Basic Essential Obstetric Care Research Articles

Quality indicators of public maternity units in the governorate of Monastir (Tunisia)

IntroductionIncreasing access to healthcare for expectant mothers is a national goal. In Monastir, Tunisia, some Peripheral Maternity Units (PMUs) required assessment. Our goals were to describe the delivery activities in MUs (maternity units) and to assess whether some of PMUs need to have their activities replaced.MethodWe analyzed aggregate data of deliveries in Monastir from 2015 to 2020. The gouvernorate’s seven public MUs were included. Only the morning activity was allotted for obstetricians and gynecologists, in RMUs 1 and 2, whereas they were not available in all PMUs. Data was gathered from the reports of the National Perinatal Program. Both the availability of Comprehensive Essential Obstetric Care (CEOC) and Basic Essential Obstetric Care (BEOC) were calculated. Trends were calculated using Joinpoint software. The Annual Percent Change (APC) was calculated.ResultsThe number of births decreased from 2015 to 2020 (APC= -4.3%: 95%CI : -6; -2.4; p = 0.003). The largest significant decreases in APCs of deliveries were reported in PMU 2 (APC = -12.6% (95%CI : -20; -4.4; p = 0.014), in PMU 3 (APC = -29.3% (95%CI : -36.5; -21.4; p = 0.001), and in PMU 4 (APC = -32.9% (95%CI: -49.1; -11.5); p = 0.016). If PMU 3 and 4 were no longer operating as maternity facilities, BEOC and CEOC standards would still be adequat. For accessibility, both PMU 3 and PMU 2 are accessible from PMU 4 and PMU 1, respectively.ConclusionsPregnant women prefer to give birth in obstetric services with ability to perform emergency caesarean at the expense of PMU. Nowadays, it appears that accessibility is less important than the presence of qualified human resources when a pregnant woman choose a maternity hospital.

Utilization of Basic Essential Obstetric Care Services Among Bajun Women Attending Post Natal Clinic in Faza Division, Lamu County, Kenya

Purpose: The objective of the study was to establish the level of utilization of obstetric care services; to establish factors promoting utilization of obstetric care services, and to identify factors hindering utilization of essential obstetric care services among Bajun women in the Faza Division.Methodology: The study was cross-sectional. Purposive and systematic sampling was used in getting participants. The research instruments to be used were self-administered semi-structured questionnaires and Focused Group Discussions (FGDs). Chi-square values were used to test the significance of the association between the dependent and independent variables. Qualitative data from FGDs were transcribed and analyzed by the thematic content analysis technique.Results: More than half of the respondents (95.6% (175)) indicated that obstetric services are important essential services while 4.4% (8) of them indicated that obstetric services are not important essential services. More than half of the respondents, (74.4% (131)) indicated that they have ever been provided with these services while 25.6% (45) of them indicated that they have never been provided with these services. The findings also indicate that there was an insignificant association (x2 = 2.135a, p = 0.711) between age of the respondents, the level of education (x2 = 0.258, p = 0.612) and (X2 = 1.144a, P = 0.887) between religion of the respondents and the utilization of essential obstetric care services. There is thus, a high probability of utilization of essential obstetric care services (1.049, 2.045, 1.219 and 1.051 times respectively) for those women who have received the information about obstetric services from mass media, the health care, parents and their teachers respectively compared to those who received information from their peers. For the women who were pregnant, the findings indicate a low probability of the utilization of essential obstetric care services for the women who sought pregnancy help from their doctors and nurses/wives (0.357 and 0.102 times respectively). There is also a high probability of utilization of essential obstetric care services for those women who have ever been pregnant, those who have ever had complications during pregnancy, labour & delivery, those who seek help during their pregnancy complications and those who seek help from the hospital during their pregnancy complications.Unique contributions to theory, policy and practice: Therefore, the study recommends the intensification of knowledge to the women in Faza Division, Lamu County about the importance of utilization of essential obstetric services. This will help to reduce the cases of complications affecting mothers during pregnancy, labour and delivery and thus reduce the infant as well as the maternal mortality rate in the County.

Availability and Continuity of Care for Maternal Health Services in the Primary Health Centres in Nnewi, Nigeria (January - March 2010).

