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Program note

2002; Elsevier BV; Volume: 78; Issue: 3 Linguagem: Português

10.1016/s0020-7292(02)00190-x

1879-3479

Global Maternal and Child Health

International Journal of Gynecology & ObstetricsVolume 78, Issue 3 p. 275-282 Averting maternal death and disabilityFree Access Program note Using UN process indicators to assess needs in emergency obstetric services: Pakistan, Peru and Vietnam AMDD Working Group on Indicators, AMDD Working Group on Indicators pbailey@fhi.org Search for more papers by this author AMDD Working Group on Indicators, AMDD Working Group on Indicators pbailey@fhi.org Search for more papers by this author First published: 09 October 2002 https://doi.org/10.1016/S0020-7292(02)00190-XCitations: 18 Corresponding author. P.E. Bailey, Family Health International, Research Triangle Park, NC 27709, USA. Tel.: +1-919-544-7040; fax: +1-919-544-7261 AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat This is the third Program note in a series that features the UN process indicators for monitoring obstetric services [1,2]. Issued by UNICEF, WHO and UNFPA, they are used to identify the availability, use, and, to some extent, quality of emergency obstetric care (EmOC) [3]. They are also useful at monitoring changes in these three important aspects of health care. The definitions are summarized in Table 1 and recommended levels can be found in the results tables. Table 1. Definitions Process indicator Definition Availability of EmOC Number of facilities that provide EmOC per 500 000 population Proportion of all births in Proportion of all births in EmOC facilities EmOC facilities Met need Proportion of women with obstetric complications treated at EmOC facilities Cesarean deliveries as a Cesarean deliveries as a proportion of all births proportion of all births Case fatality rate Proportion of women with obstetric complications admitted to a facility who die The UN indicators developed from an understanding that certain medical services or procedures are necessary to save the lives of women with obstetric complications. These procedures or 'signal functions' distinguish facilities that provide basic or comprehensive emergency obstetric care from those that do not. If a facility has provided the first six functions in the past 3 months, it provides basic EmOC and if it has provided all eight of the functions, it qualifies as comprehensive: – parenteral antibiotics; – parenteral oxytocic drugs; – parenteral anticonvulsants for pregnancy-induced-hypertension; – manual removal of placenta; – removal of retained products (e.g. vacuum aspiration); – assisted vaginal delivery (e.g. vacuum extraction, forceps); – surgery (e.g. cesarean delivery); and – blood transfusion. The following brief reports present the data from the Needs Assessments in Pakistan, Peru and Vietnam undertaken in 2000. Each case reflects 12 months of facility data. A needs assessment was the first step in carrying out the Averting Maternal Death and Disability (AMDD) Program in participating countries. In the case of Pakistan and Peru, the Program has been implemented in a subset of the surveyed facilities. In Vietnam the Needs Assessment focused exclusively on the five facilities selected for interventions. 1 Results from Pakistan 2000 [4] In the Needs Assessment, 70 governmental facilities were surveyed in three districts of the Province of Sindh (Sanghar, Hyderabad and Karachi West). It was conducted by the Department of Health of the Government of Sindh and UNICEF between February and April of 2000; service statistics reflect patient activity between January and December of 1999. The 1998 population census estimate of the three districts was 6 450 439 inhabitants with a crude birth rate of 30 per 1000 population. 1.1 Availability of EmOC For the three districts with a combined population of this size, 52 basic and 13 comprehensive EmOC facilities are the minimum recommended number of facilities (one comprehensive and four basic facilities for every 500 000 population). Overall 13 facilities provide the full range of comprehensive functions, but availability varies from Karachi West, where only half of the recommended facilities can be found for the population size, to Hyderabad, which exceeds the minimum by two comprehensive facilities (Table 2). Basic facilities fall short of the number recommended, especially in Karachi West. Table 2. Availability of EmOC District Population Baseline availability Recommended number size Basic Comprehensive Basic Comprehensive All three districts 6 450 439 16 13 52 13 Karachi West 2 105 923 2 2 17 4 Sanghar 1 453 028 6 3 12 3 Hyderabad 2 891 488 8 8 23 6 It should be noted that the survey did not include hundreds of private hospitals, maternity homes and smaller clinics, especially numerous in Karachi, some of which provide comprehensive EmOC services. However, these facilities are not accessible to much of the population for economic reasons. 