Basic Emergency Obstetric Care Facilities Research Articles

The Availability of Emergency Obstetric Care in Birthing Centres in Rural Nepal: A Cross-sectional Survey

The purpose of this health system's study is to assess the availability of Emergency Obstetric Care (EmOC) services in birthing centres in Taplejung District of eastern Nepal. A cross-sectional survey was conducted in 2018 in all 16 public health facilities providing delivery services in the district. Data collection comprised: (1) quantitative data collected from health workers; (2) observation of key items; and (3) record data extracted from the health facility register. Descriptive statistics were used to calculate readiness scores using unweighted averages. Although key health personnel were available, EmOC services at the health facilities assessed were below the minimum coverage level recommended by the World Health Organisation. Only the district hospital provided the nine signal functions of Comprehensive EmOC. The other fifteen had only partially functioning Basic EmOC facilities, as they did not provide all of the seven signal functions. The essential equipment for performing certain EmOC functions was either missing or not functional in these health facilities. The Ministry of Health and Population and the federal government need to ensure that the full range of signal functions are available for safe deliveries in partially functioning EmOC health facilities by addressing the issues related to training, equipment, medicine, commodities and policy.

Strengthening and monitoring health system's capacity to improve availability, utilization and quality of emergency obstetric care in northern Nigeria.

BackgroundQuality improvement in emergency obstetric care (EmOC) is a critical and cost-effective suite of interventions for the reduction of maternal and newborn mortality and morbidity. This study was undertaken to evaluate the impact of quality improvement interventions following a baseline assessment in Bauchi state, Nigeria.MethodsThis was a prospective before and after study between June 2012, and April 2015 in Bauchi State, Nigeria. The surveys included 21 hospitals designated by Ministry of Health (MoH) as comprehensive EmOC centers and 38 primary healthcare centers (PHCs) designated as basic EmOC centers. Data on EmOC services was collected using structured established EmOC tools developed by the Averting Maternal Death and Disability (AMDD), and analyzed using univariate and bivariate statistical analyses.ResultsFacilities providing seven or nine signal EmOC functions increased from 6 (10.2%) in 2012 to 21 (35.6%) in 2015. Basic EmOC facilities increased from 1 (2.6%) to 7 (18.4%) and comprehensive EmOC facilities rose from 3 (14.3%) to 13 (61.9%). Facility birth increased from 3.6% to 8.0%. Cesarean birth rates increased from 3.8% in 2012 to 5.6% in 2015. Met need for EmOC more than doubled from 3.3% in 2012 to 9.9% in 2015. Direct obstetric case fatality rates increased from 3.1% in 2012 to 4.0% in 2015. Major direct obstetric complications as a percent of total maternal deaths was 70.9%, down from 80.1% in 2012.ConclusionThe rise in the percent of facility-based births and in met need for EmOC suggest that interventions recommended and implemented after the baseline study resulted in increased availability, access and utilization of EmOC. Higher patient load, late arrival and better record keeping may explain the associated increase in case fatality rates.

Measuring the preparedness of health facilities to deliver emergency obstetric care in a South African district.

BackgroundImproving the delivery of emergency obstetric care (EmNOC) remains critical in addressing direct causes of maternal mortality. United Nations (UN) agencies have promoted standard methods for evaluating the availability of EmNOC facilities although modifications have been proposed by others. This study presents an assessment of the preparedness of public health facilities to provide EmNOC using these methods in one South African district with a persistently high maternal mortality ratio.MethodsData collection took place in the final quarter of 2014. Cross-sectional surveys were conducted to classify the 7 hospitals and 8 community health centres (CHCs) in the district as either basic EmNOC (BEmNOC) or comprehensive EmNOC (CEmNOC) facilities using UN EmNOC signal functions. The required density of EmNOC facilities was calculated using UN norms. We also assessed the availability of EmNOC personnel, resuscitation equipment, drugs, fluids, and protocols at each facility. The workload of skilled EmNOC providers at hospitals and CHCs was compared.ResultsAll 7 hospitals in the district were classified as CEmNOC facilities, but none of the 8 CHCs performed all required signal functions to be classified as BEmNOC facilities. UN norms indicated that 25 EmNOC facilities were required for the district population, 5 of which should be CEmNOCs. None of the facilities had 100% of items on the EmNOC checklists. Hospital midwives delivered an average of 36.4±14.3 deliveries each per month compared to only 7.9±3.2 for CHC midwives (p<0.001).ConclusionsThe analysis indicated a shortfall of EmNOC facilities in the district. Full EmNOC services were centralised to hospitals to assure patient safety even though national policy guidelines sanction more decentralisation to CHCs. Studies measuring EmNOC availability need to consider facility opening hours, capacity and staffing in addition to the demonstrated performance of signal functions.

