Need Assessment of Emergency Obstetric and Neonatal Care
(EmONC) in Selected Health Care Facilities across Pakistan
Dr Farah Rashid SiddiquiAssociate Professor
Yusra Medical & Dental CollegeIslamabad
Background • The EmONC is a descriptive need assessment of
selected health facilities of Pakistan.
• The assessment by definition examined only facility-based services.
• The current needs assessment is designed to identify needs and gaps and to inform programmatic efforts for increasing quality, coverage, and utilization of EmONC services
Basic EmONC (B.EmONC )To qualify for a B. EmONC facility, the health centres and hospitals must have performed the following seven signal functions within the past 3 months (WHO, 2009)
1)administered parenteral antibiotics;2)administered parenteral anticonvulsants;3)administered parenteral oxtyocics;4)performed manual removal of placenta;5)performed removal of retained products (MVA)6)performed assisted vaginal delivery (with vacuum
extractor or forceps); and7)performed neonatal resuscitation with bag and
mask.
Comprehensive EmONC (C.EmONC• For a C.EmONC facility, the hospitals must have
performed following two additional signal functions besides above seven, within the past 3 months:
• Blood transfusion; and• Caesarean section.
Objective:• To assess the EmONC available in selected
Health Care Facilities across Pakistan with a view to identify gaps and suggest measures to bridge those gaps in service delivery.
• This needs assessment examined facility readiness, provider skills, the quality of services, coverage and utilization of EmONC services.
Selection of Health Facilities
• 31 Basic EmONC health facilities in 14 districts and
• 11 Comprehensive EmONC health facilities in 10 districts of;
• Punjab, Sindh, KPK, Balochistan and AJK
Table 1: Distribution of type of health facility by Province for B.EmONC
Province Type of health facility BHU RHC THQ Total
Punjab 9 2 1 12 Sindh 4 1 2 7 Khyber Pakhtoonkhwa 1 2 1 4 Balochistan 2 1 1 4 Azad Jammu & Kashmir 1 1 1 3
Table 2: Distribution of type of health facility by Province for C.EmONC
Province Type of health facility RHC THQ DHQ Total
Punjab 0 2 1 3 Sindh 1 1 1 3
Khyber Pakhtoonkhwa 0 1 2 3 Balochistan 0 0 1 1
Azad Jammu & Kashmir 0 1 0 1
Methodology &EmONC Assessment Tool:
• It was a cross-sectional survey conducted during 2010-2011. Data was collected on a structured checklist.
• Key Informant interviews with;– EDOH, – Medical Officer In charge, – dispensers and – community members; were conducted
Indicators 1 Infrastructure status 2 Staff availability 3 Basic Equipment
(Functional) 4 EmONC equipment
(Functional) 5 Knowledge of LHVs on
MNCH 6 EmONC signal functions 7 HIS stationary 8 Client satisfaction 9 Disaster Management
Plan 10 Blood transfusion
available 11 C-Section performed 12 Lab services available
Indicators B EmONC(%) C EmONC(%)
Infrastructure status 71.2 78.2Staff availability 92 86.4Basic Equipment (Functional) 46.7 96.4
EmONC equipment (Functional) 18.8 80.6
Knowledge of LHVs on MNCH 45.4 54.5
EmONC signal functions 69.2 86.8
HIS stationary 77.4 63.6Client satisfaction 70 80Disaster Management Plan 19.4 27.2
Blood transfusion available N/A 91
C-Section performed N/A 91Lab services available 38.7 82
Results
Comparison of the responses to the most important indicators information is presented in a consolidated manner
(%) for EDOH, MO and Community members
Indicators EDOH(%)
MO(%)
Community(%)
24/7 EmONC functionality 100 94 67
EmONC services availability 95.6 92 50
Staff well trained 84 91 71
Disaster responsiveness 69 50 46
B.EmONC health facilities- comparison of data for March 2010-11
March 2010 March 2011
ANC 56,904 57,172TT 32,906 33,237Deliveries 13,344 14,009PNC 12,487 14,593Children vaccinated for Measles 35,611 33,256
C.EmONC health facilities- comparison of data for March 2010-11
March 2010 March 2011
ANC 23,179 26,462Deliveries 21,091 27,190C-section 531 647PNC 18,344 19,417Children vaccinated for Measles 54,173 65,329Maternal deaths 8 9Neonatal deaths 30 36
1. Infrastructure Figure 1.1 B.EmONC Figure 1.2 C.EmONC
73.75
65
87.5
82.5
56.25
71.25
0 20 40 60 80 100
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
