1. MATERNAL HEALTH 12-Jul-05
Photo credit: Media for Development International

2. Learning Objectives
At the end of this session, participants will be able to:
Describe a conceptual framework for maternal health
Identify the main interventions/approaches to improve maternal health
Discuss core output and outcome indicators; recognize their strengths and limitations
The learning objectives of this module are first to describe a conceptual framework for maternal health, second to identify the main interventions and approaches to improve maternal health, third to discuss key indicators of maternal health and service utilization. We will talk about how to measure these indicators, including how to interpret them and their strengths an weaknesses.

3. Maternal Health: Problem
Annually, 585,000 women die of pregnancy related complications
Every Minute...
380 women become pregnant
190 women face unplanned or unwanted pregnancy
110 women experience a pregnancy-related complication
40 women have an unsafe abortion
1 woman dies from a pregnancy-related complication
About 585,000 women die of pregnancy-related complications every year. Every minute, about 380 women become pregnant; 190 women face an unplanned or unwanted pregnancy; 110 women experience a pregnancy-related complication; 40 women have an unsafe abortion; and one woman dies from a pregnancy-related complication. Almost all of the deaths from pregnancy-related complications occur in the developing world. In the developing world, maternal death is leading cause of adult female death in many countries.
Source: JHPIEGO

4. Global Causes of Maternal Mortality
The majority of maternal deaths in developing countries result from five direct obstetric causes: hemorrhage, infection or sepsis, eclampsia, obstructed labor, and complications of abortion. Indirect obstetric complications are due to pre-existing conditions (malaria, anemia, hepatitis, and increasingly, HIV/AIDS) and account for about 20 percent of maternal deaths.
India alone accounts for 25% of all maternal deaths. One woman in 12 dies of maternal causes in sub-Saharan Africa compared to one in 4000 in northern Europe. For every woman that dies, at least 30 suffer injuries.

5. WHY Do These Women Die? Delay in decision to seek care
Three Delays Model
Delay in decision to seek care
Lack of understanding of complications
Acceptance of maternal death
Low status of women
Socio-cultural barriers to seeking care
Delay in reaching care
Mountains, islands, rivers — poor organization
Delay in receiving care
Supplies, personnel
Poorly trained personnel with punitive attitude
Finances
Multiple factors affect WHY a woman dies during pregnancy. The “three delays” model” identifies three groups of factors: (a) Delay in decision to see care: lack of information about problems/warning signs, social factors; (b) Delay in reaching care: having transportation, road conditions; (c) Delay in receiving care: lack of equipment or personnel at facility, lack of funding, poor attitude of personnel.
Class Activity:
What are the major factors contributing to maternal death in your respective countries?

6. Global Targets Target 6 of the MDGs
To reduce the maternal mortality ratio by three-quarters between 1990 and 2015.
Target 6 set by the MDGs is to reduce the maternal mortality ratio by three-quarters between 1990 and 2015.

7. Interventions to Reduce Maternal Mortality
HISTORICAL REVIEW
Antenatal care
Traditional birth attendants
Risk screening
CURRENT APPROACH
Skilled attendance at delivery
Many interventions have been implemented to try to improve maternal mortality. We will review the ones used to date. Antenatal care is a big pillar of safe motherhood. It has not been shown to have a direct relationship with maternal mortality but it remains an important intervention because it provides an opportunity to detect problems and be prepared to handle them. TBAs play a useful role in the maternal health network but there will not be a substantial reduction in maternal mortality by TBAs delivering clinical services alone. Risk screening is another intervention that has been used. It is problematic because only about 10-15% of women who are thought to be “at risk” for a complication actually go on to have a problem. And most women who do develop complications have no risk factors. Current approaches focus on skilled attendance at delivery. Other interventions can make some difference but not as substantial as skilled attendance. This is because the majority (two-thirds) of maternal deaths occur within 48 hours of delivery. Essential for any safe motherhood program is the understanding that no one intervention can make a difference for maternal morbidity and mortality.

8. Recommended Birth Preparedness, Including Complication Readiness
Preparing for Normal Birth
Skilled attendant
Place of delivery
Finance
Nutrition
Essential items
Readiness for Complications
Early detection
Designated decision maker(s)
Emergency funds
Communication
Transport
Blood donors
Planning and preparation for mother, family, community, and skilled care provider and complication readiness are key to survival. Individual birth plans will be shaped by culture, socioeconomic and geographical situation of the family as well as by the needs and conditions of individual clients. In rural areas of the developing world as many as 12 to 15 hours may elapse between the decision to seek treatment and the beginning of travel towards that treatment. Considering that the interval from onset to death for antepartum hemorrhage can be approximately 12 hours, while the interval from onset to death for postpartum hemorrhage can be two hours, the hours required for making arrangements may define the line between life and death.

9. ANC Recommendations (I)
Goal-directed visits by skilled provider
Four visits for normal pregnancy
Counseling
Nutrition, FP, danger signs, breastfeeding, HIV/STIs
Detection/management of existing diseases & conditions
WHO recommends four-focused visits as sufficient for normal pregnancy. Counseling is also recommended. Nutrition counseling is particularly important because underweight moms are more likely to have low birth weight babies. Low iron intake also contributes to anemia. Families of pregnant women also need to know how to recognize the signs of complications as well as what to do and where to get help. Detection and management of existing conditions include HIV, STIs, tuberculosis and malaria.

