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 Monitoring
emergency obstetric care

a handbook
 Monitoring
emergency obstetric care

a handbook
WHO Library Cataloguing-in-Publication Data :

Monitoring emergency obstetric care: a handbook.

1.Obstetrics - standards. 2.Emergency services, Hospital - statistics and numerical data. 3.Data collection - methods. 4.Quality indicators,
Health care. 5.Maternal health services - supply and distribution. 6.Maternal mortality - prevention and control. 7.Handbooks. I.World Health
Organization. II.United Nations Population Fund. III.UNICEF. IV.Mailman School of Public Health. Averting Maternal Death and Disability.

ISBN 978 92 4 154773 4 (NLM classification: WA 310)

© World Health Organization 2009

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue
Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission
to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the
above address (fax: +41 22 791 4806; e-mail: [email protected]).

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever
on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concern-
ing the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be
full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the
World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of
proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication.
However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the
interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising
from its use.

Printed in France
Contents
Abbreviations iv

Acknowledgements v

Preface vi

Executive summary vii

1. INTRODUCTION 1

1.1 Overview of indicators 4

1.2 Signal functions of EmOC 6

1.3 Use of the EmOC indicators 9

2. INDICATORS FOR EmOC 10

2.1 Indicator 1: Availability of EmOC services 10

2.2 Indicator 2: Geographical distribution of EmOC facilities 13

2.3 Indicator 3: Proportion of all births in EmOC facilities 16

2.4 Indicator 4: Met need for EmOC 19

2.5 Indicator 5: Caesarean sections as a proportion of all births 25

2.6 Indicator 6: Direct obstetric case fatality rate 31

2.7 Indicator 7: Intrapartum and very early neonatal death rate 34

2.8 Indicator 8: Proportion of deaths due to indirect causes in EmOC facilities 36

2.9 Summary and interpretation of indicators 1–8 38

3. COLLECTING DATA FOR THE INDICATORS 43

3.1 Types of data required 43

3.2 Preparation 43

3.3 Form 1: All potential EmOC facilities in selected areas 46

3.4 Form 2: Review of EmOC at facilities 48

3.5 Form 3: Summary of data on EmOC facilities in an area 50

3.6 Form 4: Calculation of indicators for each area 51

3.7 Form 5: Calculation of indicators for the country 51

3.8 Monitoring at the area level 51

REFERENCES 54

APPENDIX A: Forms and worksheets for data collection and calculation of EmOC indicators 61