Infrastructure status at B-EmONC facilities (%)
100.0
55.0
83.3
60.0
85.0
78.2
0.0 20.0 40.0 60.0 80.0 100.0 120.0
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
Infrastructure status at C-EmONC facilities (%)
2. Staff Availability
Figure 2.2 C.EmONCFigure 2.1 B.EmONC
94
92
100
94
0
92
0 20 40 60 80 100
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
Human resource Availability on day of visit(%)
97.6
71.4
92.9
78.6
85.7
86.4
0.0 20.0 40.0 60.0 80.0 100.0
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
Human resource Availability on day of visit(%)
3. Basic Equipment Availability & Functionality
45.0
16.7
73.3
45.0
83.3
46.7
71.7
86.7
76.7
75.0
83.3
75.0
0.0 20.0 40.0 60.0 80.0 100.0
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
Basic Equipment Availability & Functionality (%)
Available
Functional
4. EmONC related Equipment Availability & Functionality
Figure 4.1 B.EmONC Figure 4.2 C.EmONC
13.8
20.0
35.0
20.0
0.0
18.8
42.5
40.0
45.0
38.8
0.0
40.6
0.0 20.0 40.0 60.0 80.0 100.0
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
B.EmONC related equipment Availability & Functionality (%)
Available
Functional
89.9
82.6
84.1
43.5
73.9
80.6
0.0 20.0 40.0 60.0 80.0 100.0
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
C.EmONC related equipment Functionality (%)
5. HMIS- Figure 5.1 B.EmONC Figure 5.2 C.EmONC
93.8
40
80
75
0
77.4
0 20 40 60 80 100
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
HIS Stationary Availability (%)
100
0
100
0
1
63.6
0 20 40 60 80 100
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
HIS Stationary Availability (%)
. 6. Availability of Essential drugs
Figure 6.1 B.EmONC Figure 6.2 C.EmONC
75.7
82.9
77.1
95.7
42.9
78.6
0.0 20.0 40.0 60.0 80.0 100.0
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
Essential drugs availability at health facilties (%)
100.0
63.9
69.4
75.0
100.0
79.5
0.0 20.0 40.0 60.0 80.0 100.0
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
Essential drug availability at health facilties (%)
7. Knowledge of LHV on MNCHFigure 7.1 B.EmONC Figure 7.2 C.EmONC
40.0
40.0
58.5
57.7
61.5
45.4
0.0 20.0 40.0 60.0 80.0 100.0
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
Knowledge of LHVs on MNCH issues(%)
69.7
39.4
60.6
36.4
54.5
54.5
0.0 20.0 40.0 60.0 80.0 100.0
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
Knowledge of LHVs on MNCH issues(%)
8. Knowledge of WMOs on C-section sterilization and post-op care
55.6
22.2
44.4
0.0
33.3
36.4
0.0 20.0 40.0 60.0 80.0 100.0
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
Knowledge of WMOs on C-section, sterilization & post-op care (%)
9. Availability of EmONC services including all the signal functions
Figure 9.1 B.EmONCFigure 9.2 C.EmONC
63.1
66.2
83.1
78.5
84.6
69.2
0.0 20.0 40.0 60.0 80.0 100.0
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
Availability of Basic EmONC services including signal functions (%)
100.0
90.0
65.0
95.0
95.0
86.8
0.0 20.0 40.0 60.0 80.0 100.0 120.0
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
Availability of Comprehensive EmONC services including signal functions (%)
10.Disaster management plan for MNCH
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Yes No
27.2%
72.8%
Do you have a disaster management plan for B.EmONC
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Yes No
19.4%
80.6%
Do you have a disaster management plan for C.EmONC
The health facilities who shared the disaster management plan, had the following components covered;
• Extra beds are placed in the hospital for affectes
• Extra supplies are made available• Coordination is made with donors• Coordination is made with DGHS
11. Community SatisfactionFigure 11.1 B.EmONC Figure 11.2 C.EmONC
64.4
57.8
91.1
80.0
88.9
70.0
0.0 20.0 40.0 60.0 80.0 100.0
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
Community Service users satisfaction (%)
88.9
70.4
88.9
55.6
88.9
80.8
0.0 20.0 40.0 60.0 80.0 100.0
Punjab
Sindh
KPK
Balochistan
AJK
Pakistan
Community Service users satisfaction (%)
Conclusion
• There is a need to provide improved EmONC services through Quality, Effectiveness, Acceptability, Accessibility and Affordability.