10. ANC Recommendations (II)
Detection/management of complications
Prevention
All women:
Tetanus toxoid vaccination
Iron folate supplementation
Select populations:
Malaria intermittent preventive treatment
Routine hookworm treatment
Iodine supplementation
Vitamin A supplementation
Detection and management of complications such as severe anemia, vaginal bleeding, eclampsia, malpresentation after 36 weeks is also recommended. Tetanus toxoid vaccinatin has been around for more than 50 years and is produced in many developing countries. It is effective in preventing neonatal tetanus, which causes approximately half a million deaths a year and maternal tetanus, which is estimated to cause 30,000 deaths annually. Iron folate supplementation is important for the prevention of anemia, a major cause of low birth weight. In select populations, malaria intermittent preventive treatment, routine hookworm treatment, iodine supplementation, and vitamin A supplementation are also recommended.

11. Logic Model Input Process Output Outcome Impact I. Behavior Change
Birth Preparedness
Attendant at birth
Complication Readiness
Collaboration
Transport
Finances
Blood (walking donor)
Community availability of emergency transport
Trained providers in EmOC
Increased access to mat. health services
Increased competence of skilled birth attendants
Skilled attend-ance at birth
Increas-ed know-ledge of danger signs
Finance
Equipment
Supplies
Transport
Staff
Maternal and newborn
Survival
Here is a logic model that sets out the linkages between inputs, processes, outputs, outcomes and impact for a maternal health program. The program inputs include finance, equipment, supplies and staff. There are three main activities or processes. The first focuses on behavior change communication regarding birth preparedness and complication readiness. The second focuses on policy and advocacy to establish an enabling environment for access to and increased quality of services. The third activity comprises in-service and pre-service training in emergency obstetric care for persons responsible for maternal and newborn care. The direct outputs of these activities are the availability of emergency transport at the community level, providers trained in emergency obstetric care, increased access to maternal health services, and the increased competence of skilled birth attendants in terms of the appropriate management of women with complications at the health facility level and reduced case fatality rates. At the population level, these outputs lead to skilled attendance at birth and increased knowledge of the signs of obstetric complications. The ultimate impact is improved maternal and newborn survival.
II. Policy/Advocacy
Policy & environment for quality, access
III. Essential Ob. Care
In-service & pre-service training in EmOC

12. M&E Challenges (I) Establishing causality
Maternal health is multifactorial
Improvements in overall health status are not necessarily followed by concomitant changes in mortality
Considerable time lag to measure mortality change
One of the major challenges of evaluating maternal health programs relates to establishing causality and laying out the causal framework linking program inputs, direct and intermediate outputs, and health outcomes and impacts. The lack of reliable evidence on the efficacy and effectiveness of interventions aimed at maternal health, such as prenatal care, makes it difficult to establish the nature, strength and stability of many of these linkages. To confuse matters further, maternal health is multi-factorial. Detecting significant changes at the population level is largely dependent on the functioning of the whole social and economic system. This means that there are many external factors that can influence the effectiveness of individual interventions. A third challenge is that improvements in overall health status are not necessarily followed by concomitant changes in mortality. For example, a prenatal care program can lead to positive health outcomes without substantial influence on the occurrence of maternal death. Because morbidity and other health outcomes may be affected by interventions more directly or to a different degree than mortality, it is important to go beyond the measurement of maternal mortality. Lastly, many health planners and program administrators are eager to demonstrate changes in health outcomes after a short length of time, sometimes as little as one year or even a few months. However, depending on the disease and the intervention, a considerable time lag may need to occur before mortality changes become measurable.

13. M&E Challenges (II) Rarity of maternal deaths
Data collection costs
Confidence intervals
Identifying deaths related to early pregnancy and induced abortion
Establishing trends in maternal mortality
Reliable cause-of-death data are difficult to obtain
In maternal health, there have been significant methodological improvements in obtaining community-based information on baseline levels of maternal mortality. However, because maternal deaths are relatively rare, there are significant cost implications for measuring the effectiveness of Safe Motherhood Programs on the basis of mortality indicators alone. The small number of maternal deaths also affects the confidence intervals of the estimates and makes it difficult to test for statistically significant differences and disaggregate maternal mortality rates by key variables such as age and parity. It is especially difficult to identify pregnancy-related deaths, in particular those related to early pregnancy and induced abortion. For example, recent WHO calculations using demographic models show that numbers of maternal deaths have been systematically underestimated by at least one third in countries where routine cause-of-death statistics are poorly documented. Establishing trends in maternal mortality is difficult. The most innovative method for establishing maternal mortality, the sisterhood method, provides retrospective estimates for the 12-year period prior to the survey. Although it is theoretically possible to calculate trends using information from a single round of sisterhood surveys, this requires huge increases in sample size. Finally, safe motherhood programs typically address a variety of health problems and complications rather than a single disease. However, reliable cause of death data are difficult to obtain.

