Staffan Bergström
Development of Obstetric Process Indicators
In the ETATMBA Project we have used the six UN process indicators as follows:
The six process indictors universally utilized have been addressed according to locally
prevailing realities. Below there is a short description of what the project has achieved in
the individual process indicators.
UN Process Indicators:
1. Amount of EmOC services available
2. Geographical distribution of EmOC
facilities
3. Proportion of all births in EmOC
facilities
4. Met need for EmOC services
5. Cesarean sections as a percentage of all
births
6. Case fatality rate
1.
Amount of EmOC services available
This process indicator is not possible to influence within the existing project.
2.
Geographical distribution of EmOC facilities
Like the first process indicator this distribution of facilities cannot be influenced directly
by the project but acted upon by the Ministry of Health.
3.
Proportion of all births in EmOC facilities
We have seen in several facilities that the introduction of comprehensive emergency
obstetric care (CEmOC) to health centers has produced a virtual “flooding” of patients to
some health centers with a record increase of 300% during a period of six months in one
health center, while in other health centers the increase in proportion of all births has been
lower. We have noted that this proportion is sensitive to a number of circumstances
prevailing in health facilities, e.g. staff attitudes to patients arriving, availability of
emergency supplies, availability of drugs and other life-saving equipments. The problem
of this increased popularity of some health facilities is that the increas in number of
patients implies a risk of “burn out” of staff since the additional demands of
comprehensive emergency obstetric care imply execution also of major surgery like
cesarean section and hysterectomy. To “develop” a process indicator has also negative
repercussions on service delivery if the limitation in staff and supplies is not taken into
consideration. The ETATMBA project has been quite instructive in seeing the risks
implicit in this development of the process indicators and it is quite obvious that a too
rapid development will result in the risk of substandard care.
4.
Met need of EmOC service
The establishment of an attractive setting in health facility empirically implies the abovementioned risk of “flooding” of patients from a geographical area well beyond what has
been assumed to be the “catchment area”. This means that the calculations of “met need”
is problematic and has to take into account the risk of attraction of patients far outside the
assumed “catchment area”. This leads to a denominator error by using an erroneous
(assumed) area of recruitment of patients. We have found in the project that this indicator
is so problematic that it is virtually impossible to use over time, since there are so many
confounding factors influencing the met need.
5.
Cesarean sections as a percentage of all births
A quite conspicuous effect of providing comprehensive emergency obstetric care at
health center level including cesarean sections is that there is a risk of a “local pandemic
of cesarean sections” at the expense of other methods, for instance assisted vaginal
delivery. We have noted in some facilities that this upsurge of cesarean sections, many of
which are non-justified have poorly motivated clinical indications. It is normally assumed
that the optimum percentage of cesarean sections of all births should be in the range of 515%. This can be questioned, however, and there are many examples of settings with less
than 5% cesarean sections with the maternal mortality of 20 per 100,000 live births and
perinatal deaths less than 20 per 1000 total births. Therefore, we have been active in
introducing clinical audit of all cesarean sections and all vacuum extractions as a better
tool to evaluate quality of comprehensive emergency obstetric care.
6.
Case fertility rate
Case fertility rate is theoretically a good expression of a “process”. In reality, however
this is a very difficult parameter and indicator of a “process”. The reason is that the
denominator, the aggregate obstetric morbidity, is very poorly registered in general
(denominator error) implying that we have an erroneously inflated case fertility rate in
facilities with poor morbidity registrations but with better mortality registration. The only
way out of this dilemma is to be much more careful in distinguishing case fatality rates
specifically per morbidity (for instance eclampsia, post partum hemorrhage, obstructed
labor etc). If this is not the case it is almost impossible both to analyse case fertility rate
retrospectively and even prospectively, unless the morbidity registration is not improved
very significantly. This would require special training of health staff in diagnostic
accuracy.