care (EmOC) services in rural areas where skilled obstetricians are not available One EmOC center in each state of India

Target area: All rural areas of India Source: Desai 2006 Glossary Term: Emergency obstetric care (EmOC)

Did you know?

To make 2,000 referral sites functional, 6,000 doctors who are competent in emergency obstetric and newborn care (EmONC) are required.

Highlights The Federation of Obstetrics and Gynecological Societies in India (FOGSI) has 184 chapters and nearly 21,000 members from both the public and the private sectors.

FOGSI is the largest association of obstetricians and gynecologists in the world.

Case Study: India FOGSI Project Activities ●

●

●

●

●

●

●

●

Adopting EmOC as a permanent project of FOGSI Advocacy and policy change to allow non-specialists to provide comprehensive EmOC Negotiating for funds and technical assistance (from the MacArthur Foundation, JHPIEGO, Averting Maternal Death and Disability (AMDD), Indian Institute of Management, the government of India, UNICEF) Finalizing training materials Preparing trainers at Christian Medical College of Vellore Setting up training centers in partnership with leading medical schools (At each center four trainers are prepared for six months. Medical officers at district hospitals are trained as clinical preceptors.)

Coordinating with state health authorities Training and onsite mentoring in two types of EmOC courses

Source: Desai 2006 Highlights Two Types of EmOC Competency-based Courses Offered in This Project A three-week basic emergency obstetric care (BEmOC) course to upgrade the skills of doctors already working in rural or underserved areas A 16-week course for medical officers to include cesarean sections - two weeks classroom, four weeks supervised clinical, ten weeks self-directed clinical practicum with onsite mentoring and evaluation

Accomplishments and Results in India Comprehensive EmONC training is now available in three high-performing sites.

●

●

●

●

●

●

Approximately twenty first referral units are now providing comprehensive EmONC services with providers trained in the FOGSI program.

A FOGSI monitoring program (to measure quality of services at training sites, competency of trainers, and competency of graduates) has been established.

EmONC training is now incorporated into medical schools' internship programs.

The EmONC certification course is recognized by the government of India.

The government of India has provided five million US dollars to FOGSI to set up fifteen EmONC training centers to train 2,000 MBBS doctors over five years.

Sources: Desai 2006; JHPIEGO 2007 Glossary Term: MBBS

Highlights The government of India now considers FOGSI a premier partner in maternal health programs.

Lessons Learned in the FOGSI Project in India

National advocacy by a professional association is key to policy change – Policy change

●

●

●

●

required the concerted effort of FOGSI members.

Quality standards must guide training - A standardized approach to, and materials for, training are needed.

Close coordination with the government is essential - Coordination with the state government for the release of candidates to attend training and to avoid transfers of trained manpower is key to effectiveness and sustainability.

Attention must be paid to avoid trainer burnout - Demands are heavy on trainers. So, workload must be divided among a larger group of trainers.

Source: Desai 2006

Building EmONC Services in Francophone Africa

Background: Given the situation of high maternal and newborn mortality in the four African countries shown in the chart above, AMDD and the Maternal and Neonatal Health Program (MNH) Program decided to carry out an intiative based on their experience in developing EmONC teams in five south Asian countries.

Objective: Build core EmONC training teams (an obstetrician, a midwife, and an anesthetist) in the four target countries listed below.

Target Area: Francophone Africa, specifically, Burkina Faso, Cote d'Ivoire, Niger, and Rwanda Did you know?

This initiative was carried out in collaboration with AMDD and the MNH program (led by JHPIEGO, an affiliate of the Johns Hopkins University).

Training and Mentoring in Francophone Africa Teams of three to four providers from the four target countries received training to

develop competency in both basic and comprehensive EmONC functions.

Onsite mentoring and support assisted the teams to apply their new knowledge and skills in their own clinical sites.

Teams were given competency-based training in teaching these evidence-based practices and skills to other providers in their countries.

New EmONC training teams in each country were mentored as they taught EmONC courses to colleagues.

Glossary Term: Competency-based training Ideas in action In-country stakeholder support included policy dialog, advocacy in academic institutions and professional organizations, and role modeling with colleagues.

Achievements and Results in the Francophone Africa EmONC Initiative

Quality of EmONC improved in hospitals. ●

●

●

The use of evidence-based practices increased (including infection prevention, cesarean section, and spinal anesthesia).

Respect for clients' rights improved (i.e., treating women with kindness, involving support persons, and providing privacy to clients).

Institutions adopted standardized techniques.