1.2 Proportion of births in EmOC public sector facilities The UN indicator specifies 'births in EmOC facilities,' i.e. those facilities that can treat most if not all obstetric emergencies. An estimated 15% of pregnant women develop obstetric complications that require medical care, therefore, the recommendation that at least 15% of births deliver in EmOC facilities [3]. Fewer than 15% of births occur in the public health facilities surveyed, ranging from almost 12% in Hyderabad to 4% in Karachi West (Table 3). Table 3. Proportion of births District Number of Expected number Proportion Recommended births of births (%) (%) All three districts 15 368 193 513 7.9 >15 Karachi West 2500 63 178 4.0 >15 Sanghar 2781 43 590 6.4 >15 Hyderabad 10 087 86 745 11.6 >15 1.3 Met need The numerator of met need is comprised of the major obstetric complications that are treated in EmOC facilities, i.e. those complications leading to the direct causes of death. The denominator is an estimate of the number of women expected to have a serious complication, i.e. 15% of the expected number of births in the population [3]. According to this definition, 12% of the women in need of treatment in the district of Sanghar and 11% of the women in Hyderabad received treatment (Table 4). Table 4. Met need Districts Number of Expected Met need Recommended women with number of (%) (%) complications complications in treated populationa Karachi West Not available 100 Sangharb 190 1533 12.4 100 Hyderabadb 120 1082 11.1 100 a Population refers to the sub-district catchment area of each hospital. b Data are not from the Needs Assessment but from one hospital in each district in 2000. 1.4 Cesarean deliveries in public sector facilities as a proportion of all births One percent of all births in the total population are delivered by cesarean in the public sector facilities surveyed; as many as 2% of the births in Hyderabad are cesareans (Table 5). Because cesareans performed at private facilities have not been counted, this proportion is likely to underestimate the true proportion. It is also likely that many women who would benefit from surgical deliveries are not receiving this potentially life-saving intervention. Table 5. Cesarean deliveries District Number of Expected number Proportion Recommended cesareans of births (%) range (%) All three districts 1976 193 513 1.0 5–15 Karachi West 204 63 178 0.3 5–15 Sanghar 50 43 590 0.1 5–15 Hyderabad 1722 86 745 2.0 5–15 1.5 Case fatality rate for hospitals surveyed The case fatality rate at each of the two facilities that reported maternal deaths and complications is below the recommended maximum of 1% (Table 6). This may reflect either good provider practices, low utilization of services or problems with the registration of deaths and complications, or some combination of these explanations. Table 6. Case fatality rates District Number of maternal Case fatality rate Recommended deaths/complications (%) maximum (%) Karachi Westa 5/Not available Not available 1% Sanghara 1/190 0.5 1% Hyderabada 0/120 0 1% a Data are not from the Needs Assessment but from one hospital in each district in 2000. 2 Results from Peru 2000 [5] The Needs Assessment for Peru covered all major facilities in the six most northern provinces of the department of Ayacucho. The six provinces have a population of approximately 413 500. In 2000 the crude birth rate for this largely rural department was 24 births per 1000 population. The survey was conducted in May and June of 2000 by the Regional Directorate of Health and the FEMME (Foundations to Enhance the Management of Maternal Emergencies) Project at CARE in Ayacucho; the service statistics reflect patients who presented between May 1999 and April 2000. A total of 31 facilities were surveyed, including five that are not part of the Ministry of Health network. Five facilities are hospitals. 