Form 1. List of possible EmOC facilities 63

Form 2. Review of possible EmOC facilities 69

Form 3. Summary of data on EmOC facilities in the area 85

Form 4. Calculation of indicators for geographical area 107

Form 5. Calculation of indicators for a country 123

APPENDIX B: Information on registers and data collection 145

APPENDIX C: Random number table 151

iv Monitoring emergency obstetric care: a handbook

Abbreviations
AMDD Averting Maternal Death and Disability Program

EmOC Emergency Obstetric Care

HIV Human immunodeficiency virus

UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

WHO World Health Organization

 Monitoring emergency obstetric care: a handbook 5v

Acknowledgements
Monitoring emergency obstetric care: a handbook of the Witwatersrand, Johannesburg, South Africa),
was prepared by Deborah Maine (Boston University, Samantha Lobis (AMDD), Deborah Maine (Boston
Boston, Massachusetts, United States of America, University, Boston, Massachusetts, United States,
and the Averting Maternal Death and Disability and AMDD), Saramma Mathai (UNFPA), Affette
Program (AMDD), Mailman School of Public Health, McCaw-Binns (University of the West Indies), Isabelle
Columbia University, New York City, New York, United Moreira (UNFPA), Luwei Pearson (UNICEF), Rosalind
States), Patsy Bailey (Family Health International, Raine (University College London, London, England),
Research Triangle Park, North Carolina, United Geetha Rana (UNICEF), Judith Standley (UNICEF),
States, and AMDD), Samantha Lobis (AMDD) and Nancy Terreri (UNICEF), Kanako Yamashita-Allen
Judith Fortney (AMDD). (World Bank, Washington DC, United States), Jelka
Zupan (WHO), Katherine Ba-Thike (WHO), Alexis
The handbook is based on the publication Guidelines Ntabona (WHO), Matthews Matthai (WHO).
for monitoring the availability and use of obstet-
ric services (1997) prepared by Deborah Maine, Lale Say (WHO) helped in revision of the handbook by
Tessa Wardlaw (UNICEF) and a team from Columbia facilitating the technical consultation, reviewing draft
University (Victoria Ward, James McCarthy, Amanda versions, and coordinating the publishing process.
Birnbaum, Murat Alkalin and Jennifer Brown), and on Vincent Fauveau (UNFPA), Judith Standley (UNICEF)
recommendations made during a technical consul- and Lynn Freedman (AMDD) reviewed many drafts
tation held in 2006 at WHO in Geneva, in which the within their organizations. Jennifer Potts (AMDD)
following persons participated: Patsy Bailey (Family and Vincent de Brouwere reviewed several versions
Health International and AMDD), Shelah Bloom and made substantive contributions to the text. Yves
(University of North Carolina, Chapel Hill, North Bergevin (UNFPA), Luc de Bernis (UNFPA), Juliana
Carolina, United States), David Braunholtz (Initiative Bol (RAISE Initiative, Columbia University, New York
for Maternal Mortality Programme Assessment City, New York, United States), Sara Casey (RAISE
(IMMPACT) Project, University of Aberdeen, Initiative), France Donnay (UNFPA), Metin Gulmezoglu
Aberdeen, Scotland), Vincent de Brouwere (Prince (WHO), Joan Healy (Ipas), Rita Kabra (WHO), Barbara
Leopold Institute of Tropical Medicine, Antwerp, Kwast (AMDD), Carine Ronsmans (London School of
Belgium), Marc Derveeuw (UNFPA), Hemant Dwivedi Hygiene and Tropical Medicine, London, England) and
(UNFPA), Øystein Evjen Olsen (Institute for Health Cynthia Stanton (Johns Hopkins Bloomberg School of
Research and Development and Primary Health Care, Public Health, Baltimore, Maryland, United States) also
Iringa, United Republic of Tanzania), Vincent Fauveau reviewed the handbook. Lucy Anderson, Alexandra
(UNFPA), Judith Fortney (AMDD), Lynn Freedman DelValle, Gina Gambone, Laura Harris, and Christen
(AMDD), Joan Healy (Ipas, Chapel Hill, North Mullen helped in compilation of the references. Paul
Carolina, United States) Justus Hofmeyr (University Van Look reviewed the text.

Conflict of interest
The participants of the technical consultation were Columbia University who have been engaged in in-
primarily independent experts from academia. No country application of the indicators reviewed at the
conflicts of interest were declared. Other partici- consultation.
pants included staff from WHO, UNFPA, UNICEF, and
vi Monitoring emergency obstetric care: a handbook

Preface
Efforts to improve the lives of women and children health care including family planning and delivery with
around the world have intensified since world leaders the help of a skilled health professional also plays
adopted the United Nations Millennium Declaration in an important role in reducing maternal and neonatal
September 2000 and committed themselves to reach- mortality, this handbook focuses on the critical role
ing Millennium Development Goals 4 and 5, on child of EmOC in saving the lives of women with obstet-
mortality and maternal health. The original targets for ric complications during pregnancy and childbirth and
these Goals were a two-thirds reduction in the mortal- saving the lives of newborns intrapartum. The hand-
ity of children under 5 and a three-quarters reduction book describes indicators that can be used to assess,
in the maternal mortality ratio between 1990 and 2015. monitor and evaluate the availability, use and quality
There is worldwide consensus that, in order to reach of EmOC.
these targets, good-quality essential services must be
integrated into strong health systems. The addition in Whilst this handbook focuses on emergency care,
2007 of a new target in Goal 5—universal access to a broader set of indicators should be used to moni-
reproductive health by 2015—reinforces this consen- tor fundamental aspects of reproductive health pro-
sus: all people should have access to essential mater- grammes designed to reduce maternal mortality,
nal, newborn, child and reproductive health services ensure universal access to reproductive health care
provided in a continuum of care. and reduce child mortality.

