3.1. Health Systems and Service Delivery
Facts/messages: In this section, the focus changes from fertility, its variations and its direct determinants to specific service interventions that affect both fertility and broader SRH issues. One of the most important agreements of the World Summit of 2005 was the inclusion of a target to achieve “universal access to reproductive health” by 2015, in accordance with the Plan of Action of the International Conference on Population and Development (ICPD). This new target complemented strategies aimed at achieving the development goals that had been internationally agreed in the Millennium Declaration: reducing maternal mortality, improving maternal health, reducing infant mortality, promoting gender equality, combating HIV/AIDS, and eradicating poverty (paragraph 57, g). The latter can be considered as recognition of the crucial role played by UNFPA in supporting countries to attain the MDGs.
Both men and women need access to information and appropriate health services throughout their lives. Such services need to be gender sensitive and allow: 1) All individuals to make informed choices about sexuality and reproduction, and to have a safe and satisfying sexual life, free of violence and coercion; 2) Women to go safely through pregnancy and childbirth; 3) Couples to have the best chance of having a healthy infant; 4) Women to avoid unwanted pregnancy and to address the consequences of unsafe abortion; 5) Access to prevention, treatment and care for sexually transmitted infections, including HIV.
A full sexual and reproductive health package includes:
- Family planning/birth spacing services;
- Antenatal care, skilled attendance at delivery, and postnatal care;
- Management of obstetric and neonatal complications and emergencies;
- Prevention of abortion and management of complications resulting from unsafe abortion;
- Prevention and treatment of reproductive tract infections and sexually transmitted infections including HIV/AIDS;
- Early diagnosis and treatment for breast and cervical cancer;
- Promotion, education and support for exclusive breast feeding;
- Prevention and appropriate treatment of sub-fertility and infertility;
- Active discouragement of harmful practices such as female genital cutting;
- Adolescent sexual and reproductive health;
- Prevention and management of gender-based violence.
The quality of care encompasses various dimensions, such as 1) Access to services; 2) Adequate supplies and equipment; 3) Application of evidence-based clinical protocols; 4) Technical, managerial and interpersonal skills of health staff.
Methodology: The following tools have been developed to assess information on the capacities, availability and distribution of health services.
The Service Provision Assessment (SPA) survey is a nation-wide survey intended to measure the capacity of health facilities to deliver quality services in the areas of maternal and child health and HIV/AIDs. The survey collects information on preventive, diagnostic and treatment services in the major topic areas listed above.
The Service Availability Mapping (SAM) is intended to collect and present basic information on the availability and distribution of health services. It is used at the sub-national or district level in conjunction with WHO’s Health Mapper application. SAM collects statistics on the following areas: availability of health services and resources and the mapping of facility distribution in a given area. Health Services include infrastructure, infection control procedures, staffing, laboratory facilities, essential medicines, supplies and treatment guidelines, to determine the distribution and nature of existing service delivery points.
It includes two components. The first is a key informant survey, an interview given to health personnel at the district level to ascertain service availability, human resources, medicines, supplies and coverage of national programmes. The second is the facility census, a questionnaire applied to all formal public and private health facilities in the community to complement and validate information collected from the interviews. The key output is a national database of health facilities, equipment and services offered. It should be noted that this tool is intended to retrieve information on all key public health interventions. It does not include information beyond the facility and does not directly assess the quality of services provided at each facility. It may be difficult to identify all health facilities in a country. Small clinics and private facilities are often un-registered, making them difficult to identify.
The Service Provision Assessment (SPA) survey uses the following four instruments to gather a comprehensive picture at each health facility: 1) Facility inventories; 2) Clinical observation checklists to measure provider performance; 3) Health worker interviews; and 4) Client exit interviews. The information gathered from this process provides valuable baseline data and is very useful for long-term planning.
- Specialized surveys;
- Facility censuses.
- Country Reports available at: http://www.measuredhs.com/pubs/search/search_results.cfm?Type=21&srchTp=type&newSrch=1;
- National reports. Available at: http://www.who.int/healthinfo/systems/samdocs/en/index.html;
- WHO: Detailed report on SAM. Available at: http://unfpa.org/webdav/site/global/shared/documents/publications/2010/srh_guide/index.html.