The quality of free antenatal and delivery services in Northern Sierra Leone

BackgroundThe number of maternal deaths in sub-Saharan Africa continues to be overwhelmingly high. In West Africa, Sierra Leone leads the list, with the highest maternal mortality ratio. In 2010, financial barriers were removed as an incentive for more women to use available antenatal, delivery and postnatal services. Few published studies have examined the quality of free antenatal services and access to emergency obstetric care in Sierra Leone.MethodsA cross-sectional survey was conducted in 2014 in all 97 peripheral health facilities and three hospitals in Bombali District, Northern Region. One hundred antenatal care providers were interviewed, 276 observations were made and 486 pregnant women were interviewed. We assessed the adequacy of antenatal and delivery services provided using national standards. The distance was calculated between each facility providing delivery services and the nearest comprehensive emergency obstetric care (CEOC) facility, and the proportion of facilities in a chiefdom within 15 km of each CEOC facility was also calculated. A thematic map was developed to show inequities.ResultsThe quality of services was poor. Based on national standards, only 27% of women were examined, 2% were screened on their first antenatal visit and 47% received interventions as recommended. Although 94% of facilities provided delivery services, a minority had delivery rooms (40%), delivery kits (42%) or portable water (46%). Skilled attendants supervised 35% of deliveries, and in only 35% of these were processes adequately documented. None of the five basic emergency obstetric care facilities were fully compliant with national standards, and the central and northernmost parts of the district had the least access to comprehensive emergency obstetric care.ConclusionThe health sector needs to monitor the quality of antenatal interventions in addition to measuring coverage. The quality of delivery services is compromised by poor infrastructure, inadequate skilled staff, stock-outs of consumables, non-functional basic emergency obstetric care facilities, and geographic inequities in access to CEOC facilities. These findings suggest that the health sector needs to urgently investigate continuing inequities adversely influencing the uptake of these services, and explore more sustainable funding mechanisms. Without this, the country is unlikely to achieve its goal of reducing maternal deaths.

Application of “Capacity Cascade” as Novel Approach to Emergency Obstetric Care Readiness Assessment in Guatemala [38G

INTRODUCTION: Preventing maternal and neonatal morbidity and mortality in health care facilities depends heavily on the provision of emergency obstetric care (EmOC). A dominant framework for assessing EmOC capacity focuses on the presence of tracer items (e.g. antibiotics, MgSO4) for signal functions (e.g. sepsis treatment, management of preeclampsia). Our study aims to assess the feasibility of a novel capacity cascades framework to measure facility EmOC readiness and to compare it with the known signal function framework. METHODS: The capacity cascades framework is characterized by three stages of EmOC readiness: 1) identification of emergency, 2) treatment, 3) monitoring and modification of treatment. Retrospective facility inventory data were obtained from 36 Guatemalan basic EmOC facilities. Mapping of the capacity cascades and signal function framework variables was done using STATA12 for: hemorrhage, hypertensive emergency, retained placenta, sepsis. Proportion of facilities meeting criteria for readiness based on each cascade stage and signal function was calculated. RESULTS: For hemorrhage EmOC readiness, 75.0% of facilities met signal function criteria versus 97.2% capacity cascade stage 1; 75.0% stage 2; 33.3% stage 3. For hypertensive emergency, 86.1% versus 97.2%; 77.8%; 38.9%. For retained placenta, 75.0% versus 97.2%; 52.8%; 13.9%. For sepsis, 100% versus 100%; 75%; 33.3%. CONCLUSION: This study shows that capacity cascade framework is easy to apply and demonstrates a discrepancy from the signal function framework that suggests an overestimate of EmOC readiness by the latter. An early study in Kenya showed similar trends, demonstrating reproducibility. Further work needs to be done investigating association with clinical outcomes to determine clinical relevance.

