Designing a national network of referral maternity facilities
3. Approach for implementing the design phase (detailed in Chapter 8) – the national workshop to analyse the situation and design the national network of
referral maternity facilities
The national workshop for developing the network of EmONC facilities is generally held over four days and brings together national managers, maternal and reproductive health partners/stakeholders, regional directors and regional/district managers of the MNH programme. It is suggested to be structured in three parts:
● The first part consists of a presentation on the EmONC situation in the country (if possible, based on the results from the most recent EmONC Needs Assessment, or its shortened version)and a discussion of the results and the obstacles identified in developing a national network of EmONC facilities. It should emphasize the importance of result indicators, particularly those relating to availability of, access to, and quality of EmONC. This first part is also an opportunity to clarify key concepts such as the EmONC facility network, BEmONC facilities, and referral links between BEmONC and CEmONC facilities. These concepts are defined in Technical Sheets no. 1 and no. 2.
This part of the workshop generally leads to an increased awareness from participants of the need to improve the functionality of the national EmONC network and of the country capacity to make it happen.
● The second part addresses the development of the EmONC facility network, looking at three elements:
▪ Coverage of the network: How many health facilities are included in the network compared to the recommended standard of five EmONC facilities per 500,000
population, including at least one CEmONC facility? How are these distributed across the region? Which proportion of the population do they cover? How many are functioning and how are referral links like?
▪ Service utilization and capacity of the network: What progress has this network of maternity facilities made in terms of provision of childbirth and emergency obstetric care? Which staff carry out these duties?
▪ Capacity of the HMIS to produce regular information that is useful for managing the maternal and newborn health programme, and particularly its capacity to provide quick responses to the aforementioned questions.
This part of the workshop often leads to the need to better manage the national network of EmONC facilities and the need to make key SRH/MNH information available on a routine basis in order to achieve a functioning network of referral maternity facilities.
● The third and final part of the workshop involves participants reaching a consensus to identify objectives for the development of the national network of EmONC facilities, and then milestones for managing its implementation. One of the major difficulties in efficiently managing an EmONC facility network is producing regular data on the activities of EmONC facilities and setting up a response system to address the identified gaps relating to availability and quality of care. Countries with a high MMR that successfully managed to overcome this challenge decided to do the following:
1. Limit the number of EmONC facilities so that teams of skilled healthcare professionals can be assigned to them more easily for provision of care 24h/7d, and health facilities can be better equipped and have better input supplies – this approach also facilitates the monitoring of the availability and quality of care and the implementation of responses to address gaps in availability and quality of care;
2. Establish regular data collection and analysis of data that is reliable, relevant, readily available and usable – in conjunction with the HMIS and/or other existing systems for regular data collection on the health programme;
3. Encourage staff decision-making in maternity facilities to resolve local problems related to the organization of services and quality of care.
Why not ask an obstetrician to carry out this MNH monitoring?
Ideally, there would be an obstetrician on the regional/district support team to address the clinical, technical and analytical aspects of the monitoring and quality of care improvement of EmONC facilities. However, in practice, it is difficult to find an obstetrician available for this type of work in most high burden countries. Establishing an agreement with the national association of gynaecologists and obstetricians could be an option to ensure that an obstetrician supervises the most important CEmONC facilities (university and regional hospitals). However, doctors who can administer EmONC or experienced midwives would generally stand in for obstetricians. Evaluations (carried out by UNFPA in some countries, but not published) show that doctors and midwives are sometimes more effective than obstetricians at providing this type of support, which requires skills beyond clinical expertise, such as management and analysis skills. Thus, it is important to be pragmatic and keep all options open.
Why not monitoring other health facilities that attend to births?
The primary objective of the approach detailed in this manual is to measure progress and address shortcomings in health facilities that are designated to provide EmONC services (BEmONC and CEmONC services). This approach is not aimed at monitoring health facilities that have not the mission to manage obstetric and neonatal complications and are therefore not equipped with the necessary means (in terms of human resources, equipment, range of activities, distance, etc.).
In the initial stages, health facilities that are not included in the EmONC facility network (meaning health facilities that can manage a routine delivery in satisfactory conditions but cannot attend to a referred emergency) are not monitored. These facilities often only manage a few births per month. Furthermore, the cost/benefit ratio of such monitoring covering a large number of health facilities that rarely attend to births would be much too high. These health facilities can be followed with the ‘traditional’ monthly HMIS reports of the MoH.
However, once the monitoring has been established in the designated EmONC health facilities and is well managed (in terms of both data collection, data analysis and response), the Ministry of Health and its technical and financial partners may decide to monitor other health facilities at the peripheral level of the EmONC network (eg. maternities performing routine deliveries). Such improvement of the availability and quality of care in peripheral metrenities should then be led by the district officers and include the participation of the skilled birth attendants of the EmONC facilities. The financial cost and the cost of human resources associated with this decision should be carefully weighed.