- UNFPA. Sexual and Reproductive Health Assessment Tools for Situation Analysis;
- UNFPA. A Guide to Tools for Assessment of Sexual and Reproductive Health. Available at: http://unfpa.org/webdav/site/global/shared/documents/publications/2010/srh_guide/index.html;
- Service Provision Assessment (SPA). Available at: http://www.measuredhs.com/aboutsurveys/spa/start.cfm;
- Service Availability Mapping (SAM): Available at: http://www.who.int/healthinfo/systems/serviceavailabilitymapping/en/index.html.
3.2. Emergency Obstetric Care
Facts/messages: To achieve the Millennium Development Goal of a 75% reduction in the maternal mortality ratio between 1990 and 2015, countries throughout the world are investing more energy and resources into providing equitable, adequate maternal health services. One way of reducing maternal mortality is by improving the availability, accessibility, quality and use of services for the treatment of complications that arise during pregnancy and childbirth. These services are collectively known as Emergency Obstetric Care (EmOC). Access to EmOC in high-income countries has helped to ensure that pregnancy and childbirth are no longer major threats to the lives of women and newborns. But in most low– and middle-income countries, where 99% of all maternal deaths occur, this is not the case. Their health systems still fail to provide widespread access to this life-saving solution.
Basic emergency obstetric and newborn care includes the capabilities for 1) Administration of antibiotics, oxytocics, and anticonvulsants; 2) Manual removal of the placenta; 3) Removal of retained products following miscarriage or abortion; 4) Assisted vaginal delivery, preferably with vacuum extractor; 5) Newborn care.
Methodology: The handbook on Monitoring Emergency Obstetric Care (WHO/UNFPA/UNICEF/ AMDD) assesses the availability, use and quality of obstetric services. The Handbook is often used as a resource for conducting Needs Assessments of Emergency Obstetric and Neonatal Care (EmONC). The indicators described in this handbook can be used to measure progress in a programmatic continuum. The indicators address the following areas: availability, use, and quality of emergency obstetric and newborn care services in a given facility, area or country.
The Needs Assessments of Emergency Obstetric and Newborn Care (EmONC) toolkit provides detailed guidance and tools for conducting an EmONC Needs Assessment along the programmatic continuum from the availability of and access to services to the use and quality of services. The toolkit is comprised of modules (data collection tools) and accompanying guides for assessment facilitators, data collector trainers, data collectors, and data analysts. Major areas covered within this toolkit are: availability, use, and quality of EmONC services in a given area or country.
The handbook describes the process of collecting data from health facility registers and with checklists, calculating the EmOC Indicators and interpreting results at the facility, sub-national and national levels. EmOC Indicators are essential for monitoring trends in obstetric care by facility staff, and to programme planners and managers for measuring the availability, utilization and quality of EmOC services which are critical to reducing maternal and neonatal mortality. EmOC Indicators are:
1) Availability of emergency obstetric care: basic and comprehensive care facilities;
2) Geographical distribution of emergency obstetric care facilities;
3) Proportion of all births in emergency obstetric care facilities;
4) Meeting the need for emergency obstetric care: proportion of women with major direct obstetric complications who are treated in such facilities;
5) Caesarean sections as a proportion of all births (estimated proportion of births by caesarean section in the population is not less than 5% or more than 15%;
6) Direct obstetric case fatality rate;
7) Intrapartum and very early neonatal death rate; and
8) Proportion of maternal deaths due to indirect causes in emergency obstetric care facilities.
The Needs Assessments of Emergency Obstetric and Newborn Care (EmONC) toolkit is a facility-based, cross-sectional study that collects data from medical registers, observation, and provider interviews using a set of modules that are adapted to local context. Collect data from every health facility in the area or country, including all hospitals, while selecting from lower-level health facilities. EMOC is emergency treatment for the direct obstetric causes of maternal and newborn mortality. There are different interventions, such as providing antibiotics, cesarean sections, and blood transfusions that make up EmOC. Depending on the methodology for facility selection, results may contain limitations. If facilities are selected deliberately or through restricted census, results cannot be extrapolated to the entire country, while if a random sample of facilities is selected, results may be of limited use for district-level planning. Establish baseline data for a carefully selected group of EmOC Indicators to adequately measure availability, utilization and quality of EmONC services, at national and sub-national levels. The Indicators focus on actual, rather than theoretical, functioning.
