Met need for EmOC

The percent of all women with major direct obstetric compli­cations who are treated in a health facility providing emergency obstetric care (EmOC) in a given ref­erence period.

This indicator is calculated as:

(Number of women treated for direct obstetric complications at EmOC facilities, over a defined period / Estimated number of women who would have major obstetric complications (or 15% of expected births), during the same defined period) x 100

The direct or major obstetric complications in­clude:

  • Hemorrhage: antepartum, intrapartum, or post­partum;
  • Prolonged/obstructed labor;
  • Postpartum sepsis;
  • Complications of abortion;
  • Severe pre-eclampsia/eclampsia;
  • Ectopic pregnancy; and
  • Ruptured uterus.

 Number of women with a major obstetric complication includes both women admitted with the complication and women who develop the complication in the facil­ity.

EmOC facilities include both basic and comprehen­sive levels of essential obstetric care.

Met need should be calculated at all health facilities as well as at EmOC facilities to provide a more complete picture of the use of the health system and where women are being treated (WHO, 2009).

The number of women with a major obstetric compli­cation treated in EmOC facilities during the reference period; (an estimate of) the number of women with major obstetric complications in the population during the reference period

Facility records (for number of women treated) The number of pregnant women who develop obstetric complications requiring medical care to avoid death or disability is estimated to be 15 percent (WHO, 1994a). The number of live births frequently serves as a proxy for all births or pregnancies; when data on the numbers of live births are absent, evaluators can estimate them from total expected births = population x crude birth rate.

The purpose of this indicator is to gauge the level of use of EmOC services by women experiencing a major obstetric complication in a specified time period and geographical area.  Met need is a more refined measure of the use of EmOC than Proportion of all births in EmOC facilities.

Facility record-keeping systems may require adjust­ments for the routine collection of data on obstetric com­plications. A useful system will record major compli­cations in the patient register or maternity logbook. Evaluators must ensure that they gather information from all relevant parts of the facility (e.g., gynecology ward, surgical ward, abortion ward, morgue) and not just from the maternity ward. They must also include complications from all EmOC facilities in the area under study in the numerator.

UNICEF/WHO/UNFPA has set the minimum accept­able level of "met need" as 100 percent, but in most developing country settings, this target is unrealistic. If evaluators find less than 100 percent, they conclude that some women with complications are not receiving the necessary medical care. However, if "met need" is low, researchers should seek other data to determine whether the problem lies in the availability, accessibility, qual­ity of care provided, or other factors, such as cultural factors, that determine the utilization of services.

Theoretically "met need" can exceed 100 percent, if more than 15 percent of pregnant women in the popula­tion develop major obstetric complications. In devel­oped countries, the proportion of women with compli­cations managed in EmOC facilities may be greater than 15 percent of all births. Over-diagnosis of complica­tions, which is seen in parts of Eastern Europe, can also cause this ratio to exceed 100 percent.

One difficulty with "met need" is that complications are subject to numerous recording biases and, even when standard definitions are in place, results can vary greatly with the data collection system being used and the train­ing of the staff.  Furthermore, routine maternity record systems in many countries may not register the "reason for admission" or "maternal complications", although complications can lead to maternal deaths (WHO, 2009).

"Met need" is also particularly sensitive to the number of abortions included in the numerator. If the incidence of unsafe abortion is high, "met need" is likely to be high. The inclusion of all abortions can cause "met need" to be twice or three times as high as it would be without the abortions. Given this inflation of "met need" as a result of the inclusion of all abortion complications, a growing number of advocates for the indicator calcu­late it both ways, with and without all abortions. By excluding postabortion complications, estimates may be more comparable.

The appropriateness of using 15 percent of all births/ pregnancies to estimate the number of women who ex­perience obstetric complications is also open to discus­sion. WHO‘s estimates of births with complications may be higher than 15 percent: hemorrhage, 10 percent of pregnancies; sepsis, 8 percent; hypertensive disorders of pregnancy, 5 percent; obstructed labor, 5 percent (WHO, 1996a). However, prospective data from West Africa suggest that 6 percent more reasonably estimates severe obstetric complications (Prual, 2000). The nar­rower the definition of what is considered a direct or major obstetric complication, the more reliable and com­parable the estimates will be (MotherCare, 2000a). How­ever, birth records and registries will likely lack suffi­cient detail on complications to allow much refinement regarding the severity of a complication.

The issue of double-counting a woman in the numera­tor (one who is admitted to the same facility more than once during her pregnancy or postpartum period or one who is admitted to more than one facility) is unlikely to seriously bias the results. If this situation were to oc­cur, it would bias the indicators by presenting a more positive view of the health system than merited.

Given that the crude birth rate (CBR), the total popula­tion, and 15 percent are all estimates and that the accu­racy of the CBR and population may vary according to the source, "met need" will likely be imprecise and may over- or underestimate the true value. To make the indi­cator useful for comparisons across facilities and dis­tricts or over time, one must use the same definitions and document the criteria used in each definition.

access, health system strengthening (HSS), obstetric fistula (OF), emergency, safe motherhood (SM)

Monitoring Emergency Obstetric Care: a handbook.  WHO, UNFPA, UNICEF, AMDD, 2009.

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