Assessment of Emergency Obstetric Care Services in Ibadan-Ibarapa Health Zone, Oyo State, Nigeria.

Nigeria's high maternal mortality has been attributed to poor utilization of obstetric care services to handle complications of pregnancy and childbirth. But how available are standard emergency obstetric care services? This facility based cross sectional study assessed the availability and accessibility of emergency obstetric care services in Oyo State, Nigeria. Using a multi-stage sampling technique, 61 primary and 10 secondary health care facilities were selected. Data was collected using a structured questionnaire from the heads of the maternity units. Spatial mapping of the facilities was also produced. Results showed availability of comprehensive emergency obstetric care (CEmOC) facilities (0-3.9/500,000 population) was adequate, however a gross lack of basic emergency obstetric care (BEmOC) facilities (0-5.4/500,000 population) was observed, where available, they were clustered in the urban settlements. Prompt action needs to be taken to upgrade basic emergency obstetric care facilities accessible to the larger rural population dwellers to improve maternal health indices.

Skilled birth attendants in Tanzania: a descriptive study of cadres and emergency obstetric care signal functions performed.

Although most developing countries monitor the proportion of births attended by skilled birth attendants (SBA), they lack information on the availability and performance of emergency obstetric care (EmOC) signal functions by different cadres of health care providers (HCPs). The World Health Organisation signal functions are set of key interventions that targets direct obstetric causes of maternal deaths. Seven signal functions are required for health facilities providing basic EmOC and nine for facilities providing comprehensive EmOC. Our objectives were to describe cadres of HCPs who are considered SBAs in Tanzania, the EmOC signal functions they perform and challenges associated with performance of EmOC signal functions. We conducted a cross-sectional study of HCPs offering maternity care services at eight health facilities in Moshi Urban District in northern Tanzania. A questionnaire and health facility assessment forms were used to collect information from participants and health facilities. A total of 199 HCPs working at eight health facilities in Moshi Urban District met the inclusion criteria. Out of 199, 158 participated, giving a response rate of 79.4 %. Ten cadres of HCPs were identified as conducting deliveries regardless of the level of health facilities. Most of the participants (81 %) considered themselves SBAs, although some were not considered SBAs by the Ministry of Health and Social Welfare (MOHSW). Only two out of the eight facilities provided all of the required EmOC signal functions. While Assistant Medical Officers are expected to perform all the signal functions, only 38 % and 13 % had performed vacuum extraction or caesarean sections respectively. Very few registered and enrolled nurse-midwives had performed removal of retained products (22 %) or assisted vaginal delivery (24 and 11 %). Inadequate equipment and supplies, and lack of knowledge and skills in performing EmOC were two main challenges identified by health care providers in all the level of care. In the district, gaps existed between performance of EmOC signal functions by SBAs as expected by the MOHSW and the actual performance at health facilities. All basic EmOC facilities were not fully functional. Few health care providers performed all the basic EmOC signal functions. Competency-based in-service training of providers in EmOC and provision of enabling environment could improve performance of EmOC signal functions in the district.

The status of maternal and newborn care services in Sierra Leone 8 years after ceasefire

Objective To conduct a needs assessment for emergency obstetric care (EmOC) to address the unacceptably high maternal and newborn mortality indices in Sierra Leone 8 years after the end of the civil war. Methods From June to August 2008, a cross-sectional survey was conducted of health facilities in Sierra Leone offering delivery services. Assessment tools were local adaptations of tools developed by the Averting Maternal Death and Disability program at Columbia University, New York, USA. Results There were enough comprehensive EmOC (CEmOC) facilities in the country but they were poorly distributed. There were no basic EmOC (BEmOC) facilities. Few facilities (37% of hospitals and 2% of health centers) were able to perform assisted vaginal delivery (AVD), and 3 potentially BEmOC facilities did not meet the standard only because they did not perform AVD. Severe shortages in staff, equipment, and supplies, and unsatisfactory supply of utilities severely hampered the delivery of quality EmOC services. Demand for maternity and newborn services was low, which may have been related to the poor quality and the high/unpredictable out-of-pocket cost of such services. Conclusion Significant increases in the uptake of institutional delivery services, the linkage of remote health workers to the health system, and the recruitment of midwives, in addition to rapid expansion in the training of health workers (including training in midwifery and obstetric surgery skills), are urgently needed to improve the survival of mothers and newborns.

