The Unmet Obstetric Needs Network

Final Report

Part I. Synthesis

Dominique Dubourg

Vincent De Brouwere Wim Van Lerberghe Contract B7-6310/98/02 Fabienne Richard Vincent Litt

Marc Derveeuw

Strengthening Essential Obstetric Care, basic and comprehensive, is the key strategy to obtain rapid improvements in safe motherhood. Essential Obstetric Care encompasses a wide range of interventions. These include a set of major surgical and technical interventions that may be required to treat a number of conditions that directly threaten the life of the mother during labour. For a number of these interventions, the "major obstetric interventions for absolute maternal indications"1 it is possible to map under-utilisation: the unmet need for this type of care. In countries with high levels of maternal mortality policy makers and health care providers are often unaware of the extent of the unmet need for essential obstetric care - and of the often very real possibilities to improve things. Mapping unmet need for these "major obstetric interventions for absolute maternal indications" does not measure all the unmet need for basic or comprehensive essential obstetric care. It can however be useful to trigger the interest of a wide range of actors, lay and professional, in improving maternal health policies and services. The UON network brings together ministries of health, development organisations, scientific institutions and practitioners who want to map unmet need for "major obstetric interventions for absolute maternal indications" as a starting point - not just to improve maternal health but also the overall functioning of their health care system. The UON-network provides technical support for national teams involved in this kind of work, as well as opportunities to learn from each other. 1 Major Obstetric Interventions: caesarean section, laparotomy for uterine breach, internal version, symphysiotomy, craniotomy. Absolute Maternal Indications: severe antepartum haemomhage (placenta praevia and abruptio placentae), severe postpartum haemorrhage, foeto-pelvic dystocia, malpresentation (traverse lie and brow presentation).

UON Network – Unmet Need for Major Obstetric Interventions Co-ordination and Management Team http://www.uonn.org − e-mail : [email protected]

The UON Network is supported by: In collaboration with: • Deutsche Gessellschaft für Technische Zusammenarbeit (GTZ) – University of Heidelberg the European Commission DG VIII • World Health Organisation (WHO) Co-ordinated by : • United Nations Fund for Population Activities (UNFPA) Institute of Tropical Medicine (ITM) • United Nations Children’s Fund (UNICEF) Department of Public Health Nationalestraat 155 • Directorate General of International Co-operation – Belgium (DGIC) 2000 Antwerpen / Belgium

UON Network - Tackling Unmet Need for Major Obstetric Interventions 1

ric needs ...... 14 I

Network ...... 15 PART

–

ees, task forces and research teams ...... 21 SLAMABAD I untries...... 16 on unmet obstet ? ...... 9 CONTENTS t ObstetricNeed e UON case studies...... 17 BIDJAN AND A lection of co NTERNATIONAL COMPARISON NTERNATIONAL I ...... 4 ...... 5 COST APPROACH - per country ...... 18 ns ...... 10 ...... 3

...... 2 UTPUTS ? ...... 9 O icatio TUDIES AND TUDIES S EXT N EGIONAL MEETINGS IN UIDELINES ASE R G Baseline maps for planning and monitoring performance...... Baseline maps for planning and 6 Capacity building...... 7 Policy shifts ...... 8

C

HAT HAT ACKGROUND FAST AND LOW AND FAST ETWORK II III IV ESSONS LEARNT The extent of unmet obstetric need in poor countriesThe extent of unmet ...... 5 exercise...... to a country of doing a UON On the usefulness 6 Using UON for advocacy ...... 8 BBREVIATIONS ART ART ART Annex 5. Chronogramme of th Annex 6. Synthesis Annex 7. Constitution of Scientific Committ

Annex 4. Criteria for the se Annex 3. Structure of the Unme 4. A 2. N 3. L Annexes Annex 1. Publ Annex 2 Conferences and workshops 5. W P P P A