14. M&E Challenges (III) Evaluation study design
Incomplete vital registration systems
Selectivity bias with health services data
Estimating denominators for facility-based maternal mortality rates
Rural-urban differences in maternal mortality may reflect differences in fertility patterns
There are a number of study design issues in monitoring the progress of safe motherhood programs. A crucial factor is the need to control for artifactual changes by making comparisons between time periods, populations, or population sub-groups. This has important sample-size implications, as adequate numbers need to be reached in each of the comparison groups. It is often not possible to conduct randomized double blind controlled trials at the individual or community level. One of the methodological difficulties is to find large enough areas that can be matched on a number of important demographic and socio-economic characteristics, so that the causal relationship between maternal mortality and interventions can be established. An additional issue is that few developing countries have vital registration systems that are sufficiently complete to provide reliable population estimates (AbouZahr, 1998). A main drawback of health services data relates to selectivity bias, which arises from the low rates of health services utilization. Estimating the denominators for health-services-based maternal mortality rates may also be challenging. Without detailed knowledge of the catchment population, it is hard to gauge whether the maternal mortality ratio under or over estimates the level for the general population.

15. Defining Maternal Death
According to the Tenth Revision of the ICD:
Maternal Death:
A maternal death is the death of a woman while pregnant or
within 42 days of termination of pregnancy, irrespective of the
duration and the site of the pregnancy, from any cause related
to or aggravated by the pregnancy or its management but not
from accidental causes (WHO 1993).
NOTE: 2 criteria
Temporal relationship to the pregnant state
Causal relationship to the pregnant state
Pregnancy-related death: “time of death” definition;
Irrespective of cause.
We will now discuss indicators of maternal mortality but before we do so, it is important for us to define maternal mortality. This slide presents two definitions that are commonly used: a maternal death and a pregnancy-related death. (Read definitions). The method of data collection determines the definition used. Both definitions have potential limitations. For example, “pregnancy-related death” includes deaths to pregnant women from traffic accidents.
Class Activity:
Ask the class: What about 17 yr old Bangladeshi unmarried girl who is pregnant and commits suicide? Is this a true maternal death?

16. Maternal Mortality Indicators
Maternal mortality ratio
Maternal mortality rate
Life-time risk of maternal morality
Proportion maternal
What indicators should we use to measure maternal mortality? There are four main indicators of maternal mortality: the maternal mortality ratio, maternal mortality rate, the life-time risk of maternal mortality, and proportion maternal. We will discuss each of these in turn.

17. Maternal Mortality Ratio
MMRatio:
N of maternal deaths in a specified period *100,000
N of live births in same period
Interpretation:
MMRatio = per 100,000 live births
Problems with quality of care
MMRatio > 250 per 100,000 live births
Problems with quality of care & access
The maternal mortality ratio is defined as the number of maternal deaths per 100,000 live births in a specified period. By expressing maternal deaths per live birth rather than per woman of reproductive age, this definition is designed to express OBSTETRIC RISK.
Class Activity:
Ask class: Do you see any problems with this definition? (Answer: By putting LB in denominator, we overestimate risk (denominator should be larger and include pregnancies))
The international community clings to this definition. Although the maternal mortality ratio is a rough estimate, it is useful for advocacy and planning purposes. For example, a MMRatio of, say, per 100,000 live births points to problems of the quality of care for labor/delivery. Higher MMRatios (more than 250 per 100,000 live births suggests there are problems of access as well. Note that specific MMRatios are likely to vary considerably from year to year and should not be used for determining service program plans or changes in implementation.

18. Maternal Mortality Rate
MMRate:
N of maternal deaths in a specified period *1000
N of women of reproductive age
The maternal mortality rate is defined as the number of maternal deaths per 1000 women of reproductive age in a specified period. By expressing maternal deaths per woman of reproductive age, this definition is a cause-specific death rate.

19. Relation Between Rate and Ratio
MM Rate = MM ratio * GFR
MM Ratio = MMRate / GFR
Example: the maternal mortality rate is 2 per 1,000 women years and the general fertility rate is 200 per 1,000 women 15-49, what is the maternal mortality ratio?
Ratio = .002/.2 * 100,000 = 1,000 per 100,000 live births
The MM Rate can be estimated from the MM ratio (or vice versa) using information on the general fertility rate in the country as shown in these equations. So, for example, if the MM rate is 2 per 1,000 women age And the GFR is 200 per 1,000 women age 15-49, the MM ratio is 1,000 per 100,000 live births. Note that the MM rate depends on both the risk of death per pregnancy, or obstetric risk, measured by the MM ratio and the frequency of exposure to pregnancy, measured by the GFR.
General fertility rate = 1000*(N of live births in a period) / (N of women of reproductive age in a period)

20. Other Maternal Mortality Indicators
Life time risk of maternal mortality = (N of maternal deaths over the reproductive life span) / (women entering the reproductive period)
Proportion maternal = proportion of all female deaths due to maternal causes = (N of maternal deaths in a period/Number of all female deaths in same period) * 100
Life-time risk reflects the risk that a woman will die of maternal causes at some point of her reproductive span, given current rates of maternal mortality and fertility. This indicator is a good complement to the maternal mortality ratio. The proportion maternal is simply the proportion of all female deaths that are due to maternal causes.

