Definition of a national reference document for BEmONC facilities

It is difficult to suggest an international standard for BEmONC facilities that could be adapted to all contexts, beyond the framework proposed in this technical sheet. As such, we recommend that countries develop a national BEmONC reference document.

This document should specify the duties, technical attributes, organization and clinical referral arrangements between peripheral health facilities (non EmONC) and BEmONC facilities or CEmONC facilities and between BEmONC and CEmONC facilities, as well as the process for monitoring the obstetric and newborn activity.

It should also set out the number and competencies of staff required in a BEmONC facility to guarantee 24h/7d services. The human resources appointed should be determined by the obstetric activity and other tasks assigned to a country’s BEmONC facilities. It is critical to know the number of midwives per BEmONC facility for determining the human resource requirements within the EmONC network. Given the absence of recommendations on this question at the international level, except the FIGO Statement (cf. footnote ix) on staffing requirements for delivery care, countries should set their own national standard based on the following questions:

- considering the other duties assigned to a midwife in a BEmONC facility, what is the maximum number of births per month that she/he should attend to?

- what is the minimum number of midwives required at a BEmONC facility to provide 24/7 obstetric and newborn care?

We also recommend that countries create a standard infrastructure plan for BEmONC facilities at the national level, adapted to the duties of a BEmONC facility, in order to optimize the effectiveness of the working environment for the staff. In Haiti, an architect from the United Nations Office for Project Services (UNOPS) was appointed by the Ministry of Health to draw up such a floor plan over the course of a year. The process involved consultations with the Department of Family Health, the Department of Health Service Organization, professional organizations (of obstetricians and midwives), managers from health departments, UNFPA, WHO and UNICEF, to reach a consensus on cost and functionality (see Figure 33).

FIGURE 33: STANDARD FLOOR PLAN OF A BASIC EMERGENCY OBSTETRIC AND NEWBORN CARE (BEmONC) FACILITY, MINISTRY OF HEALTH, HAITI

Such national standard for the infrastructure of a BEmONC facility is very useful for laying out the vision of a BEmONC facility and integrating the national standard of a BEmONC facility in the health system (irrespective of the denomination of the health facility in the hierarchy of the health system), for assisting with resource and infrastructure planning as well as organizing the evaluations and audits of the EmONC network. In Haiti, the Ministry of Health bases its authorizations for renovation and construction of EmONC facilities on this model; which should of course be adapted to local circumstances, particularly taking into account the physical space available in urban areas.

Septic tank

Laundry room

Waiting area

Area: 227 square meters

2. Technical Sheet no. 2: Collaboration links within the EmONC network 2.1. Structure of the EmONC network

As previously mentioned in this document, the EmONC facilities should be organized into a network with a standard pyramid structure. The aim of the network should be to provide the majority of pregnant women and newborns with the defined national quality of care standards (which should align to WHO quality of care standards for MNH¹⁹). This requires to ensure good referrals for obstetric and newborn emergencies and technical support for staff.

The time factor to reaching care (second delay) is key with regards to ensuring the management of obstetric emergencies at the appropriate level within the network.²⁰ Referral time depends on road conditions, access to transportation means, and the number of EmONC facilities that cover a population area. This number in turn depends on the human and financial resources required and available to set up an EmONC facility (see Technical Sheet no.1 on resources to be allocated to a BEmONC facility).

It is necessary to find a suitable balance among these various parameters in order to achieve SDG 3.1 national target of MMR reduction . And, as detailed in the prioritization phase in Chapter 4, this exercise is a determining factor in ensuring the efficiency of the EmONC network. Each country should develop a system in which the levels of the various health facilities are clearly defined: peripheral facilities performing a limited number of normal deliveries or rarely, BEmONC facilities (first referral level - and part of primary healthcare) performing normal deliveries and managing basic obstetric and newborn complications, and CEmONC facilities (second referral level) performing normal deliveries and managing basic and complex complications, including the ones requiring surgery. The development of this system is illustrated in Figure 34.

FIGURE 34: SET-UP OF A NETWORK OF EMERGENCY OBSTETRIC AND NEWBORN CARE (EmONC) REFERRAL FACILITIES

To a network of designated EmONC Health Facilities From a non structured EmONC network...

HEALTH FACILITY Routine SRMNH care only

HEALTH FACILITY Routine SRMNH care

+ CEmONC HEALTH FACILITY

Routine SRMNH care + BEmONC

HEALTH FACILITY Routine SRMNH care

HEALTH FACILITY Routine SRMNH care

+ BEmONC HEALTH FACILITY Routine SRMNH care only

HEALTH FACILITY Routine SRMNH

care only

DESIGNATED BEmONC HEALTH FACILITY

(midwifery led) Routine SRMNH care + BEmONC

DESIGNATED CEmONC HEALTH

FACILITY Routine SRMNH care + CEmONC

HEALTH FACILITY Routine SRMNH

care only

DESIGNATED BEmONC HEALTH FACILITY

(midwifery led) Routine SRMNH care + BEmONC

HEALTH FACILITY Routine SRMNH

care only

Referral links with no major obstacles and within 2 h LEGEND

Referral links with obstacles requiring improvement

Referral links with obstacles requiring multi sectoral interventions and more than 4h