In order to reduce maternal mortality, Emergency

Obstetric Care (EmOC) must be available and acces-
sible to all women. While all aspects of reproductive
7 This page has been left blank Monitoring emergency obstetric care: a handbook vii

Executive summary
Reducing maternal mortality has arrived at the top In June 2006, an international panel of experts partici-
of health and development agendas. To achieve the pated in a technical consultation in Geneva to discuss
Millennium Development Goal of a 75% reduction in modifications to the existing indicators for EmOC and
the maternal mortality ratio between 1990 and 2015, revisions to the Guidelines, taking into account the
countries throughout the world are investing more accumulated experience and increased knowledge in
energy and resources into providing equitable, ade- the area of maternal health care. The present hand-
quate maternal health services. One way of reduc- book contains the agreed changes, including two
ing maternal mortality is by improving the availability, new indicators and an additional signal function, with
accessibility, quality and use of services for the treat- updated evidence and new resources. In addition,
ment of complications that arise during pregnancy the Guidelines were renamed as the Handbook, to
and childbirth. These services are collectively known emphasize the practical purpose of this publication.
as Emergency Obstetric Care (EmOC).
The purpose of this handbook is to describe the
Sound programmes for reducing maternal mortality, indicators and to give guidance on conducting stud-
like all public health programmes, should have clear ies to people working in the field. It includes a list of
indicators in order to identify needs, monitor imple- life-saving services, or ‘signal functions’, that define
mentation and measure progress. In order to fulfil a health facility with regard to its capacity to treat
these functions, the data used to construct the indi- obstetric and newborn emergencies. The emphasis is
cators should be either already available or relatively on actual rather than theoretical functioning. On the
easy and economical to obtain. The indicators should basis of the performance of life-saving services in the
be able to show progress over a relatively short time, past 3 months, facilities are categorized as ‘basic’ or
in small as well as large areas. Most importantly, the ‘comprehensive’. The section on signal functions also
indicators should provide clear guidance for pro- includes answers to frequently asked questions.
grammes—showing which components are working
well, which need more input or need to be changed The EmOC indicators described in this handbook can
and what additional research is needed. be used to measure progress in a programmatic con-
tinuum: from the availability of and access to EmOC
For a variety of technical and financial reasons, the to the use and quality of those services. The indica-
maternal mortality ratio does not meet these require- tors address the following questions:
ments. Consequently, in 1991, UNICEF asked Columbia
• Are there enough facilities providing EmOC?
University (New York City, New York, United States of
America) to design a new set of indicators for EmOC. • Are the facilities well distributed?
The first version was tested in 1992. In 1997, the indi- • Are enough women using the facilities?
cators were published as Guidelines for monitoring
• Are the right women (i.e. women with obstetric
the availability and use of obstetric services, issued by
complications) using the facilities?
UNICEF, WHO and UNFPA (1). These indicators have
been used by ministries of health, international agen- • Are enough critical services being provided?
cies and programme managers in over 50 countries
• Is the quality of the services adequate?
around the world.
viii Monitoring emergency obstetric care: a handbook

The handbook provides a description of each indica-

tor and how it is constructed and how it can be used;
the minimum and/or maximum acceptable level (if
appropriate); the background of the indicator; data
collection and analysis; interpretation and presenta-
tion of the indicator; and suggestions for supplemen-
tary studies. There is a further section on interpretation
of the full set of indicators. Sample forms for data col-
lection and analysis are provided.