21. Where Do Maternal Mortality Data Come From?
Vital registration data - MM Rate and MM Ratio
Health service data – maternity registers - MM Ratio
Special studies
Hospital studies – tracing deaths, interviews
Ramos studies
Longitudinal studies, verbal autopsy
Surveys & censuses
Direct estimation - Rate and Ratio
Sisterhood method (indirect) – Rate and Ratio
Data on maternal mortality can be obtained from a variety of sources. Vital registration should provide data on maternal mortality but in most developing countries the quality of vital registration data is poor and insufficient to provide good quality estimates. Even in countries with good vital registration systems, maternal deaths are typically under-reported. Alternatives to full vital registration in countries with weak vital registration systems are demographic surveillance systems and sample vital registration systems with verbal autopsy to determine cause of death. For example, a lot of studies have been done on maternal mortality in Bangladesh based on the Matlab demographic surveillance system.
Health facility service statistics also provide estimates of maternal mortality. All health facilities that conduct deliveries include a maternity, or birth register, which provides data on the outcome of deliveries. These can be used to estimate the MM ratio. Question: What are the limitations of using hospital service statistics to estimate maternal mortality? What kinds of biases might you see?
(Answer: In many countries, many if not most deliveries do not take place in hospitals/clinics so the deliveries covered by this data source are a select sample. The biases caused by this selection can be in two directions. More affluent/urban women may be the ones who deliver in facilities which would cause a downward bias in MMR. An upward bias could be obtained if women tend to go to health facilities only when they have complications. Reporting of maternal deaths can also be incomplete; for example if the woman dies after delivery or is transferred to another department (e.g. surgery), her death may not be recorded in the maternity registers.)
Given the limitations of service statistics and vital registration, special studies are often conducted to provide more complete data on maternal mortality. These usually include intensive efforts to identify and investigate deaths to women of reproductive age, either through the health system or through community-based methods. Ramos studies are often seen as providing the most complete estimates of maternal mortality. RAMOS (Reproductive Age Mortality Studies) are considered the gold standard for measuring maternal mortality. They involve using a variety of sources to get as complete a count as possible of deaths to women of reproductive age and of maternal deaths. However, RAMOS studes are expensive to conduct and only a few countries have done them. Sometimes, information from in-depth studies can be used to adjust routine facility-based statistics (e.g, Guatemala).
Finally household surveys and censuses have been increasingly used to estimate maternal mortality at the population level. These can use indirect or direct methods to obtain estimates of the maternal mortality rate. Census data typically need adjustment for data quality to obtain estimates (see MEASURE Evaluation manual on this topic). We will discuss survey-based estimates in more detail in the following slides.

22. Sisterhood (Indirect) Method to Estimate Maternal Mortality
Questions are asked to female respondents about the number of sisters and how many have died during pregnancy, childbirth and puerperium (no questions about age of sisters)
Gives life time risk and proportion of adult female deaths due to maternal causes
Gives deaths covering 40 year-period, centering on 12 years before the survey
In the absence of complete and reliable vital registration, there are two common ways to obtain a rough national (or large population aggregate) estimate of maternal mortality: the sisterhood or indirect method; the direct method. We will first discuss the sisterhood method. The sisterhood method is an indirect technique for estimating maternal mortality from household surveys. Questions are asked to female respondents aged about: (1) the total number of sisters who have reached adulthood or marriage and who were born to the respondent’s mother; and (2) the number of those sisters who died during pregnancy, childbirth or the postpartum period. The postpartum period is defined as six weeks following childbirth. This approach identifies pregnancy-related death rather than maternal death. From the sisterhood method, you can get the life-time risk and the proportion of adult female deaths due to maternal causes.
Activity: Ask the class: What are the advantages of this method? (Answer: in a high fertility setting you have expanded sample size with little additional cost; hence this method is comparatively inexpensive; Because the method focuses on adult deaths, reporting problems such as ignorance of sibling deaths prior to respondents birth are avoided).
Ask the class: What are the disadvantages of this method? (Answer: by using a time-of-death definition, some deaths due to incidental and non-obstetric causes will be classified as maternal. The period for the estimate is very wide and not very precise.)