Background:In some primary health care settings, even where the health services are not available, provisions are not made to ensure continuity of care. This study aimed to determine the availability and level of continuity of care for maternal health services in the primary health centers (PHCs) in Nnewi, Nigeria.Methods:This was a cross-sectional survey. Using multistage sampling technique, 280 women utilizing maternal health services from four randomly selected public PHCs in Nnewi, Nigeria were chosen for the study. Data collection employed a mix of quantitative and qualitative methods.Results:The mean ± standard deviation for age of the respondents was 29.2 ± 5.9 years. The facilities studied provided out-patient services, but the only in-patient services provided was for women who delivered or those in labor. None of the facilities is equipped to provide even basic essential obstetric care services. None had standardized a protocol for referring clients, referral forms, a transport system, or a community loan scheme in place. Forty-four (15.7%) women were referred for care outside of the PHCs for the following reasons: Lack of drugs and supplies (9.1%); lack of equipment (90.9%), lack of skilled personnel (45.5%) among others.Conclusions:This study showed that despite the unavailability of some services, appropriate strategies were not in place to ensure the coherent pattern of services within and between the PHCs and other levels of care. Delivery to the clients of comprehensive and integrated maternal health services, and efficient referral systems are thus recommended.

Midwifery and Midwives Service Scheme: A Panacea for Improvement of Some Maternal and Neonatal Indices in Nigeria—A Brief Review

Introduction: Midwifery is the art of caring for women during childbearing. It is practiced throughout the world according to the norms, traditions and cultural practices found in each country. Maternal mortality in Nigeria is high but there are wide variations between the geopolitical zones of the country. Government has established the midwives service scheme (MSS) as part of efforts towards reversing the country’s unacceptably high maternal mortality trends. To improve these indices, the MSS in Nigeria engaged newly graduated unemployed and retired midwives to work temporarily in rural areas. The midwives are posted for twelve months to selected primary care facilities linked through a cluster model in which four such facilities with the capacity to provide basic essential obstetric care are clustered around a secondary care facility with the capacity to provide comprehensive emergency obstetric care. This brief review is an attempt at exploring the impact of the midwives service scheme on maternal and neonatal indices in Nigeria. Main content: The outcome of the MSS four years has been an improvement though unevenly and marginally, in these indices in the various geopolitical zones of Nigeria. Improvements have been noticed in maternal indices such as antenatal care attendance, women receiving two doses of tetanus toxoid and number of deliveries by skilled personnel. Also reduction in maternal and neonatal mortality has been observed over the years following introduction of the scheme. Major challenges however, include lack of essential drugs, poor accommodation facilities for MSS staff, irregular payment of their remuneration and lack of water/power supply to some designated facilities for the scheme. Recommendations and conclusions: It is therefore recommended that 24 hours availability of essential drugs at primary healthcare centers be maintained. This should happen in conjunction with regular payment of full entitlements and benefits and provision of secured, habitable and good accommodation for MSS staff. Finally, aggressive community mobilization should continue in order to engender community involvement and participation for sustainable program development.

Assessment of Essential Obstetric Care Services in Health Care Facilities in Benin City, Edo State

Background: In Africa healthcare service delivery is a huge challenge. This is compounded by inadequate health care facilities, poor distribution and citing of health care facilities, lack of equipments and drugs to mention a few. This study was conducted to assess the level of health care facility preparedness to render basic and comprehensive essential obstetric care services to pregnant women, with view to encourage health facility deliveries and care. Methodology: A descriptive cross sectional study design was conducted involving 114 selected Health facilities using a health facility audit tool adapted from JHPIEGO safe mother hood questionnaire. The data collected was analyzed using SPSS 16.0 statistical software with statistical significance set at p<0.05. Results: One hundred and fourteen health care facilities were assessed, comprising 36(31.6%) public and 78(68.2%) private health care facilities. Eighty eight (77.2%) of these health care facilities were well prepared, 14(12.3%), partially prepared and 12(10.5%) not prepared respectively for basic essential obstetric services while 88 (70.2%) well prepared, 30 (26.3%) partially prepared and 4(3.5%) not prepared respectively to render comprehensive essential obstetric care services. Private owned health care facilities compared to public health care facilities were significantly better prepared to render both basic essential obstetric care and comprehensive obstetric care (OR=0.111; p=0.002 and OR=0.082; p=0.01 respectively), with availability of skilled staff identified a significant predictor for basic (OR=0.042; p=0.0001) and comprehensive essential obstetric care (OR=0.015; p=0.001) respectively. Conclusion: Majority of health care facilities studied were well prepared to render essential obstetric care services but a lot more needs to be done to improve these services at the public health care facility level especially in relation to twenty four hour coverage and skilled man power needed to help improve maternal health outcome.