Availability and quality of emergency obstetric care in Shanxi Province, China

Objective To investigate the availability and quality of emergency obstetric care (EmOC) received by women in a rural Chinese province. Methods The study was conducted in 7 rural counties and townships in Shanxi Province, China. Data sources included interviews with 7 hospital leaders, 5 maternal and child health workers, and 7 obstetricians; 118 records of complicated delivery were audited, 21 Maternal and Child Health Annual Reports analyzed, and observations conducted of facilities and advanced labor care. Results The number of comprehensive EmOC facilities was adequate in all counties. Three counties had fewer basic EmOC facilities than recommended and only 4 counties reached the recommended level. Most of the existing township hospitals did not provide birthing services. All the county hospitals could perform cesarean deliveries with rates from 6.8%–40.8%. The management of complications was not evidence-based. For example, women with pre-eclampsia and eclampsia were given too little magnesium sulfate; women were not closely monitored for hemorrhage after birth and the partograph was used incorrectly with consequences for obstructed labor. Conclusion Basic EmOC facilities are not adequate and township hospitals should be upgraded to provide birthing services. The quality of EmOC is poor and needs improvement.

Availability, utilization and quality of normal delivery and emergency obstetric care in Eritrea

Objective: To determine the availability utilization and quality of delivery and emergency obstetric services in Eritrea. Methods: All of the 17 hospitals that provide maternity services 46 health centers and 41 randomly selected out of210 health stations in Eritrea were included in this study. Clients of the health facilities who attended the facilities on the day of the visit and birth attendants were interviewed and record cards were reviewed to assess the quality of care provided for normal and complicated deliveries. Findings: The assessment of the delivery and emergency obstetric services revealed gaps in availability quality and utilization of the services. Some of the quality gaps identified were poor monitoring of normal and complicated labor especially lack of use of the partograph. Conclusion: The availability of emergency obstetric care services in Eritrea could be doubled using the existing number of health facilities by upgrading the hospitals and the health centers to function as comprehensive and basic emergency obstetric care facilities respectively.

Skilled attendance: the key challenges to progress in achieving MDG-5 in north central Nigeria.

The importance of skilled attendance at delivery, as reflected in the MDG 5, is being promoted in developing countries to address the high maternal/perinatal morbidity and mortality. Evaluation of personnel skills and availability of material resources are central to elimination of barriers to delivery of basic Emergency Obstetric Care (EOC) to the community. We designed a semi-structured, interviewee-administered questionnaire for 54 certified Nurse-Midwives working in Primary Health Care (PHC) clinics in Nasarawa State, central Nigeria, and examined their knowledge and competencies in the five major areas responsible for maternal mortality in sub-Saharan Africa, including power supply, referral linkages and motivation to work. Majority 51 (94.4%) of PHCs neither used the Partograph nor performed manual vacuum aspiration. Referral systems and feedback mechanisms were practically non-existent, 38 (70.4%) of facilities were >5 km from the nearest referral centre, with 14 (29.5%) connected to the national grid. Majority (68.5%) of respondents would want to work abroad. The quality of skilled attendance is low and basic EOC facilities are lacking, a situation further threatened by potential emigration to greener pastures. Governments and development partners need to address facility and skilled manpower shortages in developing countries to make a modest attempt at meeting the MDG on maternal health.