23. Direct Maternal Sibling Method to Estimate Maternal Mortality
Questions are asked to female (and male) respondents about the sisters born to the same mother
age of surviving siblings
age at death of siblings who died
number of years ago the sibling died
whether the sister died during pregnancy, childbirth and puerperium (no questions about age of sisters)
Gives maternal mortality rate for 7-year period prior to the survey; gives age-specific mortality rates
Gives maternal mortality ratio, using the general fertility rate
Like the indirect sisterhood method, the direct sibling history method uses information from women on deaths of adult sisters. However, the questions are much more detailed and involve collecting a complete maternal sibling history. This method obtains information of the age of siblings when they died and allows the placement of deaths in time to give estimates for defined periods before the survey. Estimates are usually made for the periods 0-6 and 7-13 years before the survey. The 7-year window is use to balance recency of the estimates and obtaining enough deaths to make a reasonably stable estimate.
Class Activity:
Ask the class: What are the advantages of this method? (Answer: (1) It allows for calculation of rates and ratios for the reference period of interest; (2) it allows the monitoring of trends; (3) it permits maternal mortality to be analyzed by parity (that is, the number of children ever born); (4) it permits substantial no of data quality checks for completeness and plausibility that are not possible with the indirect approach).
Ask the class: What are the disadvantages of this approach? (Answer: (1) It requires an additional eight to ten minutes on average per interview; (2) It requires additional training and supervision in the field; (3) It makes data processing more complex; (4) data quality may be poor if women have lost contact with their siblings and/or if knowledge of dates is poor).

24. Maternal Mortality: Not Easy to Measure
Estimates not precise
Estimates refer to periods several years before survey
Surveys are expensive
Difficult to assess change due to wide confidence intervals on estimates
Maternal mortality should be measured once every 7-10 years
Neither of the two survey methods described so far can be used for monitoring changes in maternal mortality given the usual project/program period of three to five years. The reasons are as follows: As we have discussed, maternal mortality is a rare event even where the risk is high. Moreover, maternal mortality is difficult to sample and is usually under-reported. To establish reliable estimates and demonstrate change over time, large sample sizes are required, which is costly. Furthermore, the sisterhood and direct methods yield a retrospective estimate for the past years rather than a current estimate, and its confidence intervals are generally wide. Consequently, maternal mortality should only be measured once every 7 to 10 years.

25. Maternal mortality ratios with 95 % confidence intervals
This slide illustrates the 95% confidence intervals typically obtained for estimates of the MMR in survey data. These estimates are based on DHS data.
Activity: What can you say about change in maternal mortality in Malawi and Senegal based on these data? What are the possible explanations for these trends?
Answer: In both Malawi and Senegal, the estimated MMR is higher for the more recent period (0-6 years before the survey) than for the earlier period (7-13 years before the survey), so maternal mortality appears to be increasing. However, in neither country is this increase significant, even though in Malawi the point estimate of the MMR almost doubled from 400 per 100,000 live births to nearly 800 death per 100,000 live births between the two periods. In Senegal, the change is so small that one could only conclude that there is no evidence of any change in maternal mortality. Possible explanations for the apparent increase in the point estimate of the MMR include: (1) genuine increase in maternal mortality, particularly in Malawi which has high HIV prevalence in the more recent period; (2) completeness of reporting of sibling deaths may be better closer to the date of the survey; (3) displacement of sibling deaths to more recent periods in time.
Malawi 1992
Senegal

26. Measuring Utilization of MH Services
Percent of births attended by skilled health personnel
N of live births attended by skilled health personnel
Total no. of live births
Percent of women attended at least once during pregnancy by skilled health personnel
Skilled attendant at birth is one of the most widely promoted indicators of maternity health service use. It is expressed in two different ways. The first is the percent of births attended by skilled health personnel. The denominator is restricted to live births simply due to the fact that data on pregnancies are not available. The second is the percent of women aged attended at least once during pregnancy by skilled health personnel. What experience do we have measuring skilled attendant at birth? Well, data are available for many countries in the world and it has been shown that the indicator is a valid reflection of international patterns in access to delivery care. The indicator also provides useful information in local settings, particularly when birth attendance is broken down by type of attendant and place of delivery. When measured in surveys, the indicator is defined as the percentage of births attended by trained personnel. It is not clear, however, that small changes in the proportion of births attended by skilled health personnel are a sensitive marker for changes in maternal mortality.
Class Activity:
Ask the class what is the definition of a skilled attendant? Are TBAs included in the definition of a skilled attendant? (Answer: skilled attendants at birth include midwives, doctors, and practitioners who have received at least 18 months of midwifery training and attend on average 5-10 deliveries per month. A skilled attendant may include auxiliary nurse-midwives, community midwives, and health visitors if they have been specially trained. Trained TBAs are not included).

27. UNICEF, WHO, UNFPA “Process Indicators”:
Availability of Emergency Obstetric Care (EmOC)
Geographical distribution of EmOC facilities
% of births attended in an Emergency Obstetric Care facility
Cesarean section rates
Met Need for Obstetric Care
Case Fatality Rate (from hospitals)
Given the difficulties of measuring maternal mortality, many safe motherhood programs may also use indicators of change along the pathway to reduced maternal mortality. Recognizing that the majority of maternal deaths in developing countries result from 5 direct obstetric causes which can be addressed through access to well-defined medical interventions, UNICEF, WHO, and UNFPA developed 6 indicators known as the UN “process indicators” for monitoring emergency obstetric care. These first two indicators are the availability of emergency obstetric care and the geographical distribution of EmOC facilities. These indicators answer the questions: Are the services available and accessible. The third and fourth indicators are the percent of births attended in an emergency obstetric care facility and the cesarean section rate. These indicators answer the question: Are the services being used. The fifth indicator is met need for obstetric care. This indicator answers the question: Are the services being used by those in need. Lastly, the sixth indicator is the case fatality rate. This indicator answers the question: Is the quality of services adequate. All 6 indicators can be calculated from facility records.
UNICEF, WHO, UNFPA, 1997