The midwives service scheme in Nigeria.

Maternal, newborn, and child health indices in Nigeria vary widely across geopolitical zones and between urban and rural areas, mostly due to variations in the availability of skilled attendance at birth. To improve these indices, the Midwives Service Scheme (MSS) in Nigeria engaged newly graduated, unemployed, and retired midwives to work temporarily in rural areas. The midwives are posted for 1 year to selected primary care facilities linked through a cluster model in which four such facilities with the capacity to provide basic essential obstetric care are clustered around a secondary care facility with the capacity to provide comprehensive emergency obstetric care. The outcome of the MSS 1 year on has been an uneven improvement in maternal, newborn, and child health indices in the six geopolitical zones of Nigeria. Major challenges include retention, availability and training of midwives, and varying levels of commitment from state and local governments across the country, and despite the availability of skilled birth attendants at MSS facilities, women still deliver at home in some parts of the country.

A Safe Motherhood project in Kenya: assessment of antenatal attendance, service provision and implications for PMTCT

To investigate uptake and provision of antenatal care (ANC) services in the Uzazi Bora project: a demonstration-intervention project for Safe Motherhood and prevention of mother-to-child transmission of HIV in Kenya. Data were extracted from antenatal clinic, laboratory and maternity ward registers of all pregnant women attending ANC from January 2004 until September 2006 at three antenatal clinics in Mombasa and two in rural Kwale district of Coast Province, Kenya (n = 25 364). Multiple logistic and proportional odds logistic regression analyses assessed changes over time, and determinants of the frequency and timing of ANC visits, uptake of HIV testing, and provision of iron sulphate, folate and single-dose nevirapine (sd-NVP). About half of women in rural and urban settings (52.2% and 49.2%, respectively) attended antenatal clinics only once. Lower parity, urban setting, older age and having received iron sulphate and folate supplements during the first ANC visit were independent predictors of more frequent visits. The first ANC visit occurred after 28 weeks of pregnancy for 30% (5894/19 432) of women. By mid-2006, provision of nevirapine to HIV-positive women had increased from 32.5% and 11.7% in rural and urban clinics, to 67.0% and 74.6%, respectively. Equally marked improvements were observed in the uptake of HIV testing and the provision of iron sulphate and folate. Provision of ANC services, including sd-NVP, increased markedly over time. While further improvements in quality are necessary, particular attention is needed to implement evidence-based interventions to alter ANC utilization patterns. Encouragingly, improved provision of basic essential obstetric care may increase attendance.

Quality of Obstetric Care in Public-sector Facilities and Constraints to Implementing Emergency Obstetric Care Services: Evidence from High- and Low-performing Districts of Bangladesh

This study explored the quality of obstetric care in public-sector facilities and the constraints to programming comprehensive essential obstetric care (EOC) services in rural areas of Khulna and Sylhet divisions, relatively high- and low-performing areas of Bangladesh respectively. Quality was explored by physically inspecting all public-sector EOC facilities and the constraints through in-depth interviews with public-sector programme managers and service providers. Distribution of the functional EOC facilities satisfied the United Nation's minimum criteria of at least one comprehensive EOC and four basic EOC facilities for every 500,000 people in Khulna but not in Sylhet region. Human-resource constraints were the major barrier for maternal health. Sanctioned posts for nurses were inadequate in rural areas of both the divisions; however, deployment and retention of trained human resources were more problematic in rural areas of Sylhet. Other problems also plagued care, including unavailability of blood in rural settings and lack of use of evidence-based techniques. The overall quality of care was better in the EOC facilities of Khulna division than in Sylhet. 'Context' of care was also different in these two areas: the population in Sylhet is less literate, more conservative, and faces more geographical and sociocultural barriers in accessing services. As a consequence of both care delivered and the context, more normal vaginal and caesarian-section deliveries were carried out in the public-sector EOC facilities in the Khulna region, with the exception of the medical college hospitals. To improve maternal healthcare, there is a need for a human-resource plan that increases the number of posts in rural areas and ensures availability. All categories of maternal healthcare providers also need training on evidence-based techniques. While the centralized push system of management has its strengths, special strategies for improving the response in the low-performing areas is urgently warranted.

