1 HEALTH SERVICES DELIVERY
1.1
1.1.3.c Strengthening the Emergency Obstetric & Neonatal Care services (As of
October 2008)
Focal Point
Implementing Agencies
Director Family Health Bureau
FHB with provincial health authorities
Target Areas & Beneficiaries Districts where there is no EMOC facility and having a high maternal mortality rates would be selected as target areas for this project.
All pregnant mothers and newborns, specially the mothers with an obstetric complications and life threatening complications and premature babies who need life saving comprehensive newborn care will be the beneficiaries of this project.
Project Summary:
It is now acknowledged that risk factors such as parity and age while identifying groups of women who are more likely to have complications; will not necessarily predict which individuals will have complications. While most obstetric complications can neither be predicted nor prevented, they can be successfully treated if access to quality emergency obstetric care services is available.
“Interventions that reduce maternal mortality have often been confused with what improves maternal health. Emergency obstetric care is essential and life saving for complications that may arise with pregnancy and childbirth. Also needed are interventions that improve women’s health and wellbeing, such as providing quality antenatal care, sharing information, treating anaemia and improving nutrition”.
Evaluations of maternal programmes in most countries in South Asia show that management and leadership are the most critical issues that affect programmes. Thus the project: “Women’s
Right to Life and Health” will mainly address leadership and management issues related to implementation of maternal care programmes at all levels of implementation. The project is based on the epidemiological praise that:
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Maternal mortality is a result of complications that develop in pregnancy,
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That these complications cannot be reliably predicted or prevented,
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Death from complications can be averted with timely medical care.
It mainly supports the third delay of the “3 delays mode” namely the delay in the hospital.
The reasons include lack of motivation, teamwork, commitment, leadership and management as well as lack of resources and technical skills
Provision of Emergency Obstetric care and Neonatal care aims at reduction of maternal mortality and morbidity and new born morbidity and mortality in Sri Lanka. Improvement of
Emergency Obstetric care and ensure a safe delivery will have impact not only on maternal health. It has a greater impact on Newborn health. Provision of EMOC services can further

reduce the case fatality rates due to haemorrhage and other major obstetric complications. The major areas that will be addressed in the programme are infrastructure development, Human
Resource development and development of other recourses Improvement of quality of care is a major area that will be addressed.
1. Justification:
Maternal death is a tragedy and also a social injustice for individual women, their families and their communities. Most maternal deaths are avoidable, and thus unacceptable. A woman dies from the complications of pregnancy and childbirth due to many factors. Availability of adequate health services to treat life saving complications is curial. However if deaths are to be avoided women must have access to these services. Maternal mortality is also closely linked with health of children. It is known that the same factors that cause maternal mortality and adversely influence child survival effecting a healthy early start for the baby.
In Sri Lanka maternal mortality rate declined appreciably during the last few decades from
1600/ 1000 live birth in 1945 to 46/ 1000 lb in the year 2001. The National Maternal death reviews revealed that 86% of maternal deaths are preventable. Deaths due to haemorrhage was the commonest cause while the next was PIH. Although the MMR at present is 46/1000 lb it has a very high inter district variation as 167/1000 LB in Nuwaraeliya and 26/1000 LB in
Colombo. It is observed that all maternal deaths could be explained according to three-delay model. This model explains the direct or indirect contribution of the services related, social and other factors related to maternal deaths. The third delay explains the maternal deaths due to non-availability of EMOC facility in the institutions. This highlights the need to pay more attention for further reduction of maternal mortality.
At present in Sri Lanka, IMMR is 15.2/1000 LB and Neonatal Mortality
Rate is 12.9/1000LB. Although the IMR has declined from 263/1000 LB in
1935 to current level ,75-80% of neonatal deaths are accounted for infant deaths in Sri
Lanka. Prematurely , Asphyxia neonatarum and infections have contributed for majority of deaths. Further reduction of NNMR needs well-focused interventions and should be implemented during intrapartum period.
In Sri Lanka 94% of the deliveries take place in hospitals and >70% are at specialised institutions. In spite of this high coverage of institutional deliveries need assessment done in
2001 observed that inadequate access to Emergency Obstetric care as one of the key issues that are contributing for high maternal mortality rates in under served / under privileged areas in Sri
Lanka. Therefore appropriate interventions during intra-partum period, namely Emergency
Obstetric Care and Comprehensive New born Care will play a major contribution to reduce
MMR and NNMR in Sri Lanka.
2. Important Assumptions and Risk conditions:
Human resource allocation and development for EMOC and New Born care need to be addressed by Ministry of Health on priority basis.
Stewardship issues need to be adequately addressed by MOH and provincial health authorities is fundamental important for implementation of project in the periphery.