28. Indicators of Services Availability
Facilities
Basic Emergency Obstetric Care facilities per 500,000 population (4)
Comprehensive Emergency Obstetric Care facilities per 500,000 population (1)
Distributions
Geographic distribution
The first two indicators measure the availability and distribution of health facilities that provide basic and comprehensive emergency obstetric care. There should be 1 Comprehensive and 4 Basic EmOC facilities per 500, 000 population. The geographic distribution of EmOC facilties is best assessed by mapping tools. One limitation of this indicator is that accessibility of services does not only imply geographical accessibility, but also financial access.
UNICEF, WHO, UNFPA, 1997

29. BASIC Basic and Comprehensive EmOC Facilities
EmOC Facilities Provide the first 6 Services
Antibiotics (intravenous or by injection)
Oxytocic Drugs (ditto)
Anticonvulsants (ditto)
Manual Removal of Placenta
Removal of Retained Products
Assisted Vaginal Delivery
Let’s talk about the differences between basic and comprehensive emergency obstetric care facilities. Basic EmOC facilities provide the first 6 services. Comprehensive EmOC services provide the first 6 obstetric services plus cesarean section and blood transfusion.
Surgery (Cesarean Section)
Blood Transfusion

30. % of births attended in an Emergency Obstetric Care facility
(Number of live births attended in an EmOC facility)/(All live births*) (> 15%)
* The numerator is the sum of births taking place in EmOC facilities. The denominator is restricted to live births simply due to the fact that data on pregnancies are not available (often estimated from census or other pop-based data).
The proportion of births attended in an EmOc facility is a measure of institutional delivery. At least 15 percent of births should occur in basic and comprehensive EmOC facilities. This is because it has been estimated that around 15 percent of pregnant women develop life-threatening obstetric complications. This is true of pregnant women in the U.S. and Europe, as it is of women in Africa, Asia, and Latin America. Nobody knows why this happens. It is a fact of life.
Class Activity:
Can facility data be effectively be substituted for population-based data collection in the estimation of institutional delivery? What is the value of using facility data? What are the limitations of facility data?

31. Experience with % births in EmOC facilities
Requires collecting and summing information across facilities in a geographic area
Questions as to how important/feasible it is to ask health facility staff to adjust population totals
Requires knowledge as to the state of services being offered at multiple health facilities (ie, reaching criteria for Basic, Comprehensive obstetric care)

32. Population-based C-section Rates
(N of caesarian section operations in geographic area per time period)/(N of live births) (5-15%)*
NOTE: must be interpreted entirely differently than hospital-based caesarian section rates. In Referral Hospitals, one may see C-Section Rates of 25-35% and that may be appropriate because of its referral status.
The caesarean section is a useful indicator of use/coverage of emergency obstetric care services. The minimum value for the c-section rate is 5% and the maximum accepted value is 15%. If the c-section rate is below 5%, it means that too few women are getting this potentially life-saving service. If the c-section rate is greater than 15%, it implies over-medicalization. The c-section rate can be misleading if one is looking at referral hospitals. One also needs to look at the rate for women of different socioeconomic status as an overall rate can mask socioeconomic differentials in access to care. Note that the c-section rate uses a denominator based on expected number of births in a catchment population and so is a coverage indicator calculated in a way similar to how childhood immunization indicators are calculated.

33. Case Fatality Rate
Percent of women with obstetric complications in a specific facility who die (1%)
Strengths & limitations
Definition of a “fatality” is straight forward
Easy to understand/interpret
Is best used in hospitals with a large volume of births/deaths
Follow up requires more in-depth investigation (maternal death audits or other qualitative methods)
The case-fatality rate measures the proportion of deaths among women with obstetric complications admitted to a particular facility. This indicator is used as a proxy for the quality of care. It can be calculated for specific complications or for all obstetric complications but frequently one sees case fatality rates calculated for all obstetric complications. The case-fatality rates has certain advantages as an indicator. It is easy to understand and interpret and the definition of a fatality is fairly straightforward. However, there is a problem of rarity. Even hospitals with a large number of deliveries may have few deaths. Case fatality rates can be misleading. Very low recorded CFRs for a condition may be caused by over diagnosis of the condition or by under-recording of deaths. This can obscure high rates for other conditions. Cause-specific fatality rates in particular need large sample size and can be calculated only in large hospitals. If an alternative all-cause case fatality rate is used, the rate will vary immensely between settings depending on how broadly complications are defined.The definition of the denominator may also be problematic (for example, women with postpartum hemorrhage).