Public-sector Maternal Health Programmes and Services for Rural Bangladesh

Achieving Millennium Development Goal 5 in Bangladesh calls for an appreciation of the evolution of maternal healthcare within the national health system to date plus a projection of future needs. This paper assesses the development of maternal health services and policies by reviewing policy and strategy documents since the independence in 1971, with primary focus on rural areas where three-fourths of the total population of Bangladesh reside. Projections of need for facilities and human resources are based on the recommended standards of the World Health Organization (WHO) in 1996 and 2005. Although maternal healthcare services are delivered from for-profit and not-for-profit (NGO) subsectors, this paper is focused on maternal healthcare delivery by public subsector. Maternal healthcare services in the public sector of Bangladesh have been guided by global policies (e.g., Health for All by the Year 2000), national policies (e.g., population and health policy), and plans (e.g., five- or three-yearly). The Ministry of Health and Family Welfare (MoHFW), through its two wings-Health Services and Family Planning-sets policies, develops implementation plans, and provides rural public-health services. Since 1971, the health infrastructure has developed though not in a uniform pattern and despite policy shifts over time. Under the Family Planning wing of the MoHFW, the number of Maternal and Child Welfare Centres has not increased but new services, such as caesarean-section surgery, have been integrated. The Health Services wing of the MoHFW has ensured that all district-level public-health facilities, e.g., district hospitals and medical colleges, can provide comprehensive essential obstetric care (EOC) and have targeted to upgrade 132 of 407 rural Upazila Health Complexes to also provide such services. In 2001, they initiated a programme to train the Government's community workers (Family Welfare Assistants and Female Health Assistants) to provide skilled birthing care in the home. However, these plans have been too meagre, and their implementation is too weak to fulfill expectations in terms of the MDG 5 indicator-increased use of skilled birth attendants, especially for poor rural women. The use of skilled birth attendants, institutional deliveries, and use of caesarean section remain low and are increasing only slowly. All these indicators are substantially lower for those in the lower three socioeconomic quintiles. A wide variation exists in the availability of comprehensive EOC facilities in the public sector among the six divisions of the country. Rajshahi division has more facilities than the WHO 1996 standard (1 comprehensive EOC for 500,000 people) whereas Chittagong and Sylhet divisions have only 64% of their need for comprehensive EOC facilities. The WHO 2005 recommendation (1 comprehensive EOC for 3500 births) suggests that there is a need for nearly five times the existing national number of comprehensive EOC facilities. Based on the WHO standard 2005, it is estimated that 9% of existing doctors and 40% of nurses/midwives were needed just for maternal healthcare in both comprehensive EOC and basic EOC facilities in 2007. While the inability to train and retain skilled professionals in rural areas is the major problem in implementation, the bifurcation of the MoHFW (Health Services and Family Planning wings) has led to duplication in management and staff for service-delivery, inefficiencies as a result of these duplications, and difficulties of coordination at all levels. The Government of Bangladesh needs to functionally integrate the Health Services and Family Planning wings, move towards a facility-based approach to delivery, ensure access to key maternal health services for women in the lower socioeconomic quintiles, consider infrastructure development based on the estimation of facilities using the WHO 1996 recommendation, and undertake a human resource-development plan based on the WHO 2005 recommendation.

Critical care management of eclamptics: challenges in an African setting

We conducted a retrospective study of the management and outcome for eclampsia patients in the intensive care unit (ICU) of National hospital, Abuja between November 2001 and April 2005 (42 months). The patients' case files and ICU records were used to extract the necessary data. During the study period, there were a total of 4857 deliveries, with 5051 total births (including multiple births) and 4854 live births. Forty eclamptics were admitted to the ICU, giving an ICU admission rate of 8.2/1000 live births. The records of two patients were incomplete. The average age of the patients was 28.4 years (range 17-4 years). Six patients (15.8%) were booked and 32 (84.2%) were not. The average duration of stay in ICU was 5 days. Twenty patients (52.6%) had antepartum eclampsia, 12 (31.6%) had postpartum eclampsia and six (15.8%) presented with intrapartum eclampsia. Twenty-nine (76.3%) gave birth via caesarean section and nine (23.7%) delivered per vagina augmented by oxytocin infusion. Seventeen (45%) received mechanical ventilation; 20 (53%) received oxygen via nasal prongs, nasal catheters or variable performance facemask. One patient (2%) did not receive oxygen therapy. All the patients were admitted postpartum. There were 11 maternal deaths, giving a case fatality rate of 29%. There were five (45.4%) deaths due to haemolysis, elevated liver enzymes and low platelet count syndrome and two (18.2%) due to disseminated intravascular coagulation. The remaining deaths were due to cerebrovascular accident (9.1%), lobar pneumonia (9.1%), acute renal failure (9.1%) and multiple organ failure (9.1%). All patients were admitted postpartum. This fatality rate is higher than that detailed in the reports reviewed in this study. Early referral of eclamptics or at risk patients to a tertiary care institution may help reduce morbidity and mortality. In addition, early referral to a facility providing basic essential obstetric care or comprehensive essential obstetric care is also important. Another important factor is the correct diagnosis of pre-eclampsia during antenatal and postpartum care by screening, noting blood pressure levels, performing urinalysis for protein and asking about warning signs such as headache, blurred vision, epigastric pain, etc.