Policy was strengthened in four countries. ●

●

●

●

Global standards were adopted through the use of the World Health Organization (WHO) IMPAC guidelines: Managing Complications in Pregnancy and Childbirth.

A competency-based approach, with a standard curriculum, was used for EmONC training.

Midwives, obstetricians, and anesthetists learned mutual respect and made client-care decisions as a team, leading to an expanded role for midwives and anesthetists.

Other organizations, including UNFPA and UNICEF, recognized the investment made in forming training teams and

continued to support them as they trained other teams. This led to support by ministries of health and other donor organizations.

Opportunities expanded. ●

●

●

●

EmONC was identified as key strategy for maternal and neonatal mortality reduction in the target countries.

The use of evidence-based knowledge and skills led to the revision of the midwifery pre-service curriculum in at least two countries.

Other development partners seized the opportunity to support EmONC, leading to scale-up (e.g., the Twubkane Project in Rwanda).

The core EmONC teams have provided leadership in their countries for the expansion of these interventions.

Ideas in action "Teams" in training and service delivery were composed of obstetricians, midwives, and anesthetists.

Challenges and Lessons Learned in Francophone Africa The Burkina Faso team led all facets of the initiative, and the power of

South-to-South collaboration lent great credibility to these efforts.

The teams from each country faced resistance from senior obstetric and anesthesia colleagues about new interventions (e.g., spinal anesthesia for cesarean section), but persistent teamwork helped in overcoming this resistance.

Developing proficient providers who can act as champions of evidence-based interventions requires time and financial resources but can lead to success stories. For example: ●

The Rwandan core training team trained six other teams. With the support of in-country partners, each of these teams trained five other district hospital teams, and are rolling this training out to their attached health centers.

Providers at these twelve hospitals and at approximately 120 health centers in Rwanda will have the capacity to provide basic and comprehensive EmONC in areas where none formerly existed.

Case Studies: Nepal and Peru Postabortion Care: Situation in Nepal In the early 1990s: ●

●

●

●

Nepal had one of the world's highest maternal mortality rates - 539/100,000 live births. (FHD 1998) Of maternal mortality, 15% to 30% was attributed to complications of abortion.

Of hospital-based maternal deaths, 50% were attributed to complications of abortion. (Thapa, Thapa, and Shrestha 1992) All patients with abortion complications were treated with dilatation and curettage (D&C), which required hospital admission and was not linked to family planning services.

Objective Increase accessibility of postabortion care (PAC) services in referral hospitals to provide management of complications of incomplete, spontaneous, and septic abortion.

Source: Malla 1996 Glossary Term: Curettage Did you know?

Essential Elements of PAC Services Emergency treatment of incomplete abortion and potentially life-threatening complications Postabortion family planning counseling and services Links between emergency PAC services and other reproductive health care

Establishing PAC Services in Nepal The Maternity Hospital was selected as the initial site for establishing PAC services and training providers of PAC services.

The project was led by the Ministry of Health (MOH) with technical support from JHPIEGO, EngenderHealth, and Family Health International. The director of the Maternity Hospital provided essential leadership and commitment to the establishment of PAC services.

The project included: ●

●

●

●

●

●

●

Renovation of space to provide safety and privacy Procurement (primarily from hospital sources) of the essential supplies, equipment, and drugs Ensuring 24-hour staff coverage in the PAC unit Coordination and linkage with other hospital departments (e.g., the operating theater, the ob/gyn clinic, the outpatient family planning clinic, central sterile supply, pharmacy, medical records, and the clinical laboratory) Orientation of hospital staff to the establishment of a PAC unit Resolution of service delivery issues (e.g., patient flow, continuous supply of expendables, development of a fee-for-service system, a medical record system, and a referral system - between hospital departments) Training of teams of PAC service providers, including physicians, nurses, supervisors, and ward attendants

Source: Malla 1996 Did you know?

At the time of this intervention, the Maternity Hospital in Kathmandu was: ●

●

●

Conducting 16,000 deliveries annually Treating 1,400 women annually who were suffering from complications of abortion Performing sharp D&C under general anesthesia as 20% to 30% of the operating theater cases

Accomplishments and Results in Nepal By 2001: ●

●

●

●

●

Comprehensive PAC services were established in fifteen hospitals, both inside and outside Kathmandu valley.

PAC training centers were established in the Maternity Hospital and the Tribhuvan University Teaching Hospital.

PAC services were made more accessible to women. (Originally physicians were trained in PAC services and nurses were trained as assistants. In 1999, the MOH expanded PAC providers to include nurses.)

Physicians providing PAC services became more involved in the counseling and "total care" of patients.