3. Project Objective:
Objective
To improve the health of pregnant women and newborn by providing high quality Emergency
Obstetric Care and comprehensive newborn while respecting women’s rights.
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Indicators
Availability of -24 hour-EMEC facilities per
500,00 population
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Met need for EMOC
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LSCS rate in districts
CFR for all complications
Proportion of MMR due to haemorrhage and PIH and complications
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% of hospitals equipped to 24 hour blood transfusion service
 proportion of new born deaths due to Asphyxia
Neonatorum and Neonatal
Septicaemia
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Institutional NMMR
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
Institutional MMR
Hospital Still Birth rate
4. Project Output/Product
Outputs
EmOC facilities for
Indicators

Percentage of districts
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Means of Verification
Routine MIS
EMOC MIS
NMMR
Perinatal mortality reviews
Peri-natal data
MIS CMCM
RHIS
Means of Verification

Reports from the districts
(at district level) established in all districts
500,000 population
Supportive service for
EmOC established
Quality of care in EMOC, improved
Hospital staff trained on
EmOC service delivery, management, Information system on EmOC facilities

Availability of human resource policy. Percentage of EmOC facilities having
Supportive service
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Report from
Medical
Institutions

Institutional reviews
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
CFR for different causes
Hospital Infection Rate
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Percentage hospital staff trained of
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Percentage of hospitals using MIS on EmOC
 and central level
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Reviews at provincial
Reproductive H. Return from institution (RHIS)
Progress of EmOC service delivery is monitored
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Percentage of MIS on EmOC hospitals conducting progress review
Policies on newborn care services established meetings
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Indicators developed
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Existence of policies on newborn care services
Perinatal mortality reviews

Report on perinatal
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Policy report from Ministry of
Health/FHB
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Report

established
Newborn care facilities at district level established.(at least 1 per district)
Sick baby unit at each district established
(SCBU) mortality reviews produced
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
Percentage of provinces with new born units established
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Reports from provincial plans
Essential equipment and supplies for the new born facilities and EmOC facilities provided
Hospital staff involved in the management of newborns trained on essential newborn care including neonatal resuscitation and ventilation and the MIS on newborn care
New born service delivery monitored
SCBU established
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Percentage of hospital
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Percentage of hospital where essential equipment provided
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MOH Reports
FHB Reports staff trained

Percentage of hospital
 where essential list of
 equipment identified
MOH FHB
Reports from provincial / district authorities
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Percentage dealing on newborns trained
Percentage of hospitals using MIS on newborns of hospital staff trained
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Reviews at provincial and central level
Project No.
1.1.3
1.2.1
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No.of reviews done
Indicators identified
Periodically reviews at district and provincial level on newborn mortality & morbidity conducted
System of accountability in

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Pattern of newborn mortality, morbidity is reviewed.
Leading cause of death identified obstetric and new born care units improved
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Patient hand over/take over check lists, developed (as rubber stamp)
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Availability and usage
Referral system of check list for discharge
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Percentage of for Institutions with referrals done
EMOC facilities established
5. Related Projects:

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MOH
FHB Reports
Reports from Institutions, district and provincial level
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Reports of the review meetings
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Institutional reports
Supervision reports from
MOO/MCH
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Project Title
Strengthen the service for mother & child
Medical supplies including drugs
Reports from hospitals

6. Relevant Agencies to be Coordinated
Ministry o f Health, Nutrition & Welfare
Provincial Government
7. Monitoring and Evaluation
1. Who? Central Level – Ministry of Health (Family Health Bureau),
Provincial, District Leve– PDHS, DPDHS, Overall and detail supervision
supervision by MO.MCH
2. When? Annually reports – Periodical Reports and routine District MCH
Reviews
Annually/ Biannually) Routine MIS on EmOC
Periodical survey
3. What actions to be taken based on results of monitoring & evaluation?
Relevant actions will be taken to overcome the identified deficiencies to improve
the existing system and constraints will be addressed
8. Activities:
Activities Expected Results Process Indicators
1. Study and analyse the neonatal care services in the country and develop policies and strategies on neonatal care.
Identify the needs to be addressed in the policies and strategic documents.
Make new policy documents and strategic documents available.
1
2
3
4
5
Establish EmOC facilities per
500,000 population
- 1 Sick Baby Unit facility per district
- 1 comprehensive newborn facility per province
Functioning units established
Provision of essential equipment & drugs Essential equipments available at facilities
Training of staff (competence based training) on the care of the new born completed
Allocation of Human Resource for
EmOC and New Born care facilities
Establishment of supportive service for EmOC service delivery such as laboratory, operating theatre facilities, blood banks
Availability of trained staff on new born care.
Policy developed
H.R .allocated
Identified supportive service and allocated
Identification of the priority districts and provinces
Essential list identified
Procured
Percentage of completed training programs
H.R. Policy and
Norms developed
Identify essential supportive service
Establish Maternal Health tertiary care services by establishing dedicated ICUs at
PHs and THs and special care baby units and transport incubator facilities at
Fully equipped tertiary care facilities in place
Identify needs on priority basis
Develop proposals selected Base, General and Provincial
Hospitals
Improvement of Quality of care on Established guidelines Norms/Standards/Develope

6 EmOC and New Born Care facilities
7
8
9
Improved Management system at
EmOC and newborn facilties
Development of MIS for EmOC and comprehensive newborn care
Competence based training for service providers
10 Development of Monitoring system on EmOC and new born care
11 Conduct periodical reviews at district and provincial level on new born mortality and morbidity
12 Study the morbidity and mortality pattern of new born
13 Development of Accountability within
EmOC, and newborn care service delivery
14 Establish perinatal mortality reviews on quality of care
Management system developed d
Indicators/Identified/
Quality assurance system developed
Management at
EmOC facilities is improved
Indicators identified MIS developed for
EmOC
Knowledge and competence improved
EmOC and newborn care monitored
Curriculum developed, no. of training programme done
Indicators and process developed
Pattern of new born mortality and morbidity studies leading causes number of review meetings conducted of death identified
Morbidity, mortality pattern of newborn identified
Accountability at hospital level improved
Research published
Hand over and take over system developed
All perinatal deaths Existence of perinatal investigated, reviewed and preventable action taken mortality reviews for all the perinatal deaths