1. B

2 UON Network - Tackling Unmet need for major obstetric interventions WHO: WorldHealth Organisation WB: WorldBank Development forInternational States Agency USAID: United Need Obstetric UON: Unmet UNICEF: United Nations Children's Fund UNFPA: United Nations Population Fund UN :UnitedNations (Benin) Santé la de Développement au d'appui PADS: Programme Organisation NGO: Non-Governmental (Tanzania) Sciences ofHealth College University Muhimbili MUCHS: MOI: MajorObstetricIntervention of Health MOH: Ministry Ratio Mortality MMR: Maternal Control in Disease science of MDC: Master (Morocco) Administration of Health Institute INAS: National Course ICHD: International HSA: HealthServices HC: HealthCentre Cooperation) (German Zusammenarbeit fürTechnische GTZ: Gesellschaft Union EU: European Directorate-General Development Commission European EC DG-DEV: Familiale Santé de la DSF: Direction Survey Health and DHS: Demographic DGA (AGM):Assistant General Manager (Benin) etDémographie Humaine Reproduction en Recherche de Centre CERRHUD: team Management and Co-ordination CAM team: Développement au Coopération la de Générale (Administration Co-operation BADC: Belgian AMI A BBREVIATIONS : Absolute Matern : Absolute

Academy (Pakistan) al Indication in Health Development Health in

UON Network - Tackling Unmet Need for Major Obstetric Interventions 3 , , 4 , Health and their : 337-342; 3 28

, 119-134; 11 WHO marketed the (Suppl 2): S259-S265. MotherCare Matters 4 p and test the UON The assumption was 7 59 (4): 3-7. , 8 , ng countries: a 'state of the would increase awareness, Obstet . International Journal of Int. J. Gynecol. Obstet. Unmet Obstetric Needs Network Needs Obstetric Unmet Int J Hlth Plan Man Int J Hlth Plan Man of Columbia University Columbia of . INAS and Ministère de la Santé Publique Van den Broek N, Van Lerberghe W, and The

5 MotherCare Matters twork had to develo twork had betweenunmetthe– both need for care –, Int. J Gynaecol provide to deal with obstetric problems in a Concepts, General Principles and International the mostmeet for basic needs health care of gap made of maternal mortality ratios (MMR). ratios mortality Although of maternal made Obstetrical interventions and health centre coverage: a . 3: 308-314; mortality. To measure the extent of this staggering should ential obstetric care in developi ferral level, Geneva: WHO; Adeyi O. and Morrow R. H. J.. ms, and to find inroads to do something about it. about something do to inroads find to ms, and availability of resources, availability of promoted the notion of Emergency Obstetric Care, the and of theand of Demonstrating programme impact on maternal mortality. also saw a number of initiatives that tried to go beyond Health Pol.Plann

ternal (Zaire). indications in Kasongo and neonatal management: lessons from Guatemala.

1 stetric Interventions. Module I. m design from the PMM projects. actually delivers, (4): 386-393. – was to map the difference, area per area, between the number of major 6 15 what health care systems . : 99-103. ‘Prevention of Maternal Mortality Programme’ 74

. ing of their health care system. The ne The 2 Basic and Comprehensive Essential Obstetric Care. (1): 16-20 Approche de la et de la morbiditémortalité au Maroc maternelles Health Policy Plan 11 ‘First Safe Motherhood Decade’ Motherhood ‘First Safe , . http:\\www.uonn.org.

ACKGROUND The In 1997 the European Commission and a number of other agencies decided to launch a formal Unmet The starting point was a rather simplistic idea: if one could provide a cheap,reliable, and easily Tackling Unmet Need for Major Ob Maine D. 1997. Lessons for progra Maine D and Rosenfield A. 2001. The AMDD program: history, focus and structure. of obstetric care WHO. 1991.at first re Essential elements Van Lerberghe, W, Pangu K. A, and Van den Broek N. 1988. Graham W. J, Filippi V. G, and Ronsmans C. 1996. M. 1996. Improving obstetrical Koblinsky Penny S. andPenny Murray S. F.. 2000. for ess Training initiatives art' review.

