In this section, we will learn about a series of indicators for monitoring the progress that countries are making toward providing EmOC, and thus reducing maternal deaths. Much of the information presented here, as well as in the preceding section, can be found in the World Health Organization's handbook, for monitoring emergency obstetric care, which can be freely accessed at the link included in the weekly reading list. In general terms, facilities providing EmOC, must be adequately, and equitably distributed in terms of geographic location. They must be used by pregnant women particularly those experiencing complications, if there not used they are not going to be helpful. They must function properly in providing critical life saving services of sufficient quality as well. To understand to whether and to what extent countries as well regions, provinces, and states within countries, are meeting these objectives. Scientists at UN agencies and various academic institutions have developed a set of eight process indicators that can be reassessed on a regular basis, preferably annually. I will be using the most recent version of these indicators from 2009. But be aware that an updated version, may be available in the next year or so. The first process indicator is availability, so in a particular region or country, are there enough health facilities with the capacity to provide EmOC? This means a minimum of one comprehensive EmOC facility, and five basic EmOC facilities per 500,000 population. This indicator is calculated by dividing the total population by 500,000 and then multiplying by 5, to give the overall minimum number of EmOC facilities. The number is then compared to that of the actual health facilities found, in order to classify services as basic EmOC, comprehensive EmOC, or neither. The results are expressed as a percentage of the minimum acceptable number of EmOC facilities. So, for example, in 2012, Amay and colleagues published a cross-sectional survey of health facilities in six developing countries. They found that in Kenya, 50% of all provincial hospitals in the country were meeting the minimum requirement for comprehensive EmOC. In India, 43% of the selected facilities in four states met the standard for comprehensive EmOC, but only 15% qualified as having basic EmOC. And in eight districts of Nigeria, no facilities offering maternal health services met the standard for comprehensive EmOC, while 2% qualified as having basic EmOC. The next process indicator is geographical distribution, are the existing EmOC facilities both adequately and equitably distributed? The minimal standard for this indicator is that all sub-national areas meet the same level as the indicator, that I just discussed, mm, in number one,. So one comprehensive EmOC facility and 5 basic EmOC facilities per 500,000 population. This indicator is calculated in the same way as the first indicator except, that it takes into consideration the geographical distribution of EmOC by using subnational areas of study, rather than region or country. The third U.N indicator, is the proportion of births in EmOC facilities. Are enough women using this care? Here the minimal acceptable standard is locally defined, based on the proportion of births that occur in health facilities currently as well as the national or subnational goals. So for example, countries estimating that 70% of, of their births are taking place in health facilities might want this number to be set at 100%, while countries with facility births at only 30% might be currently striving to achieve 50% for their goal. It's calculated by dividing the number of women registered as giving birth in an EmOC facility, by an estimate of all live births in the area. To give a more complete picture of what's going on in a country or an area, and to make comparisons, this estimate, and all of the estimates that follow, should be calculated for all health facilities, as well as for just the facilities with EmOC. The fourth UN progress indicator is proportion of women with a ma, with major direct obstetric complications who are treated in EmOC facilities. Are the right women using this care? Is the question that this indicator attempts to answer. So another term for this indicator is met need for EmOC. Which might be familiar for anyone with experience working in population studies or family planning programs, where Met need for contraception is a commonly used estimate. The goal here, is for 100% of women with major directives obstetric complications, to be treated in an EmOC facility. It's calculated by dividing the number of women treated for a complication in an EmOC facility over a specified period of time, by the expected number of women with a major, major complication, or 15% of expected, expected births during the same time period. The fifth progress indicator is the proportion of all births by cesarean section. So are enough critical services, being provided but not overused. The estimated proportion of births by cesarean section is no less than 5% or more then 15%. The optimal rate of cesarean delivery is still unknown, but is typically considered to be between 5 and 15%. This indicator is calculated by dividing the number of cesarian sections performed in EmOC facilities during a specified period, for any reason, by the expected number of live births during the same period. The sixth indicator, is proportion of women with a major direct obstetric complication, who received care in an EmOC facility, and who died prior to discharge. So this gets at the question, is the quality of maternal health services adequate? This indicator also known as the case fatality rate, the goal, for the indicator is less than 1%, so less than 1% of women with a complication in EmOC facility, died before discharge. This indicator is calculated by dividing the number of women dying from a major direct obstetric complication in an EmOC facility during a specified period, by the number of women who were treated for all direct obstetric complications during the same period. UN process indicator number seven is, proportion of births that result in a intrapartum fetal death, or an early newborn death in an EmOC facility. This indicator, is also trying to get at the question of quality, is the quality of care for fetuses and newborns sufficient? Also known as the intrapartum and very early neonatal death rate, the minimum standard for this more recently added indicator is yet to be determined. The indicator is calculated by dividing the sum of intrapartum fetal deaths and newborn deaths that occur within 24 hours of birth in an EmOC facility during a specified period, by the number of women who gave birth in that same facility during the same period. It is recommended that newborns under 2.5 kilograms be excluded from both the numerator and denominator when possible, because low birth weight babies tend to have a high fatality rate, and the purpose of this indicator is to measure quality of care. UN process indicator number eight, is proportion of maternal deaths from indirect obstetric causes in EmOC facilities, for this indicator, no standard can be set. It's a more recent indicator that is thought to highlight the broader social and health system context of a region, or country. And it has implications for intervention outside, or beyond, EmOC. If it were to be calculated, it would be calculated by dividing all maternal deaths due to indirect causes in EmOC facilities in a specified period, by all maternal deaths occurring in the same facilities during the same period. So now we've finished discussing the United Nations process indicators from the EmOC. Before moving on, I do want to note that, like many measures in global health and particularly in maternal health. These estimates are not without flaws, and have been critiqued by experts in the field for a variety of reasons. Without going in to a great deal of detail, I want to refer you to another public, publication by Gabrish and colleagues on your reading list and this is from 2012, that describes measurement inconsistencies between different UN documents. So, for example, use of different denominators for some of the indicators. This article also makes recommendations for which approach may be best to take. Next we will explore the practical applications of these process indicators in the monitoring and assessment of the MOC.