Unavailability of essential obstetric care services in a local government area of south-west Nigeria.

This paper reports the findings at baseline in a multi-phase project that aimed at reducing maternal mortality in a local government area (LGA) of South-West Nigeria. The objectives were to determine the availability of essential obstetric care (EOC) services in the LGA and to assess the quality of existing services. The first phase of this interventional study, which is the focus of this paper, consisted of a baseline health facility and needs assessment survey using instruments adapted from the United Nations guidelines. Twenty-one of 26 health facilities surveyed were public facilities, and five were privately owned. None of the facilities met the criteria for a basic EOC facility, while only one private facility met the criteria for a comprehensive EOC facility. Three facilities employed a nurse and/or a midwife, while unskilled health attendants manned 46% of the facilities. No health worker in the LGA had ever been trained in lifesaving skills. There was a widespread lack of basic EOC equipment and supplies. The study concluded that there were major deficiencies in the supply side of obstetric care services in the LGA, and EOC was almost non-existent. This result has implications for interventions for the reduction of maternal mortality in the LGA and in Nigeria.

Risk factors for obstetric fistulae in north-eastern Nigeria

SummaryThis prospective comparative study of obstetric fistulae (OF) was aimed at identifying risk factors. A total of 80 obstetric fistulae treated at the gynaecological unit of the FMCG, and 80 inpatients without fistulae recruited randomly as controls formed the basis of this study. Through interview and case record review, information on age, parity and marital status was collected. Other features were educational status, occupation and booking status of the pregnancy that might have led to this condition. The duration of labour, place of birth and mode of delivery, including its outcome were also collected. The data were analysed using the Epi Info. The majority of the patients were Hausa/Fulani 87.5%, Muslims 91.2%, with large vesicovaginal fistulae (average size 5.0 cm) mainly resulting from obstructed labour (93.7%). Major risk factors included early age at first marriage (average 14 years), short stature (average height 146.2 cm) and illiteracy (96.3%). Also low social class and lack of gainful employment were factors. Failure to book for antenatal care (93.7%), and rural place of residence (95%) were also factors associated with acquiring the fistulae. Living far away (>3 km) from a health facility also contributed or predisposed to the development of an obstetric fistula. Social violence and stigma associated with the fistulae included divorce, being ostracised as a social outcast, and lack of assistance from relations in terms of finding and funding treatment. This study supports improved access to basic essential obstetric care, family planning services, and timely referral when and where necessary. Universal education will provide a long-term solution by improving the standard of living and quality of life. Especially important are media- and community-based programmes on the ills of teenage marriage and child pregnancy using cultural and religiously-based values to give sound advice. In a male dominated society, reaching out to men with traditionally palatable messages that will change their attitude and practices to taking responsibility in reproductive health could be a winning strategy.

Roundtable: Making Pregnancy Safer in Myanmar: Introducing Misoprostol to Prevent Post-Partum Haemorrhage as Part of Active Management of the Third Stage of Labour

In Myanmar we carried out a successful pilot intervention with the prostaglandin misoprostol in the active management of the third stage of labour for prevention of post-partum haemorrhage. The pilot aimed to appraise the operational feasibility efficiency impact and cost-effectiveness of the intervention at family and community level and focused on a number of managerial and logistics issues in relation to scaling-up the intervention nationally and within the public sector where it proved to be successful. Myanmar is the largest country in mainland Southeast Asia geographically with over 70% of its population in rural areas. Over 60% of the population (55.4 million in December 2006) consists of mothers and children who are the most vulnerable group. Administratively there are 14 states and divisions which are sub-divided into 66 districts 325 townships and so on down to 65148 villages. Maternity care is equally spread across the whole country in both urban and rural areas but thereis still an under-served group in very remote hard-to-reach areas though their numbers are not very large. The number of facilities with functioning basic essential obstetric care in 2005 was eight per 500000 population and that of comprehensive essential obstetric care was four per 500000 population. (excerpt)

The contribution of privately owned hospitals in the provision of essential obstetric care in Nigeria.