approach, provide technical support as well as opportunities to learn from each other for national teams involved in this kind of work, and help countries to improve the way their health care systems deal with maternal health. 1996. Concepts and methods for of essential obstetric care. assessing the quality Pol Plann concepts of of concepts use of process indicators and the reliance on networks and human rights principles. rights human and networks on reliance the and indicators process of use ‘Averting MaternalDeath and Disability Initiative’ documentation and advocacy. MotherCare focused on improving the quality of hospital obstetric care and referral systems. that failure to perform the needed interventions would result in avoidable deaths, disability and suffering. This information,the on information coupled with pinpoint where the major problems are located, and kick-start a discussion among stakeholders on how to start improving things at local and at country level. development health, of ministries together brought UON network This Network. Needs Obstetric organisations, scientific institutions and practitioners who wanted to map unmet need for "major obstetric interventions for absolute maternal indications" as a startingpoint - to improve maternal health care and the overallfunction 7 3 4 5 6 1 2 the women in their constituencies, widespread use was was use widespread constituencies, their in women the works, what what understand to enough not it was clearly makers policy mobilising in was pivotal this works not and what should be done. human tragedy, and the failuresystems of many health to 1. B magnitude the document to better effort a major made has community the international the 1990s During of maternal health problems, and particularly maternal interventions needed to avert maternal deaths, and the actual number performed. INAS. 1992. du Royaume du Maroc eds. 130p. Casablanca: Ministère de la Santé du Maroc. Pangu K. A. 1989. Cesarean sections for ma 1-3.; Jessop S. M. 1999. Progress in Guatemala over the past decade. Gynecology & Obstetrics, of routine data for spatial analysis evaluation. Network understandable picture of it care the of population, given gap the bridging on stakeholders other and operators donors, planners, of attention the focus could this rather than on measuring the extent of the human disaster. A way to do this – inspired on previous work in the Congo and in Morocco the subject of this report, was part of this same movement: an attempt to go beyond the mere proble health of maternal extent the of measurement

4 UON Network - Tackling Unmet need for major obstetric interventions Data and Presentation of the Tables. Themodules oftheTables. Data andPresentation Establishment oftheProt ModuleII. International Network; Uganda. Burkina-Faso, Haiti, Mali, Niger, Pakistan, and Tanzania. and Pakistan, Niger, Mali, Haiti, Burkina-Faso,

10 9 8 Analysis. Data and Protocol, Collection Data Principles, General English: and French in available were modules three at theInstit based Network, ofthe team co-ordination by the developed been have level orregional atnational exercises UON forimplementing The guidelines 2. N approximately 65 million inhabitants with some 2.8 million births per year. year. per births million 2.8 some with inhabitants 65 million approximately (Final ReportPartII). studies case national seven and comparison inter-country an produced team co-ordination Part. IV).The Report (Final inAbidjan one and in Islamabad one meetings, interregional attwo discussed were results 2001. in modules ofthefirstthree version aPortuguese and 2000, in available became practices) and strategies policies, health maternal tool to document a Policy: Health the Maternal UON exercise at national or regional level. regional or atnational UON exercise 2001. November and 1998 September between period the covering grant EC from an came thiswork for corefunding The countries. poor in care forobstetric need unmet of extent and nature ofthe picture better a togive were exercises these Additionally, exercises. national the and the approach of usefulness the toevaluate and exercise, a UON forconducting up sign tovoluntarily countries seven and cheap as thought – in other words, whether whether words, other –in as thought cheap and fast as isreally exercises such conducting whether discusses Italso scene. international and national the the networ in participated that countries tothe benefits the countries; poor in need obstetric unmet of extent the about us teach exercises these what summarises A project). of the end formal the after started exercise these seven countries (the report does not cover Bangladesh,Cambodia and Cameroon where the UON Alltwelve were visitedby countries Conakry, Guinea Cameroon, Bangladesh,Benin,Cambodia, See annex 14: Tackling Unmet Need for Major Obstetric In Obstetric Unmet Need forMajor 14:Tackling Seeannex Seven countries completed the exercise and prod and the exercise completed countries Seven Ministries of Health or Research Institutes of twelve of Institutes orResearch ofHealth Ministries least at to get guidelines, and tools create to was remit Its 1999. in operational became network The This report summarises the main findings and lessons learnt by conducting the UON Exercises in in Exercises UON the conducting by learnt lessons and findings main the summarises This report ETWORK ETWORK

UON Study completed Study UON ongoing Study UON 10 A fourth module (Guidelines for Interviewing Stakeholders and Analysing the Evolution of of the Evolution Analysing and Stakeholders Interviewing for (Guidelines module Afourth Caribbean O UTPUTS F IGURE

the coordination team,butinfivethe the coordination 1.