• District wise Disaster Management Plans should be
prepared with the active involvement of EDHOs, DHOs and other important stakeholders.
• Vertical programs like National MNCH program should be
actively involved in Provincial and district disaster management plans for filling the gaps, training of staff and provision of Basic and Comprehensive EmONC services
10:59 AM 28
SECTION – V: AVAILABILITY OF LAB & DIAGNOSTIC SERVICES(Check, Observe And Report By Ticking Either “Yes” Or “No”)
Sr. Services Yes No
1. Hemoglobin
2. Blood Grouping
3. TB Lab smear diagnostic services
4. Routine blood examination services
5. X-Rays chest services (Radiological services)
SECTION – VII: DRUG STOCK OUTS (YES MEANS DRUG OUT OF STOCK)(Check, Observe And Report By Ticking Either “Yes” Or “No”)
Drug Items
At the day of VisitDuring Last 3
Months If yes, number of stock out days in last 3 months
Yes No Yes No
1. Antipyretic Syrups
2. Antibiotic Syrups
3. ORS
4. Zinc
5. Ferrous Sulphate
6. Deworming Syrups
7. Deworming Tablets
8. EmONC Drugs
9.RHZE (Rifampicin 150mg + Isoniazid 75mg + Pyrazinamde 400mg + Ethambutol 275mg)
10. HR (Isoniazid 100mg + Rifampicin 150mg)
11. Streptomycin (750mg)
SECTION – IX: QUALITY OF CARE INDICATORS Check The Appropriate “Yes” Or “No” Cell For Each Indicator After Thorough Observation.
Quality: Process Indicators Yes No
Maintenance and updating of records/ registers
Telemedicine sessions being held in the health facility
DEWS liaisoning center established
DEWS reporting systems functional in the health facility
Mobile clinics functional
Laboratory pick-up points functional
Health education MNCH, hygiene, sanitation, nutrition, breast feeding, home care of common illness developed, printed & available
Registration of Antenatal Cases complete
Antenatal cards available
Family planning 3 modern methods available
Five essential EmONC drugs available
Functional emergency newborn care unit available
Blood transfusion services available
C-Section services available
Maternal and newborn referral slips available
Facility functional 8/6 for preventive MNCH services
Facility functional 24/7 for basic EmONC Services
Facility functional 24/7 for comprehensive EmONC services
Child weights being plotted on growth charts
Children being vaccinated according to EPI protocol
Lab register maintained for STI tests
Obstetric register record updated with normal deliveries and complications
IUD cards available and filled for follow-up
Environmentally acceptable placenta disposal methods in place
Environmentally acceptable methods of risk waste disposal in place
Neonatal deaths investigate by clinical audit
Under 5 child deaths investigated by clinical audit
Maternal deaths investigated by clinical audit
Health facility has monthly performance review meeting
Health facility has quarterly performance review meeting
Quality Output/ Outcome Indicators (Ask, observe and check records) Yes No
SECTION – XAsk And Check The Figures For The Last 3 Months From Registers
Quality Outcome/ Outcome Indicators #
Number of women provided ANC
Number of MNCH health education sessions held in the community
Number of hygiene and sanitation health education sessions held in the community
Number of exclusive breast feeding and family planning health education sessions held in the community
Number of nutrition and home care of common illness health education sessions held in the community
Number of training sessions of health care providers carried out *
Number of women delivered in the health facility (Normal delivery)
Number of C-section deliveries in health facility
Number of women died during delivery
Number of women referred for delivery and complications
Number of children presented with diarrhea
Number of children with diarrhea who died
Number of children with presented with ARI
Number of children with ARI who died
Number of newborn referred
Number of newborn who died
Number of men (>18 years) diagnosed and treated through telemedicine
Number of women (>18 years) diagnosed and treated through telemedicine
Number of adolescents aged 5-18 years diagnosed and treated through telemedicine
Number of children under 5 years age diagnosed and treated through telemedicine
Knowledge of LHVs on MNCH issues
Serial no
Questions Pre-test evaluation Post-test evaluation
frequency %age frequency %age 1 How many antenatal
visits r recommended?
2 Skilled birth attendants are?
3 Danger signs during pregnancy
4 Hygiene during pregnancy
5 Danger signs after pregnancy
6 Child spacing between two pregnancy
7 Practices for clean cutting of cord
8 Myths of community in pregnancy
9 Ideal time to start breastfeeding
10 First bath to new born