Skip to main content

Table 3 Indicators, results and interpretations of EmONC indicators

From: Assessing emergency obstetric and newborn care: can performance indicators capture health system weaknesses?

 

Indicator

Descriptiona

Acceptable level

Results

Interpretations

1

Availability of emergency obstetric care: basic and comprehensive care facilities

The availability of EmONC services is measured by the number of facilities that perform the complete set of signal functions in relation to the size of the population. When staff has carried out the seven signal functions of basic EmONC in the 3-month period before the assessment, the facility is considered to be a fully functioning basic facility. The facility is classified as functioning at the comprehensive level when it offers the seven signal functions plus surgery (e.g. caesarean) and blood transfusion.

There are at least five emergency obstetric care facilities (including at least one comprehensive facility) for every 500 000 population

1 dispensary delivers 4 out of 6 (67%), 12 dispensaries deliver 3 or less out of 6 (≤50%) signal functions for BEmOCb; 3 health centres deliver 5 out of 7 (71%), 1 health centre delivers 2 out of 7 (29%) of the signal functions of BEmONC; the hospital delivers 7 out of 9 (78%) of the signal functions of comprehensive EmONC.

None of the health institutions in Magu District fulfilled the full package of expected level of EmONC

2

Geographical distribution of emergency obstetric care facilities

The geographical distribution of EmOC services is calculated in the same way as the first, but it takes into consideration the geographical distribution and accessibility of facilities. It can help program planners to gather information about equity in access to services at subnational level.

See above

The health centers and dispensaries are geographically equitably distributed over the district

The health centers and dispensaries are geographically equitably distributed over the district

3

Proportion of all births in emergency obstetric care facilities

The proportion of all births in an area that take place in EmOC health facilities (basic or comprehensive). The numerator is the number of women registered as having given birth in facilities classified as EmOC facilities. The denominator is an estimate of all the live births expected in the area, regardless of where the birth takes place.

At least 90% health facility births (Target based on Sharpened One Plan II)

Population 299,759; Crude Birth Rate (CBR) 39/1000; expected deliveries 11,690. Hospital births 2504 (21%); hospital + HCs 5035 (43%); all facilities 7635 (65%).

The majority of women give birth in facilities, which are expected to provide EmONC but remain underutilized by one third of the population.

4

Meeting the need for emergency obstetric care: proportion of women with major direct obstetric complications who are treated in such facilities

Met need’ is an estimate of the proportion of all women with major direct obstetric complications who are treated in a health facility providing EmOC (basic or comprehensive). The numerator is the sum of all women treated for direct obstetric complications at emergency care facilities over a defined period, divided by the expected number of women who would have major obstetric complications, or 15% of expected births, during the same period in a specified area. The direct obstetric complications included in this indicator are: hemorrhage (antepartum and postpartum), prolonged and obstructed labour, postpartum sepsis, complications of abortion, severe pre-eclampsia and eclampsia, ectopic pregnancy and ruptured uterus.

100% of women estimated to have major direct obstetric complications are treated in emergency obstetric care facilities

Registered direct obstetric complications: 196; Caesarean sections (CS): 192 (assumption that CSs are done to treat or prevent direct obstetric complications)

Expected number of direct obstetric complications: 11,690 × 0,15 = 1754

Met need = (192 + 196)/1754 × 100% = 22%

Health facilities are underutilized. 78% of women with complications are not seen in the facilities expected to provide EmONC services

5

Caesarean sections as a proportion of all births

The proportion of all deliveries by caesarean section in a geographical area is a measure of access to and use of a common obstetric intervention for averting maternal and neonatal deaths and for preventing complications such as obstetric fistula. The numerator is the number of caesarean sections performed in EmOC facilities for any indication during a specific period, and the denominator is the expected number of live births (in the whole catchment area, not just in institutions) during the same period.

The estimated proportion of births by caesarean section in the population is not less than 5% or more than 15%

All births: 11,690; Caesarean sections: 192. CS-percentage = 192/11,690 × 100% = 1.6% of all births

Hospital-based CS percentage: 192/2504 × 100% = 7.7%

Health facilities are underutilized; many women who should have needed a CS did not get one, as a result of poor accessibility

6

Direct obstetric case fatality rate (CFR)

The direct obstetric case fatality rate is the proportion of women admitted to an EmOC facility with major direct obstetric complications, or who develop such complications after admission, and die before discharge.

<1%

Direct obstetric complications: 196

Maternal deaths: 22 (18 in the district hospital, 4 in the community)

Direct obstetric CFR: 22/196 × 100% = 6%

Worries about quality of care in the facilities

7

Intrapartum and very early neonatal death rate

Indicator 7 is the proportion of births that result in a very early neonatal death or an intrapartum death (fresh stillbirth) in an EmOC facility. This new indicator has been proposed to shed light on the quality of intrapartum care for foetuses and newborns delivered at facilities. The numerator is the sum of intrapartum and very early neonatal deaths within the first 24 h of life occurring in the facility during a specific period. The denominator is the sum of all women who gave birth in the facility during the same period.

Standards to be determined

Fresh stillbirths (FSB) + very early neonatal deaths: 51

Hospital and health center births: 5035

Death rate: 51/5035 × 100% =1%

Low numbers of FSBs and early neonatal deaths are registered.

8

Proportion of maternal deaths due to indirect causes in emergency obstetric care facilities

The numerator of this indicator is all maternal deaths due to indirect causes in EmOC facilities during a specific period, and its denominator is all maternal deaths in the same facilities during the same period.

No standard can be set

Maternal deaths: 22; notification forms available: 16; maternal deaths classified: 15; indirect causes: 5

Proportion of indirect MD: 5/15 × 100% = 33%

Non-communicable diseases like malaria and HIV/AIDS are prevalent in the district, are important contributors to maternal mortality and are possibly inadequately prevented or treated during ANC.

  1. aFrom the handbook ‘Monitoring Emergency Obstetric Care’ developed by AMDD, WHO, UNFPA and UNICEF, [10]
  2. bSignal function 4 ‘Manual removal of placenta’ was not assessed; therefore dispensaries were assessed based on 6 signal functions