Effect of audit and feedback on the availability, utilisation and quality of emergency obstetric care in three districts in Malawi

Facility-based maternal death reviews and criterion-based clinical audit, were introduced in three districts in Malawi in 2006. Can audit and feedback improve the availability, utilisation and quality of emergency obstetric care (EmOC)? Observational study in which emergency obstetric care offered to women who gave birth in 73 health facilities (13 hospitals and 60 health centres) in three districts in Malawi in 2005 (baseline, 41,637 women) was compared to 2006 (43,729 women) and 2007 (51,085 women). The number of comprehensive and basic EmOC facilities did not change over the 3-year period (p for trend=1.000). Although institutional delivery rate decreased in 2006, overall it increased over 3 years (p for trend<0.001) - 31.8% (2005), 31.1% (2006) and 34.7% (2007), and Caesarean section rate was low and did not change (p for trend=0.257) - 1.7% (2005), 1.6% (2006) and 1.5% (2007). There was a significant increase in the met need for EmOC (p for trend<0.001) - 15.2% for 2005, 17.0% for 2006 and 18.8% for 2007. Maternal mortality decreased significantly from 250 per 100,000 women in 2005 to 222 in 2006 and 182 in 2007 (p for trend<0.001). Similarly, the case fatality rate decreased monotonically (p for trend<0.001) - 3.7% (2005), 3.0% (2006) and 1.5% (2007). Audit and feedback can improve availability, utilisation and quality of emergency obstetric care in countries with limited resources. There is need to increase availability of emergency obstetric care by upgrading some health centres to EmOC level through training of staff and provision of equipment and supplies.

Availability, Utilisation and Quality of Basic and Comprehensive Emergency Obstetric Care Services in Malawi

To establish a baseline for the availability, utilisation and quality of maternal and neonatal health care services for monitoring and evaluation of a maternal and neonatal morbidity/mortality reduction programme in three districts in the Central Region of Malawi. Survey of all the 73 health facilities (13 hospitals and 60 health centres) that provide maternity services in the three districts (population, 2,812,183). There were 1.6 comprehensive emergency obstetric care (CEmOC) facilities per 500,000 population and 0.8 basic emergency obstetric care (BEmOC) facilities per 125,000 population. About 23% of deliveries were conducted in emergency obstetric care (EmOC) facilities and the met need for emergency obstetric complications was 20.7%. The case fatality rate for emergency obstetric complications treated in health facilities was 2.0%. Up to 86.7% of pregnant women attended antenatal clinic at least once and only 12.0% of them attend postnatal clinic at least once. There is a shortage of qualified staff and unequal distribution with more staff in hospitals leaving health centres severely understaffed. The total number of CEmOC facilities is adequate but the distribution is unequal, leaving some rural areas with poor access to CEmOC services. There are no functional BEmOC facilities in the three districts. In order to reduce maternal mortality in Malawi and countries with similar socio-economic profile, there is a need to upgrade some health facilities to at least BEmOC level by training staff and providing equipment and supplies.

Emergency obstetric care: How do we stand in Malawi?

ObjectiveTo assess the availability, accessibility, utilization, and quality of emergency obstetric care (EmOC) services in Malawi. MethodsA complete enumeration was made of all hospitals and a 25% random sample of all health centers, in all districts of Malawi. Enumerators (nurses and midwives) collected data by reviewing facility registers and records, observations, and interviews with health workers to determine extent of utilization of services. In-depth interviews and focus group discussions were also held with key informants to identify barriers to utilization of services and explore participants' perceptions of quality of care. ResultsAlmost twice the minimum number of recommended comprehensive EmOC facilities exist (1.8 facilities per 500000 population), but only 2% of the recommended number of basic EmOC facilities. Met need was only 18.5%; cesarean delivery rate was less than 3%. The case fatality rate was 3.4% indicating poor quality of care, attributable partly to absence of skilled birth attendants and motivated staff, and the frequent shortage of drugs and medical supplies. ConclusionMalawi needs to improve the provision of quality EmOC services by implementing evidence-based strategies for the reduction of maternal mortality. Consequently, the Malawi Road Map for accelerating improvement was developed through multidonor and multisector collaboration with the Reproductive Health Unit of the Ministry of Health. This Road Map is now being implemented in all districts of Malawi.