Use of these EmOC indicators to assess needs can

help programme planners to identify priorities and
interventions. Regular monitoring of the indicators
alerts managers to areas in which advances have
been made and those that need strengthening. Close
attention to the functioning of key services and pro-
grammes can substantially and rapidly reduce mater-
nal mortality in developing countries.
 Monitoring emergency obstetric care: a handbook 11

1. Introduction
Over the past two decades, the international commu- approach. Even this method, however, is known to
nity has repeatedly declared its commitment to reduce give underestimates of the maternal mortality ratio
the high levels of maternal mortality in developing (4, 5).
countries, starting with the 1987 Safe Motherhood
Another approach is use of ‘process,’ ‘output’ or
Conference in Nairobi, Kenya, followed by the 1990
‘outcome’ indicators, to measure the actions that
World Summit for Children at United Nations head-
prevent deaths or illness. Widely used process
quarters, the 1994 International Conference on
indicators include rates of childhood immunization and
Population and Development in Cairo, Egypt, the
contraceptive prevalence. This handbook presents a
1995 Fourth World Conference on Women in Beijing,
series of indicators designed to monitor interventions
China, ‘Nairobi 10 Years On’ in Sri Lanka in 1997, and
that reduce maternal mortality by improving the
the Millennium Development Goals established by the
availability, accessibility, use and quality of services
United Nations in 2000. In 2007, a number of events
for the treatment of complications during pregnancy
marked the 20th anniversary of the launching of the
and childbirth. The indicators are based on information
Safe Motherhood Initiative, including the Women
from health facilities with data on population and
Deliver Conference in London, England, at which calls
birth rates. There are several advantages to this
were made for renewed commitment, programmes
approach. First, the indicators can be measured
and monitoring. Most importantly, over the past 20
repeatedly at short intervals. Secondly, the indicators
years, consensus has been reached on the interven-
provide information that is directly useful for guiding
tions that are priorities in reducing maternal mortal-
policies and programmes and making programme
ity (2). Stakeholders agree that good-quality EmOC
adjustments. It is important to remember that although
should be universally available and accessible, that all
‘process,’ ‘output’ and ‘outcome’ indicators are more
women should deliver their infants in the presence of
useful, practical and feasible than impact indicators,
a professional, skilled birth attendant, and that these
for many reasons, these measures cannot substitute
key services should be integrated into health systems.
for maternal mortality ratios as a direct measure of the
It became clear early on, however, that it would not overall level of maternal mortality in a population.
be simple to measure progress in this area. The
The Guidelines for monitoring the availability and use of
conventional approach was to monitor the number
obstetric services were initially developed by Columbia
of maternal deaths with ‘impact’ indicators such
University’s School of Public Health, supported by and
as the maternal mortality ratio. In theory, repeated
in collaboration with UNICEF and WHO. A draft version
measurements of this ratio over time can be used
was issued in 1992, and the guidelines were formally
to monitor trends. This approach has a number of
published by UNICEF, WHO and UNFPA in 1997 (1).
serious drawbacks, both technical and substantive.
Since then, they have been used in many countries
Maternal mortality is extremely difficult and costly
(Table 1). The present document is a revision of the
to measure when vital registration systems are
1997 version of the guidelines, incorporating changes
weak, and even when systems are strong (3). Even
based on monitoring and assessment conducted
innovative methods present difficulties. For example,
worldwide.
the direct ‘sisterhood’ method provides information
for a reference period of 7 years before a survey; thus,
The recommendations related to measuring the
the information gathered does not reflect the current
indicators were reviewed and updated on the basis of
situation or progress made recently. Recent advances
existing evidence, as well as experience in using the
in sampling procedures for the sisterhood method
indicators within country programmes.
have, however, greatly increased its efficiency and
have decreased costs. These changes allow for larger These recommendations will be updated regularly
samples and consequently a shorter reference period using standard WHO procedures. It is expected that
and narrower confidence intervals than the traditional the next update will be in 2014.
2 Monitoring emergency obstetric care: a handbook