2.1 Availability of EmOC One of the six signal functions for a basic EmOC facility is assisted vaginal delivery. In Peru, the use of forceps or vacuum extraction is uncommon and is no longer part of the pre-service training curriculum at some of the country's leading medical schools. Thus, we have used the designation of Basic −1 or Comprehensive −1 to reflect the absence of assisted vaginal delivery. According to the UN recommended ratio of one comprehensive facility per 500 000 population, pregnant women of northern Ayacucho have more than adequate access to comprehensive EmOC, but the region falls short of having three basic facilities (Table 7). The two comprehensive facilities are only 1 h apart by vehicle; thus, the upgrading of three facilities to a basic level of care should improve the geographical distribution of EmOC. Table 7. Availability of EmOC Population Baseline availability Recommended number size Basic −1 Comprehensive −1 Basic Comprehensive 413 494 0 2 3 1 2.2 Proportion of births in EmOC facilities One in four births takes place in the two facilities that provide comprehensive emergency obstetric care, but more than half of the deliveries take place in institutions that provide some, if not all, life-saving procedures (Table 8). Table 8. Proportion of births Type of facility Number of Expected number Proportion Recommended births of births (%) (%) Two EmOC facilities 2572 9924 25.9 >15 All facilities 5418 9924 54.6 >15 surveyed 2.3 Met need Met need is relatively high in Ayacucho; almost one in four women estimated to have severe obstetric complications receives care at an EmOC facility; overall, 38% receive some care (Table 9). These figures do not include women treated for abortion complications. Traditionally the numerator should include women with complicated abortions, generally defined by hemorrhage or sepsis [3]. If all women receiving an intervention (aspiration or curettage) are included, with no distinction made according to severity, met need increases to 53% at EmOC facilities and 82% at all facilities (data not shown). Table 9. Met need Type of facility Number of Expected Met need Recommended women with number of (%) (%) complications complications treated in population Two EmOC facilities 340 1489 22.8 100 All facilities surveyed 560 1489 37.6 100 2.4 Cesarean deliveries as a proportion of all births The cesarean rate almost meets the minimum level recommended of 5% of all births (Table 10). In several facilities an occasional cesarean is performed, although these facilities do not consistently perform all functions to qualify as an EmOC facility. Table 10. Cesarean deliveries Type of facility Number of Expected number Proportion Recommended cesareans of births (%) range (%) Two EmOC facilities 468 9924 4.7 5–15 All facilities surveyed 491 9924 4.9 5–15 2.5 Case fatality rates for hospitals and other facilities The aggregate case fatality rate at the two comprehensive EmOC facilities is just above the recommended maximum of 1% (Table 11). However, rates are higher if a distinction is made between hospitals and health centers. There are hazards in aggregating facilities that do not have the same capacity to resolve emergencies, and in this case, not all hospitals perform surgery. But where surgery is available, the case fatality rate is the lowest. Table 11. Case fatality rates Type of facility No. of maternal deaths/ Case fatality rate Recommended complications (%) maximum (%) Two EmOC facilities 4/340 1.2 1 All five hospitals 8/386 2.1 1 Health centers and 9/182 4.9 1 other clinics 3 Results from Vietnam, 2000 [6] The Needs Assessment in Vietnam surveyed only five facilities, those targeted for interventions to reduce maternal mortality. These major hospitals are located in the Province of Thanh Hoa in the north-central part of the country and in the centrally located Quang Tri Province. The facilities included two provincial level hospitals, one area hospital and two district hospitals. The two provinces have a combined population of four million inhabitants. The crude birth rate used to calculate the expected number of births was approximately 20 per 1000 population in Quang Tri Province and 16 in Thanh Hoa. The Needs Assessment was conducted by Save the Children in August of 2000, but the data reflect service statistics from January to December of 1999. 