34. Met Need for EmOC
Percent of women with major obstetric complications who are treated (in a given geographic area and time period) (100%)*
(N of women w/ ob.complications in facilities)/(15% of estimated live births in catchment area*)
Met Need for EmOC is defined as the percent of women with major obstetric complications who are treated in a given geographic area and time period. This indicator measures the proportion of pregnant women with one or more defined obstetric complications who receive treatment in a health facility. 100% of women expected to have obstetric complications should be treated in EmOC facilities. The numerator is the number of women with obstetric complications in facilities. The denominator is based on the assumption that 15% of live births or pregnancies are associated with a major obstetric complication.
Class activity:
(1) What complications are measured in met need for EmOC? (Answer: The complications considered in the definition of met need for EmOC include hemorrhage, prolonged/obstructed labor, postpartum sepsis, abortion complications, pre-eclampsia or eclampsia, ectopic pregnancy and ruptured uterus.)
(2) How are women with more than one major obstetric complication categorized? (Answer: Women with more than one major obstetric complication are categorized by the most serious complication.)

35. Experience With “Met Need”
Assumes that the recorded complication was treated
Requires data on complications (RE: standardization of definitions, is it necessary?)
Will often require changing the delivery room register (adding a column)
Changing the register should be viewed as an intervention in and of itself
Whose responsibility is it to act on the results?

36. Utilization of “UN Process Indicators”
CALCULATING ALL 6 INDICATORS
Gives you an indication of where the problems lie and where action is needed.
Also, these indicators are sensitive to change: within months, you can know if your project is making a difference
The purpose of monitoring and evaluation is to influence decisions to continue, change, expand, or end a project or program. The next few slides show the types of decisions that can be taken based on the level of the process indicators. The process indicators are most useful when used as a set or progression. They can help to tell us whether the main problem lies in access to services or in the quality of care. Calculating all 6 indicators give you an indication of where the problems lie and where action is needed. Also, these indicators are sensitive to change. Within months, you can know if your project is making a difference. In Nepal, for example, it was found that the number of functioning comprehensive and basic emergency obstetric facilities was below the minimum and that the use of obstetric care was low. Additionally, in rural areas, only 5 percent of births were delivered at a health facility and the unmet need for obstetric care was around 95%. The cesarean section rate was less than 1 percent. As a result of these findings, the government formulated a safe motherhood plan that aims to increase the number of basic emergency care obstetric facilities by improving existing facilities and improving the quality of care offered while promoting awareness and improving access among communities. In the next few slides, we will discuss what action can be taken based on problems identified by each of the UN “process indicators”.

37. Availability of EmOC Problems:
Does Indicator # 1 show you need more EmOC facilities?
Does Indicator # 2 show you need better distributed EmOC facilities?
Action:
Most countries already have enough facilities; they may just need to upgrade services to ensure Comprehensive and 4 Basic EmOC facilities per 500,000 population
For example, does Indicator 1 show you need more emergency obstetric care facilities? Does indicator 2 show you need better distributed EmOC facilities? What action can you take? Most countries already have enough facilities. They may just need to upgrade services to ensure that they have 1 comprehensive and 4 basic EmOC facilities per 500,000 population.

38. Utilization of EmOC Problems
Does Indicator # 3 show that births in your EmOC facilities are fewer than 15% of all births in the population?
Does Indicator # 4 show that “Met Need” is less than 100%? (I.e. that not all women who experience obstetric complications are using EmOC facilities)
Does Indicator # 5 show that less than 5% of all births in the population are by Cesarean section?
Does Indicator # 3 show that births in your EmOC facilities are fewer than 15% of all births in the population?
Does Indicator # 4 show that “Met Need” is less than 100%? (i.e. that not all women who experience obstetric complications are using EmOC facilities)? Does Indicator # 5 show that less than 5% of all births in the population are by Cesarean section?

39. Collect More Information First
Utilization of EmOC
Action:
Collect More Information First
Do you have enough qualified staff?
Do you need to train staff on management of emergency obstetric complications?
Does hospital management need improvement?
What’s the supply situation like?
What’s the equipment situation like?
What actions can you take? The first thing you need to do is collect more information. Do you have enough qualified staff? Do you need to train staff on management of emergency obstetric complications? Does hospital management need improvement? What’s the supply situation like? What’s the equipment situation like? If all these things are in place, conduct focus groups in the community to find out why women are not coming for care.
If all the above is in place, conduct focus groups in the community to find out why women are not coming for care

40. Quality of EmOC Action: Problem:
Find out if your EmOC facilities are really functioning
Check staff numbers, skills, management capacity, supplies and equipment
Lobby the health ministry for more support; get community to lobby with you
Does Indicator # 6 show that more than 1% of women treated for obstetric complications are dying at your EmOC facilities?
Does Indicator # 6 show that more than 1% of women treated for obstetric complications are dying at your EmOC facilities? The next step is to get more information. Find out if your EmOC facilities are really functioning. Check staff numbers, skills, management capacity, supplies and equipment. Lobby the health ministry for more support – and get the community to lobby with you.