Table 1. Selected countries in which emergency obstetric care indicators were used in assessing needs or for
monitoring and evaluation (2000–2007)
Region and country Use of indicators References
Africa
Angola National needs assessment (report in progress)
Benin National needs assessment (6, 7)
Burundi Needs assessment planned with UNICEF
Cameroon Subnational needs assessment (8-10)
Chad National needs assessment (7, 11)
Comoros (12)
Côte d’Ivoire National needs assessment (10, 13)
Eritrea Needs assessment with partial coverage (14)
Ethiopia Programme monitoring and evaluation; needs assessment (15)
with partial coverage 1
Gabon National needs assessment (16, 17)
Gambia National needs assessment (17, 18)
Ghana Subnational needs assessment (19)
Guinea Subnational needs assessment (20)
Guinea Bissau National needs assessment (17, 21)
Kenya Subnational needs assessments 2
(22-24)
Lesotho National needs assessment (25)
Madagascar Subnational needs assessments (26)
Malawi National needs assessment; programme monitoring and (27-30)
evaluation
Mali National needs assessment; programme monitoring and (31, 32)
evaluation
Mauritania National needs assessment (10, 33)
Mozambique National needs assessment; programme monitoring and (34-37)
evaluation (data not yet analysed)
Namibia Needs assessment (38)
Niger Needs assessment (10, 39)
Rwanda Subnational needs assessment; programme monitoring (15, 23, 39-42)
and evaluation
Senegal National needs assessment (10, 37, 43)
Sierra Leone National needs assessment (44)
Uganda National needs assessment (23, 45, 46)
United Republic of Tanzania National needs assessment; programme monitoring and (15, 39, 47-51)
evaluation
Zambia National needs assessment (52)
Zimbabwe National needs assessment (53, 54)

Americas
Bolivia National needs assessment 3 (55, 56)
Ecuador National needs assessment with UNFPA, 2006
El Salvador National needs assessment (56-58)
Guatemala Needs assessment (59)
Honduras National needs assessment (56, 60)
Nicaragua National and subnational needs assessments; programme (61, 62)
monitoring and evaluation
Peru Needs assessments with partial coverage; programme (63-65)
monitoring and evaluation 4
United States National needs assessment (66)
 Monitoring emergency obstetric care: a handbook 3

Region and country Use of indicators References

Eastern Mediterranean
Afghanistan Needs assessments with partial coverage (67)
Djibouti National needs assessment (68)
Iraq Needs assessment planned
Morocco National needs assessment; programme monitoring and (62, 69)
evaluation
Pakistan Needs assessments with partial coverage; programme (70-73)
monitoring and evaluation
Somalia Subnational needs assessment (74)
Sudan National needs assessment (23, 75)
Syrian Arab Republic National needs assessment 5
Yemen Needs assessments with partial coverage

Europe
Kyrgyzstan National needs assessment 6
Tajikistan National needs assessment; programme monitoring and (76)
evaluation 7

South-East Asia
Bangladesh National and subnational needs assessments; programme (77-79)
monitoring and evaluation
Bhutan Needs assessment; programme monitoring and evaluation (9, 80)
India Needs assessments with partial coverage; programme (9, 81-85)
monitoring and evaluation
Nepal Subnational needs assessment; programme monitoring (37, 86-88)
and evaluation
Sri Lanka Subnational needs assessment; programme monitoring (62, 89)
and evaluation
Thailand Needs assessment with partial coverage (90)

Western Pacific
Cambodia Planned
Mongolia Planned
Viet Nam Needs assessment with partial coverage; programme (91, 92)
monitoring and evaluation