- Ministries of Health;
- Health facility registers;
- Medical registers.
- Doctors of the World. West Pokot facility needs assessment—maternal and newborn care. Unpublished data. Nairobi, 2007.
- AMDD, Columbia University. (2010). Needs Assessment of Emergency Obstetric and Newborn Care: Data Collection Modules. Needs Assessments of Emergency Obstetric and Newborn Care (EmONC). Available at: http://www.amddprogram.org/d/content/national-needs-assessments-emergency-obstetric-and-newborn-care;
- WHO / UNFPA / UNICEF / AMDD (2009). Monitoring emergency obstetric care: a handbook. Available at: http://unfpa.org/public/publications/pid/3073;
- UNICEF / WHO / UNFPA (1997). Guidelines for monitoring the availability and use of obstetric services;
- AMDD, Columbia University. (2003). Using the UN process indicators of emergency obstetric services: questions and answers;
- UNFPA and AMDD (2002). Reducing maternal deaths: selecting priorities, tracking progress. Distance learning courses on population issues.
Module 1: Understanding the Causes of Maternal Deaths;
Module 2: Using Indicators to Assess Progress in Reducing Maternal Deaths;
Module 3: Targeting Maternal Deaths through Policies and Programs.
3.3. Unmet Need
Facts/messages: Unmet need refers to women and couples who do not want another birth within the next two years, or ever, but do not use a method of contraception. Unmet need results from growing demand, service delivery constraints, lack of support from communities and spouses, misinformation, financial costs and transportation restrictions. As the desired family size shrinks, the unmet need tends to grow until service capacity catches up with the expressed need for fewer births and longer birth intervals. Hereafter, gains in service accessibility successively reduce unmet need.
Despite the increase in contraceptive prevalence there is still an unmet need for contraception, especially modern methods. In developing countries, total fertility regularly exceeds wanted fertility; on average the difference was around 0.8 children by the early 2000s. Overall, 29 % of women in developing countries have an unmet need for modern contraception. The highest proportion, several times the level of current use, is in sub-Saharan Africa where 46 % of women at risk of unintended pregnancy are using no method.
Methodology: Estimate the proportion of women not using contraception, who either want to stop further childbearing (unmet need for limiting) or who want to postpone birth of their next child by at least two or more years (unmet need for spacing). DHS’s measures are based on married women only, although a separate measure is used to gauge the needs of unmarried women. The measure focuses on the use of all methods of contraception, with an additional measure estimating the unmet need for modern methods.
Following standard DHS methodology for estimates of unmet need, divide all women into those using and those not using contraceptive methods. Divide the nonusers into currently pregnant or amenorrheic women and who are in neither category. Classify the pregnant or amenorrheic women by whether pregnancy or birth was intended, mistimed, or not wanted. Pregnancies and births classified as mistimed or unwanted will be regarded as one component of unmet need. The other component consists of non-users who are not pregnant or amenorrheic. First, divide the women into fecund or infecund women, with the fecund women then subdivided by their reproductive preferences. Women who desire another child soon will be excluded from the unmet need estimate, while women who wish to wait or who wish no more children are included into the category of unmet need.
The manual on Introducing Systematic Screening to Reduce Unmet Health Needs outlines a technique for integrating regular and systematic screening of the availability and quality of reproductive health services at the facility level to determine unmet need and assist developing strategies in increasing the use of existing services. It includes a tool for collecting screening data on the services women and men have come to seek at a particular facility as well as other services they may be interested in benefiting from and whether or not those services are available (met and unmet need). The manual includes guidance on how to select facilities, train screeners, gather, analyze and use data to inform programming.
- R. Vernon; J. R. Foreit and E. Ottolenghi (2008). Introducing Systematic Screening to Reduce Unmet Health Needs: a Manager’s Manual.Population Council / USAID. Available at: http://www.popcouncil.org/Frontiers/projects_pubs/topics/SLR/ SystematicScreeningManual. html.
34 UNFPA (2010). How Universal is Access to Reproductive Health? A Review of Evidence. New York, UNFPA.
35 WHO’s Health Mapper application. Availablte at: http://www.who.int/health_mapping/tools/healthmapper/en/