To highlight the private sector contribution in the provision of essential obstetric care in Abia State, Southeastern Nigeria. Following two workshops a structured questionnaire was used to seek information on the type of facility, ownership, type of services, number of staff, instruments and medical consumables, deliveries and data on clients attended to in the previous twelve months. On the basis of the response the facilities were classified into not essential obstetric care, basic essential obstetric care and comprehensive essential obstetric care. Of 638 facilities visited only 378 offered antenatal and postnatal services. The 13 government hospitals and 173 primary health centers conducted 5601 deliveries. The 146 private hospitals/clinics and 46 maternity homes conducted 21,128 deliveries. Only 121 offered essential obstetric services: 42 basic with 2488 deliveries and 79 comprehensive with 14,489 deliveries. Of the basic essential obstetric facilities that were private, 84.6% were concentrated in the 6 urban local government areas (LGA) leaving 15.4% in the 11 rural LGA. Similarly 85.6% of the comprehensive essential obstetric facilities that were private are concentrated in the 6 urban LGA leaving 14.4% scattered in the 11 rural LGA CONCLUSION: The private sector, with its greater essential obstetric facilities, is concentrated mainly in the 6 urban LGA. This resulted in 14,970 deliveries as against 2007 deliveries in the government facilities. Although there is an apparent neglect of the other 11 LGA, the deliveries in the private facilities constituted over 79% within the study period. This greater contribution should be noted and considered when planning maternal and infant mortality and morbidity reforms in Nigeria.

Role of the private sector in the provision of rssential obstetric care in Abia

Objective: To examine the role of the private sector in the provision of essential obstetric care in Abia State, Southeastern Nigeria. Method: A structured questionnaire following two workshops was used to seek information on the type of facility, ownership, type of services, number of staff, instruments and medical consumables, and data on clients attended to in the previous twelve months. On the basis of the response the facilities were classified into not essential obstetric care, basic essential obstetric care and comprehensive essential obstetric care.Results: There were 638 facilities visited and only 378 offered antenatal and postnatal services. These were 13 government hospitals, 173 primary health centers 146 private hospitals/clinics and 46 private maternity homes. Broadly 186 were government and 192 were privately owned. 121 offered essential obstetric services: 42 basic and 79 comprehensive. Of the basic essential obstetric facilities that were private, 84.6% were concentrated in the 6 urban local government areas (LGA) leaving 15.4% in the 11 rural LGA. Similarly 85.6% of the comprehensive essential obstetric facilities that were private are concentrated in the 6urban LGA leaving 14.4% scattered in the 11 rural LGA.Conclusion: The private sector has greater essential obstetric facilities, but these are concentrated mainly in the 6 urban LGA to the neglect of the other 11 LGA. With vision and goodwill, it should be possible to evenly distribute/have all government and private essential obstetric services into an efficient team in the interests of the pregnant women whose welfare they all seek to serve. One way by which the government can do this is to advance a lucrative rural insurance scheme, which will attract the private sector to the majority rural dwellers.Tropical Journal of Obstetrics and Gynaecology Vol. 22(2) 2005: 152-155

Process indicators for safe motherhood programmes: their application and implications as derived from hospital data in Nepal.

Measuring maternal mortality ratios is fraught with problems and underestimates. Therefore process indicators have been proposed for monitoring the availability and use of obstetrics services. We report the results of process indicators for measuring the availability, use and quality of obstetric care in five districts in Nepal between 1997 and 1998. The number of comprehensive essential obstetric care (EOC) facilities was adequate for four of the five districts, but none had a minimum acceptable level of basic EOC facilities as set by UNICEF et al. The proportion of expected births in hospital was 21.5% in Rupandehi and < 5% in Baglung, Kailali, Okhaldunga and Surkhet. The minimum acceptable level is 15%. The 'met need' for obstetric care which pertains to the proportion of all women with direct obstetric complications that are treated in hospital was 14.9% in Rupandehi and < 5% in the other four districts, against the required minimum of 15%. The caesarean section rate calculated of all expected births in the population varied between 0.2% and 1.4%. The case fatality rate was 4.0% in Rupandehi Zonal Hospital. Analysis of these indicators clearly identified tremendous underuse of maternity services which has stimulated national policy discussions in Nepal with ensuing safe motherhood interventions and monitoring strategies.