1
CARE. Unpublished data. 2000.
2
Doctors of the World. West Pokot facility needs assessment—maternal and newborn care. Unpublished data. Nairobi, 2007.
3
Engender Health Acquire Project. Unpublished data. 2007.
4
CARE. Unpublished data. 2004: Huancavelica region, Peru.
5
Ministry of Health and UNICEF, Unpublished data. 2004: Syria.
6
Ministry of Health of Kyrgyzstan and UNICEF, Status of Emergency Obstetric Care (EOC) in the Kyrgyz Republic. Unpublished. 2005.
7
Ministry of Health of Tajikistan and UNICEF, Unpublished data. Dushanbe, 2005.
4 Monitoring emergency obstetric care: a handbook

In this new edition, the indicators have been revised to 1.1 Overview of indicators
reflect 10 years’ wealth of experience. Other changes
In the sections below, we present a series of indicators
reflect the broadening of programmes; e.g. a signal
for monitoring progress in the prevention of maternal
function on treatment of complications in newborns
and perinatal deaths. Their order is based on the logic
and new indicators on perinatal mortality and on
that, for women to receive prompt, adequate treatment
maternal deaths reported as due to indirect causes,
for complications of pregnancy and childbirth, facilities
such as HIV and malaria, have been added. These
for providing EmOC must:
changes were discussed and agreed by an interna-
tional panel of experts at the technical consultation in • exist and function,
June 2006 (93). During the review, it was also decided • be geographically and equitably distributed,
to change the title. We use the term ‘handbook’ rather
• be used by pregnant women,
than ‘guidelines,’ because ‘handbook’ reflects more
accurately the practical nature of this document. • be used by women with complications,
Another change made in this edition is replacement of
• provide sufficient life-saving services, and
‘essential obstetric care’ by ‘EmOC’.1 Over the years,
the terminology has been adjusted so that the indica- • provide good-quality care.
tors relate specifically to treatment of the emergency
Thus, the indicators answer the following questions:
obstetric complications that cause most maternal
deaths. • Are there enough facilities providing EmOC?

This handbook includes an explanation of the current • Are the facilities well distributed?
indicators for EmOC and their implications, suggests • Are enough women using the facilities?
supplementary studies that can improve understanding
• Are the right women using the facilities?
of the situation in a given area, and provides answers
to common questions that arise when using the • Are enough critical services being provided?
indicators. This is followed by worksheets and tables
• Is the quality of services adequate?
to illustrate study questions and calculations.
The first indicator therefore focuses on the availability
The indicators described can be used at any stage of
of EmOC services. Adequate coverage means that all
the design and implementation of EmOC programmes
pregnant women have access to functioning facilities.
and can be incorporated into routine health
Once availability is established, questions of use
management information systems. In many countries,
can be addressed. Even if services are functioning,
these indicators have provided the framework for more
if women with complications do not use them (for
detailed assessments of national needs for EmOC,
whatever reason), their lives are in danger. Finally, the
establishing the availability, use and quality of services
indicators cover the performance of health services.
and the specific information needed for detailed
After all, many women die in hospital: some of them die
programme planning, such as equipment inventories.2
because they were not admitted until their condition
Modules for conducting needs assessments can be
was critical; many others, however, die because they
found at: www.amddprogram.org.
did not receive timely treatment at a health facility or
because the treatment they received was inadequate.
1
‘Emergency obstetric care’ or ‘EmOC’ is being used in this Table 2 shows the six EmOC indicators issued in 1997,
document rather than ‘emergency obstetric and newborn care’
or ‘EmONC’ because this set of indicators focus primarily on with some minor modifications suggested by the 2006
obstetric complications and procedures. While there is one new technical consultation on the basis of the participants’
signal function on neonatal resuscitation and one new indicator on
intrapartum care from the perspective of the newborn, the set of expertise and experience in various countries:
indicators do not represent the full range of emergency newborn
procedures.
2
These assessments also include more information on emergency
newborn care, and are often called EmONC needs assessments.
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longitudinal
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reported

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tropical coated

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OG vi

383

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193 habits

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238 it

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123

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