Emergency obstetric care in Punjab, Pakistan: Improvement needed

Introduction This paper describes an approach to maternal mortality reduction in Pakistan that uses UN emergency obstetric care (EmOC) process indicators to examine if public health care centres in Pakistan's Punjab province comply with minimum recommendations for basic and comprehensive services.Methods In a cross sectional study in September 2003, through random sampling at area and health-facility levels from 30% of districts in Punjab province (n = 11/34 districts), all public health facilities providing EmOC were included (n = 120). Facility data were used for analysis.Results No district in Punjab met the minimum standards laid down by the UN for providing EmOC services. The number of facilities providing basic and comprehensive EmOC services fell far short of recommended levels. Only 4.7% of women with complications attended hospitals. Caesarean section was carried out in only 0.4% of births. The case fatality rate was hard to accurately calculate due to poor record keeping and data quality.Conclusion The study may be taken as a baseline for developing and improving the standards of services in Punjab province. It is vital to upgrade existing basic EmOC facilities and to ensure that staff skills be improved, facilities be better equipped in critical areas, and record keeping be improved. Hence to reduce maternal mortality, facilities for EmOC must exist, be accessible, offer quality services, and be utilized by patients with complications.

Why are pregnant women dying? An equity analysis of maternal mortality in Malawi

Background: Malawi has one of the highest maternal mortality ratios (MMR) in the world at 1,120 per 100,000 live births. Maternal mortality is therefore a priority issue for the Ministry of Health. The Health Sector Wide Approach (SWAp) Equity and Access Subgroup commissioned a synthesis study to explore issues of access and equity relating to maternal mortality in Malawi and provide practical recommendations for SWAp implementation. Methods: The study undertook an equity analysis of existing national health databases and synthesised the available operational and academic research findings. Results: A number of strategies have been developed throughout the past decade to address maternal mortality in Malawi; however there has been a lack of effective implementation. Safe Motherhood interventions account for 46% of the total costs of the essential health package, with 47% of these spent on abortion complications. The expenditure, however, is not equitably distributed: Malawi has only 2% of the basic emergency obstetric care facilities that it requires, but nearly twice as many comprehensive obstetric care facilities, however only 20% of the population lives within 25km of the latter. Additionally, women face high direct and indirect costs in seeking services, even at government facilities which are free at the point of delivery. The total cost of seeking services is approximately 26 days worth of income for a rural woman; for the poorest quintile it can be as much as 50 days worth of income. Maternal mortality, when examined by wealth quintile, does not initially appear to be inequitable in Malawi. However reasons behind the deaths are different, with those in the upper quintiles being more related to complications of HIV and those in the lower quintiles related to lack of access to services. Levels of education and to a lesser degree, wealth have a strong correlation with skilled attendance during delivery. Conclusion: This study provides recommendations on how the current maternal mortality strategy may be implemented more equitably than past strategies therefore resulting in a lower MMR for all women, regardless of their location, poverty or educational status. Malawi Medical Journal Vol. 18 (1) 2006: pp. 32-38

Global patterns in availability of emergency obstetric care

Objective: This paper examines the availability of basic and comprehensive emergency obstetric care (EmOC), interventions used to treat direct obstetric complications. Determining what interventions are provided in health facilities is the first priority in analyzing a country's capabilities to treat obstetric emergencies. There are eight key interventions, six constitute basic EmOC and all eight comprehensive EmOC. Methods and results: Based on data from 24 needs assessments, the following global patterns emerge: comprehensive EmOC facilities are usually available to meet the recommended minimum number for the size of the population, basic EmOC facilities are consistently not available in sufficient numbers, both in countries with high and moderate levels of maternal mortality, and the majority of facilities offering maternity services provide only some interventions indicating an unrealized potential. Conclusion: Upgrading maternities, health centers and hospitals to at least basic EmOC status would be a major contributing step towards maternal mortality reduction in resource-poor countries.

Improvement of coverage and utilization of EmOC services in southwestern Bangladesh