C OUNTRIES EXPOSEDTOTHE can be downloaded from http://www.uonn.org. from http://www.uonn.org. can bedownloaded 8 Seven would eventually complete the exercise: Benin, Benin, exercise: the complete eventually would Seven it isanefficientway ocol on the Collection of Data; Module III. Analysis ofthe Analysis CollectionofData;Module III. ocol onthe ute of Tropical Medicine in Antwerp. By March 1999 1999 ByMarch Antwerp. in Medicine of Tropical ute terventions. ModuleI.Concept fter taking stock of the tools that were developed, it it developed, were that thetools of stock taking fter k; the use of the results for advocacy purposes, on on purposes, advocacy for oftheresults use k; the Haiti, Mali,Mozambique,Niger,Pakistan,Tanzania, Haiti, countries initially showed interest in conducting a conducting in interest initiallyshowed countries uced national reports. Methods and preliminary preliminary and Methods reports. national uced 9 The total population covered was of was covered population Thetotal UON clusion criteria (annex 3) were notmet. were clusion criteria 3) (annex to kick-startchange. APPROACH

s, General Principlesand s, General

UON Network - Tackling Unmet Need for Major Obstetric Interventions 5 , « Safe

need for major major for need OROCCO a priori a priori M

‘unmetneedfor major obstetrical interventions’ : Stratégies et Evidence Scientifique. De Brouwere V & urbanrural and of mothers 0.3% actually benefited , issuedin April 2001. dence, De Brouwere V & Van Lerberghe W eds. Antwerpen: the reviewresulted in strategya paperthe for EC on 11 EFICITS IN MAJOR OBSTETRIC INTERVENTIONS D

1. ABLE

T Expected Observed Number Number Observed Expected (CI) % (CI) Mali 4,960 985 3,975 (3,414 ; 4,400) 80.1% ; 82%) (78% Mali 1,898 1,617 281 (+105 ; +443) 14.8% ; +22%) (+6% Haiti 1,130 153 977 (872 ; 1,074) 86.5% ; 88%) (85% Haiti 171 244 -73 -58) (-89 ; -42.7% ; -31%) (-57% Total 29,613 6,130 23,484 (20,633 ; 26,022) 79.3% ; 81%) (77% Total 8,119 6,112 2,007 (1,254 ; 2,704) 24.7% ; 31%) (17% Niger 7,319 807 6,512 (5,832 ; 7,139) 89.0% ; 90%) (88% Niger 934 511 423 (+336 ; +503) 45.3% ; +50%) (+40% Benin 1,533 1,007 526 (384 ; 658) 34.3% ; 40%) (28% Benin 454 448 6 (-36 ; +45) 1.4% ; +9%) (-9% FOR ABSOLUTE MATERNAL INDICATIONS IN THE SEVEN COUNTRIES AND IN FOR ABSOLUTE MATERNAL INDICATIONS IN THE SEVEN COUNTRIES Pakistan 1,059 450 609 (511 ; 700) 57.5% ; 61%) (53% Pakistan 334 324 10 (-21 ; +39) 3.1% ; +11%) (-7% Morocco 7,095 1,780 5,315 (4,656 ; 5,923) 74.9% ; 77%) (72% Morocco 3,549 2,354 1,195 (865 ; 1,499) 33.7% ; 39%) (27% Burkina-Faso 6,518 948 5,570 (4,956 ; 6,118) 85.4% ; 87%) (84% Burkina-Faso 779 614 165 (+93 ; +232) 21.2% ; +27%) (+13%