3.1 Availability of EmOC and status of the five facilities surveyed If the five facilities surveyed were the only ones providing emergency obstetric care, pregnant women in these two provinces would be seriously underserved. According to other sources, however, Thanh Hoa has a total of 19 basic and nine comprehensive facilities [7]. Although 19 falls short of the 28 recommended for the size of the population, availability of services is far better than the assessment suggests (Table 12). Quang Tri Province appears to have greater availability of EmOC services than Thanh Hoa; of the three facilities surveyed two provide comprehensive care and one provides basic care. Again, additional sources indicate that Quang Tri Province has six basic and four comprehensive facilities, more than the recommended minimum number of EmOC services. Table 12. Availability of EmOC Province Population Baseline status of five facilities Recommended number size Basic Comprehensive Basic Comprehensive Thanh Hoa 3 467 600 0 2 28 7 Quang Tri 573 331 1 2 5 1 3.2 Proportion of births in five surveyed EmOC facilities In Quang Tri 17% of births occur in the three EmOC facilities surveyed; as many as 70% may take place in facilities of all levels, ranging from the provincial hospital to the 117 communal health stations. In Thanh Hoa institutional births may be equally high, however, approximately 4% of all births are delivered at the two EmOC facilities included in the survey (Table 13). Table 13. Proportion of births Province Number of Expected number Proportion Recommended births of births (%) (%) Thanh Hoa 2502 55 482 4.5 >15 Quang Tri 1930 11 510 16.8 >15 3.3 Met need at five surveyed EmOC facilities The two comprehensive facilities in Thanh Hoa Province attend 3% of the met need in the Province. In Quang Tri, at least 26% of the women with obstetric emergencies are receiving care at the three EmOC facilities surveyed (Table 14). Since not all EmOC facilities were assessed, met need has been underestimated. Table 14. Met need Province Number of Expected Met need Recommended women with number of (%) (%) complications complications treated in population Thanh Hoa 242 8322 2.9 100 Quang Tri 452 1726 26.2 100 3.4 Cesarean deliveries at five surveyed EmOC facilities as a proportion of all births The two comprehensive facilities in Thanh Hoa Province deliver at least 1% of all expected births in the Province by cesarean, falling short of the recommended lower level of 5% (Table 15). The two comprehensive facilities in Quang Tri deliver by cesarean almost 4% of the Province's expected births. Like the other indicators, provincial estimates are underestimated because not all EmOC facilities were surveyed. Table 15. Cesarean deliveries Province Number of Expected number Proportion Recommended cesareans of births (%) range (%) Thanh Hoa 700 55 482 1.3 5–15 Quang Tri 440 11 510 3.8 5–15 3.5 Case fatality rates for five surveyed hospitals In three of the five facilities, the case fatality rate exceeds the recommended maximum of 1%; it ranges from zero to a high of 3.4% at the district hospital in Hai Lang (Table 16). Table 16. Case fatality rates Province & Hospital No. of maternal Case fatality Recommended deaths/complications rate (%) maximum (%) Thanh Hoa Provincial Hospital 4/210 1.9 1 Hoang Hoa District Hospital 0/32 0 1 Quang Tri Provincial Hospital 0/332 0 1 Hai Lang District Hospital 1/29 3.4 1 Trieu Hai Area Hospital 2/91 2.2 1 4 Conclusions As with the previous Program notes [1,2], we have seen a tendency in each country towards an adequate number of comprehensive facilities but a shortage in the number of basic EmOC facilities. This may reflect the newness of the concept of basic emergency care and the planning within the health system that has not yet prioritized these services. Training staff to carry out the procedures and maintaining a constant supply of emergency drugs and functioning equipment may also require more attention. The disproportionately low number of basic facilities also may reflect patterns of low utilization of health centers in favor of more sophisticated hospitals for giving birth. In Pakistan, the group of indicators suggests disparities in access and utilization of emergency obstetric care across districts. Proportionately Karachi West has fewer EmOC facilities in the public sector than the other two districts and consequently presents a very low level of births attended in these EmOC facilities. This district has a high number of private facilities, but their service statistics are not publicly available. Hyderabad has the highest proportion of births in EmOC facilities and also the highest cesarean delivery rate, but met need in this district is low, which