Objective The Government of Bangladesh has implemented safe motherhood programs throughout the country supported by the United Nations Children's Fund (UNICEF) and United Nations Population Fund (UNFPA) aimed at reducing maternal morbidity and mortality. The objective of this study is to assess the effect of the interventions on the UN emergency obstetric care (EmOC) process indicators in Khulna division, Bangladesh. Methods Of the 71 government health facilities in Khulna division, 32 were providing comprehensive and 20 were providing basic EmOC services. Another 4 facilities were providing comprehensive or basic EmOC services during the first three-quarters but became non-functional during the last quarter. EmOC data, from January to December 2002, were collected from all these 56 facilities to determine the levels of EmOC process indicators relative to the UN guidelines and compared with baseline data from 1998 to 1999. Results There were 1.04 and 0.64 comprehensive and basic EmOC facilities respectively per 500,000 population. When compared with the baseline data, the coverage of comprehensive EmOC services was substantially increased from 0.23 to 1.04 per 500,000 population, which achieves the minimum UN standards but the coverage of basic EmOC services remained the same. The data also showed that, compared with the baseline survey, the proportion of births at the EmOC facilities increased 119% from 5.3% to 11.7% ( p < 0.001), met need increased 141% from 11.1% to 26.6% ( p < 0.001), and cesarean section as a proportion of all expected births, increased 151% from 0.5% to 1.3% ( p < 0.001), while the overall case fatality rate (CFR) decreased by 51% ( p < 0.001). Conclusion With the exception of coverage of basic EmOC after the interventions, there was significant improvement in all the EmOC process indicators in Khulna division. However, most of the process indicators are still far from the minimum recommended UN standards. Recommendations Efforts should continue to keep the EmOC facilities functional 24/7 while increasing the number of basic EmOC facilities, and improving utilization of services to reach the minimum UN standards. Community mobilization should be directed to understand the danger signs and utilization of services at functional facilities when necessary. Further research to identify the factors influencing utilization of EmOC services and continuous monitoring and periodical assessment of the process indicators are recommended to evaluate the overall situation from time to time.

Emergency obstetric care in Pakistan: Potential for reduced maternal mortality through improved basic EmOC facilities, services, and access

Objective: To ascertain and compare compliance with UN emergency obstetric care (EmOC) recommendations by public health care centers in Pakistan's Punjab and Northwest Frontier Province (NWFP) provinces. Method: Cross-sectional data were collected from July through September 2003 using UN process indicators. From each province, 30% of districts ( n = 19); were randomly selected; all public health facilities providing EmOC services ( n = 170) were included. Results: The study found that out of 170 facilities only 22 were providing basic and 37 comprehensive EmOC services in the areas studied. Only 5.7% of births occurred in EmOC health facilities. Met need was 9% and 0.5% of women gave birth by cesarean section. The case fatality rate was a low 0.7%, probably due to poor record keeping. Access and several indicators were better in NWFP than in Punjab. Conclusion: Almost all indicators were below UN recommendations. Health policy makers and planners must take immediate, appropriate measures at district and hospital levels to reduce maternal mortality.

Availability, distribution and use of emergency obstetric care in northern Tanzania

The objective of this study is to determine the availability, distribution and quality of facilities providing delivery services, as well as their use by pregnant women. The study is a survey of all facilities providing delivery services (n = 129) in six districts in northern Tanzania. The framework provided by the UNICEF/UNFPA/WHO (UN) Guidelines is applied. An attempt is made to answer the first three questions in this audit outline: are there enough emergency obstetric care (EmOC) facilities? Are they well distributed? And are enough women using them? The results show that there is a very low availability of basic emergency obstetric care (BEmOC) units (1.6/500,000), and a relatively high availability of comprehensive emergency obstetric care (CEmOC) units (4.6/500,000), both with large urban/rural variation. The percentage of expected deliveries in EmOC facilities is 36%, compared with the UN Guidelines minimum accepted threshold of 15%. Nevertheless, the distribution shows a much higher utilization in urban districts compared with rural, indicating that mothers have to travel long distances to receive adequate services when in need of them. The paper also discusses the provisional context of the services in terms of level of facilities providing them and their public/private mix. Most facility deliveries are conducted at CEmOC facilities. Pregnant women tend to utilize the services of voluntary agencies to a greater degree than government services in rural areas, while the government services have a higher burden of the workload in urban areas. A majority (86%) of the deliveries occurring in voluntary agency facilities occur in a qualified EmOC facility. Against a backdrop of a large availability of any facility regardless of their emergency obstetric care status (41.9/500,000), this paper argues that given the large number of potential BEmOC facilities, it seems more efficient to shift resources within the BEmOC level, compared with from CEmOC level down to BEmOC level, to improve access to quality services. There is a large potential for quality improvement, in particular at dispensary and health centre levels. We argue that the main barrier to access to quality care is not the mother's ignorance or their ability to get to a facility, but the actual quality of care meeting them at the facility.