PAC services were extended to a wide network of hospitals and district health centers across the country.

Sources: Rawlins, Brechin, and Giri 2001; Bhadra 2006

In 2006, more than 50 PAC sites were functioning across Nepal. (NFHP 2006) Ideas in action A study of health care provider provision of PAC services found that nurses were providing services just as competently as physicians.

Source: Rawlins, Brechin, and Giri 2001

Lessons Learned in the Establishment of PAC Services in Nepal ●

●

●

●

●

●

Commitment by the local MOH and hospital administration and staff is critical to establishment of PAC services.

Staff must play an active role from the planning stage onward.

Careful planning, policy work, and coordination are required.

The location of the PAC unit is important. It should be adjacent to the admitting area rather than deep within in-patient or outpatient facilities.

Family planning counseling and services following the manual vacuum aspiration (MVA) procedure are central to the mission of a PAC program.

Because husbands often accompany their wives to the hospital, they should be included in the decision-making process.

To provide safe services, recommended infection prevention practices must be consistently applied.

Source: Malla et al. 1996 Highlights Of patients treated in the PAC unit, 70% requested a contraceptive method.

Source: Malla et al. 1996

The Situation in Peru After the Civil War

Between 1980 and 1990, there was no state mechanism for governance, much less for health care.

The health care system was fragile nationally, but even more fragile in the poor mountainous Ayacucho region.

Most families were not able to recognize the need for medical care.

Few families in Ayachucho accessed health care services. ●

●

●

There was no access to transportation.

Facilities were inadequate (no equipment, supplies, or competent provider).

Services were not culturally appropriate. Cultural and emotional mistreatment by health center staff was one of main reasons women cited for not seeking emergency care.

Neither pre-service nor in-service medical education taught emergency obstetric care (EmOC).

Protocols for EmOC were for the hospital level only. No interventions were proposed at the health center level.

Source: Davenport 2007 Glossary Term: Emergency obstetric care (EmOC)

CARE's FEMME Project Interventions in Peru The Foundations to Enhance Management of Maternal Emergencies (FEMME), a CARE project that was part of the Averting Maternal Death and Disablity (AMDD) program, implemented the following interventions: ●

●

●

●

●

●

Maternal health advocacy work with policy makers and communities was conducted.

Communities were mobilized around issues of care seeking, transportation, etc.

Professors received updated skills training, and a system of peer teaching was established.

A multi-sectoral maternal mortality committee that included military, media, police, universities, and the Red Cross was established by the local Ministry of Health Directorate.

Health centers and hospitals were equipped and staff were trained in emergency obstetric care.

A regional referral/counter-referral system was established between health centers and the regional hospital.

Source: Davenport 2007 Ideas in action "Thanks to this training, we now know how to work as a team and involve the entire community," says midwife Maria Luz Gomez at the Tambo health center. "We know the importance of statistics and how to use them to evaluate our work. And we have the equipment and tools that we did not have before because of the managerial training we received from FEMME. We've done so well, the municpality is building us a new health center!"

Accomplishments and Results in Peru The FEMME project had an overall impact on the use of health services and improved rates of survival of women: ●

●

●

The "met need" doubled - The "met need" (percentage of women who needed emergency obstetric services and actually accessed those services) more than doubled, from 30% to 75%.

The "case fatality rate" diminished - In four years, the "case fatality rate" (the chances that a woman will die once she reaches the hospital) diminished significantly to less than 0.5%. The national case fatality rate was 2% and the case fatality rate in the comparison region, Puno, was 5.1% Maternal mortality decreased - Maternal deaths were reduced by half, twice the reduction in Puno, although the availability of equipment, supplies, and staff was similar.

Source: Davenport 2007 Did you know?

The United Nations standard criteria for case fatality rate is a maximum of 1%.

Ideas in action The multi-sector maternal mortality committee has been so successful in the Ayacucho region that it is being replicated throughout Peru.

Source: Davenport 2007

Lessons Learned in Peru Key factors that resulted in such significant improvements in Ayachucho, in contrast to the comparison region of Puno, were: ●

Effective tools - These tools included emergency obstetric guidelines and protocols based on World Health

â—?

â—?

â—?

Organization (WHO) recommendations that were made culturally appropriate for clients. Every two years, a mulidisciplinary committee will update these tools.

Effective systems and structures - The health system was approached as a social institution deeply connected to communities. Referral and communications systems between health centers and regional hospital were established.

Increased political will - Government response and commitment, in tandem with community mobilization, allowed enhanced local and regional engagement.

Improved staff capacities and attitudes toward women - Women and families trust the health care providers and seek their services.