may be a function of poor record-keeping. Major obstetric complications were infrequently registered prior to the Needs Assessment and the project interventions; thus, met need and the case fatality rates were not calculated from the same baseline data as the other baseline indicators. Pregnant women in Ayacucho, Peru, have a large number of facilities available to them compared with some regions of the world. Peru also stands out by having relatively high estimates for the proportion of births in EmOC facilities, met need and cesarean delivery. The calculation of met need in Peru presents an interesting insight into how obstetric services are being used and for what kinds of complications. Met need more than doubled when abortion-related complications were included in the calculation. However, the facilities in Peru did not distinguish between abortion cases that are routinely treated with curettage or manual vacuum aspiration and those cases that are life-threatening. Since the other two countries in this Program note did not collect information on all abortion cases, we cannot make a cross-country comparison of how the incidence of abortion affects met need. But the high abortion caseload in Peru surely accompanies a high cost for women and for the health system. Where access to cesarean delivery is relatively good, as in the case of Ayacucho, some obstetric complications that could be resolved with assisted vaginal delivery are likely to pass straight to surgery, especially if few health care professionals are trained to perform vacuum extraction or to use forceps. However, in the most inaccessible rural areas, having midlevel personnel trained to do assisted vaginal delivery would allow women to deliver safely, closer to home and without the risk of surgery and anesthesia. The results from Pakistan and Vietnam highlight the difficulties of presenting provincial or population level indicators when data are collected at a limited number of facilities. When only a few institutions collect data we can only monitor the contribution of those facilities to the indicators. In the case of Vietnam, we know that the two provincial hospitals are the highest level of care available and that they receive referrals with the most serious obstetric complications. If the other district level EmOC facilities in these provinces that were not surveyed are providing similar levels of care as those surveyed, accessibility and utilization of emergency obstetric care appear to have reached reasonable levels. The case fatality rates, however, suggest a need for further investigation—are women arriving very late or is the attention they receive poor? These particular data will be their most useful as a baseline against which to document changes at the institutional level. The process indicators will be calculated periodically to monitor the progress of program efforts towards improving access to, utilization of and quality of emergency obstetric services. Acknowledgements The Working Group on Indicators thanks the teams from Pakistan, Peru and Vietnam for sharing these early results with others. Participants of AMDD Working Group on Indicators: Pakistan: Asif Aslam, Talat Rizvi, Sher Shah Syed; Peru: Luis Vega Centeno, Raul Luna, Elena Esquiche, Luis Tam; Vietnam: Hoang Thi Bang, Pham Bich Ha, Pho Duc Nhuan, Nguyen Xuan Hoi, Hoang Van Vinh, Vo Van Thang, TranThe Binh; AMDD: Patricia Bailey, Zafar Gill, Deborah Maine, Anne Paxton, Jason Smith. References [1]Bailey P., Paxton A. Program note. Using UN process indicators to assess needs in emergency obstetric services (Mozambique, Nepal and Senegal). Int J Gynecol Obstet. 76: 2002; 299– 305 [2] AMDD Working Group on Indicators. Program note. Using UN process indicators to assess needs in emergency obstetric services: Bhutan, Cameroon and Rajasthan, India. Int J Gynecol Obstet. 77: 2002; 277– 284 [3] UNICEF, WHO, UNFPA. Guidelines to monitoring the availability and use of obstetric services. 1997 [4] UNICEF Karachi. Needs Assessment for 9 Districts in Sindh Province. 2000; UNICEF Karachi and Pakistan Medical Association [5] FEMME Peru. Reporte de la Lı́nea de Base Evaluación de Necesidades en Emergencias Obstétricas. 2000; CARE: Ayacucho [6] Save the Children. Needs Assessment reports for the provinces of Quang Tri and Thanh Hoa. 2000; Save the Children: Vietnam [7]H. Thi Bang, 2002, personal communication. Citing Literature Volume78, Issue3September 2002Pages 275-282 ReferencesRelatedInformation