Key RMNH indicators for analysing and monitoring the development of the EmONC network

The analysis indicators to be used at the national and regional/district levels should be established during the national design workshop (see Chapter 2) and based on the data specified in the monitoring sheet. We recommend using the following key RMNH indicators at the national and regional/district levels for the baseline analysis situation, and for monitoring the EmONC network development:

TABLE 6: SUGGESTED RMNH INDICATORS IN EmONC HEALTH FACILITIES

KEY INDICATORS RECOMMENDED TARGETS

1. Number of functioning CEmONC health facilities in the considered area (functioning = no shortfalls in the nine signal functions and maternal and newborn

services available 24/7) MAXIMUM five EmONC health

facilities per 500,000 population, including at least one CEmONC health facility

2. Number of functioning BEmONC health facilities in the considered area (functioning= no shortfalls in the seven signal functions and maternal and newborn services available 24/7)

3. Proportion of functioning EmONC health facilities in the considered area:

- numerator = number of functioning EmONC health facilities;

- denominator = number of designated EmONC health facilities in the considered area (in the programmatic cycle(s))

At least 80% of designated EMONC health facilities need to be functioning in the considered programmatic cycle(s)

4. Proportion of expected deliveries in functioning EmONC health facilities:

- numerator = number of deliveries in functioning EmONC facilities;

- denominator = expected number of deliveries in the considered area (in the programmatic cycle(s))

All expected deliveries should take place in functioning EmONC health facilities. An intermediary and realistic recommended target is that 30-50% of expected deliveries should be in functioning EmONC health facilities in the considered area (in the programmatic cycle(s)) 5. Proportion of expected births with major direct

obstetric complications in functioning EmONC health facilities (Met Need for EmONC):

- numerator = number of major direct obstetric complications in functioning EmONC health facilities

- denominator = expected number of major direct obstetric complications in the considered area (in the programmatic cycle(s)) - corresponding to 15% of expected births in the considered area

All expected births with major direct obstetric complications should take place in functioning EmONC health facilities. An intermediary and realistic recommended target is at least 50% of expected births with major direct obstetric complications should be in functioning EmONC health facilities in the considered area (in the programmatic cycle(s))

KEY INDICATORS RECOMMENDED TARGETS 6. Proportion of the population able to access the

closest designated EmONC health facility within 2 hours of travel time in the considered area

At least 80%

7. Proportion of the population able to access the closest functioning EmONC health facility within 2 hours of travel time in the considered area

At least 80% with intermediate realistic targets of 50% then 60%

and 70%, according to the baseline and resources available (in the programmatic cycle(s)) 8. Proportion of the population able to access the

closest functioning EmONC health facility providing quality care within 2 hours of travel time in the considered area

At least 50% with intermediate realistic targets of 20% then 30%

and 40%, according to the baseline and resources available (in the programmatic cycle(s)) 9. Proportion of regions or provinces reaching a

sufficient coverage of the population by functioning EmONC health facilities:

- numerator: number of regions or provinces reaching a sufficient coverage

- denominator: number of regions or provinces in the country

100% as all regions or provinces in the country should reach 80%

of the population covered by functioning EmONC facilities within 2 hours of travel time (in the programmatic cycle(s))

10. Caesarean section rate:

- numerator = number of caesareans in functioning EmONC facilities;

- denominator = number of expected births in the considered area

At least 5 per cent (complemented with a quality analysis using the Robson classificationon a sample of caesarean indications)

11. Direct Obstetric case fatality rate:

- numerator = number of maternal deaths due to major direct obstetric complications in EmONC facilities of the considered area - denominator = number of women treated for

major direct obstetric complications in the same EmONC facilities over the same period

Below 1%

KEY INDICATORS RECOMMENDED TARGETS

12. Intrapartum and very early neonatal death rate:

- numerator = number of intrapartum deaths (fresh stillbirths; ≥ 2.5 kg) and very early neonatal deaths (≤ 24 h; ≥ 2.5 kg) in the EmONC facilities of the considered area - denominator = number of deliveries in the

same EmONC facilities over the same period

To be decided

13. Shortfall in midwives in the EmONC network:

- numerator = number of midwives actually working in the EmONC health facilities - denominator = number of midwives required

in the national network of EmONC facilities to meet national standards

0%

14. Percentage of “good” BEmONC/CEmONC facility referral links in the national network:

- numerator = number of BEmONC/CEmONC facility referral links that are unproblematic and done in less than 2 hours

- denominator = total number of BEmONC/

CEmONC facility referral links in the considered area

90%

The monitoring of the national network of EmONC facilities allows to track on a quarterly basis the offering of the signal functions, which impacts the definition of a functioning EmoNC health facility. For example, is an EmONC health facility functioning for a year if it is functioning for the four quarters of the year or only for three quarters (including the last quarter). These questions are currently under consideration in countries that are monitoring their national EmONC network, such as Burundi, Madagascar, Senegal and Togo.

In addition, the use of AccessMod to calculate the proportion of the population covered by a functioning EmONC health facility within 2 hours or 1 hour travel of time seems to be a more interesting indicator than the “availability of EmONC”, linked to the number of functioning EmONC health facilities for 500,000 population. The authors recommend

that in the future the coverage of the population by functioning EmONC health facilities replaces the EmONC availability as international tracer.

Finally, a new indicator should be considered, the population covered within 1 or 2 hours of travel time by a functioning EmONC health facility with quality of care. The definition of the quality of care should be based on an index covering both the provision and experience of care as recommended by WHO.