41. Summary on “Process Indicators”
UN process indicators only part of picture
Maternity record keeping important
Non-standard format
Incomplete, illegible, missing records
Non standard definitions of obstetric complications
Misclassification or non-recording of maternal death
These indicators are only part of the picture however. They do not tell us all we need to know before resources are devoted to an activity. For example, they cannot tell us where facilities are needed – for this we need to consult with communities or local planners. They may not be able to tell us why facilities are not being used. For this, we need qualitative research with potential users. We may also need to work with local health providers on how to change behaviors. The indicators also cannot tell us if women with obstetric complications are correctly managed. For this, we need clinical audits or reviews and observations of provider performance.
Collecting data for the process indicators has highlighted the importance of improving maternity record keeping. For example, it is difficult to extract patient records from the registers because they are not kept in standard format and emphasize infant outcomes rather than maternal outcomes. Records are often incomplete or illegible, or simply missing. Definitions used to identify obstetric complications are often not standardized. Maternal deaths (even in hospitals) are often misclassified or not recorded. The process indicators are weakest in assessment of quality (case-fatality rates can be misleading). Fewer indicators have been developed to assess improvements in management, but management issues are at the heart of may failures of care.

42. Conclusions re Evaluation
In maternal health, no indicator of service provision or use is unequivocally linked to a reduction in maternal mortality
Maternal mortality unsuitable for documenting change at programme level
Attributing changes to the programme per se may be difficult, and providing ‘scientific’ proof of programme effectiveness may be not be achievable.
Source: Ronsmans, 2001, HSOP #17, p 337
Continued

43. References
Campbell, O., Filippi, V., Koblinsky, M., Marshall, T., Mortimer, J., Pittrof, R., Ronsmans, C., and Williams, L Lessons Learnt: A decade of measuring the impact of safe motherhood programmes.  London: London School of Hygiene and Tropical Medicine.
Stanton, C., Abderrahim, N., and Hill, K “An assessment of DHS maternal mortality indicators.” Studies in Family Planning 31(2):
Thaddeus, S. and Maine, D Too far to walk: maternal mortality in context. Social Science and Medicine 38(8):
UNICEF, WHO, and UNFPA Guidelines for Monitoring the Availability and Use of Obstetric Services. New York: UNICEF

44. Supplemental Slides I Measuring Service Utilization by Women With Complications
Count number of women with specific complications in the health facilities
Derive expected number of complications in a year
standard guesstimate: 15% of all deliveries have complications
estimate from self-reported data by women on the occurrence of complications in a survey (OVER METHOD)
Specific prevalence of complications based on literature
How can we measure service use/coverage by women with complications? In order to calculate this indicator, first count the number of women with specific complications in the health facility in a given year. Next, derive the expected number of complications in a given year. You can do this in three ways: (1) a standard guesstimate of 15 percent of all deliveries in a catchment area; (2) an estimate based on women’s self-reported prevalence of complications in a population-based survey; this method is called the Observed versus Expected Ratio (OVER) method (3) a specific prevalence of complications based on the literature. Women and their babies with complications who do not present to a health facility are considered to receive inadequate care.

45. Supplemental Slides (II) OVER METHOD
Prevalence of specific complications, known from other studies (Pitroff, 1997):
breech at delivery: per 1,000 deliveries
twin pregnancy: 28.4 per 1,000 deliveries
placental abruption:10 per 1,000 deliveries
placenta praevia: 3 per 1,000 deliveries
Example - In a district with an estimated 10,000 deliveries in a year, 40 breech deliveries were reported by the health facilities. What is the coverage of breech deliveries by health facilities?
The second method to measuring service utilization by women with complications, termed the OVER method, seeks to assess conditions that are distinct and obvious, easy to diagnosis and difficult to misclassify. The conditions have a biologically determined incidence within a population of pregnant women. This incidence is largely independent of knowledge, skills or management preferences of health providers. The criteria hold for the following conditions: (1) breech presentation in labor; (2) twin pregnancy; (3) placental abruption; and (4) placenta previa. These conditions are routinely recorded in delivery registers and annual statistics of many institutions. For breech and twin, the OVER method assesses coverage for conditions that can be diagnosed prenatally or during early labor before an emergency condition arises. For placenta praevia and placental abruption, the OVER method assesses coverage for emergencies that require rapid management (such as a caesarean section). Thus, the OVER method is expected to provide robust estimates of the use of appropriate care.
Activity: Let us take the example of district X. There are an estimated 10,000 deliveries in a year, with 40 breech deliveries being reported by the health facilities, what is the coverage of breech deliveries by health facilities. The answer is provided in the next slide.

46. Supplemental Slides (III) OVER METHOD
Problem:
Example - In a district with an estimated 10,000 deliveries in a year, 40 breech deliveries were reported by the health facilities. What is the coverage of breech deliveries by health facilities?
Prevalence of breech at delivery:
31.7 per 1,000 deliveries (Pitroff, 1997)
Answer:
10,000 * 31.7/1000 = 317 breech deliveries are expected; coverage is 40/317 = 13%
First we calculate the expected number of breech deliveries. From other studies, we know that the prevalence of breech at delivery is 31.7 per 1,000 deliveries. So in 10,000 deliveries, we expect 317 breech deliveries. Only 40 breech deliveries were reported by district X but 317 were expected. So the coverage of breech deliveries in district X is 13%.