ESSONS LEARNT To appreciate the significance of these proportions of unmet need it is useful to translate them into The co-ordination team also organised an international expert meeting on Mother’s Health and Health In the countries that were surveyed only 1.1% of Expected Observed Number (CI) % (CI) % (CI) Number Observed Expected Urban population MOI/AMI Deficits Rural population MOI/AMI Deficits Safe Motherhood of the Strategies: a Review Evi absolute figures as well. The studies in the various countries covered an estimated 2.8 million births. Out of those, at least some 37,700 were in need of a major life-saving major intervention for the indications considered. Only 12,242 of these interventions were actually performed. Of the women who benefited from interventionan between 93.8% (BurkinaFaso) and 99.5% (Pakistan) survived, as did between 59% (Benin)and 97% (Pakistan) ofthe newborns. 25,500Somepregnant women intervention did not get the they needed: they most probably died or suffered major disability. The extent of the unmet need is clearly related to access to health care infrastructure; this also explains much of the often considerable variation from one place to the other. Services in Brussels in November 2000. It reviewed the evidence on current Safe Motherhood strategies. Published in English and French in 2001,

ITGPress, 2001. 450 p.n. Réduire Maternité les Risques de la Van Lerberghe W eds. Antwerpen: ITGPress, 2001. 480 p.n. 11 3. L obstetric need in poor countries The extent of unmet The country UON assessments have resulted in a morerobust estimate of the obstetrical interventions for absolute maternal indications than was the case before the network started. We can now be reasonably confident that the figure 1.4% of (CI 1.27%-1.52%) is a sensible low-end estimate of the proportion of deliveries that require a major obstetric intervention to avoid a maternal death.

Motherhood and the European Commission: A strategy for improving maternal and perinatal health perinatal and maternal improving for A strategy Commission: European the and Motherhood through strengthening healthsystems and services» from such an intervention. In other words, the deficit, the was of 25% in urban and 79% in rural areas (Table 1).

6 UON Network - Tackling Unmet need for major obstetric interventions

unit in the health system. unit inthehealth obstetric level ofreferral situation on the only not perfo are where interventions facility onevery this kind obstetric intervention, early neonatal mortality, staffi an underwent who those among deaths ofthematernal causes the hospitals: inthe ofcare quality the of idea an gives also analysis The detailed biggest. are problems where locate merely not, however, so. doing presently are Faso) Burkina and Mali (Tanzania, countries Several interventions. obstetric major for need ofthe coverage inthe progress measure to which against line base Morocco, Niger,andat regional levelin theothers.Data collected during the surveycanused be as a Mali, Faso, Burkina in level country at exist now maps Such Faso. Burkina 3 for ofFigure example Themost directly output visiblecountry isthe level forplanning a Baseline maps agenda. on the motherhood to putsafe and issues resources human toaddress opportunity apolitical providing contributing by and(iii) do so; to capacities national byboosting (ii) performance; for monitoring and purposes planning maps for baseline national by providing which conducting UON-exercisesbroughthas benefits toth in ofareas anumber canidentify one Withhindsight health. withmaternal wayofdealing their improve to was objective theprimary thecountries For comparison. forinternational a benchmark establish to merely exercise UON a toconduct countries convince to out not set did network the Obviously, On theusefulnesstoacountryofdoingUONexercise

12 Organisation &Policy Organisation Ronsmans C. 2001. How can we monitorpr we How can RonsmansC.2001. Such maps of the unmet need for majorobstetric interventions are obvious tools for planners. Theydo

FOR MAJORLIFE 11,651 interventions 25,458 interventions performed, mothers performed, mothers 591 interventions not performed , 17 deceased : 317-342. survived 12 - SAVING OBSTETRICINTERVENTIONSINTHECOMBINEDSTUDYPOPULATION

nd monitoring performance F IGURE ogress towards improved maternal health? maternal health? towards improved ogress 2.

M ET AND UNMETNEED ET care, but indirectly on the overall performance of each of each performance overall on the indirectly but care, ng andequipment,etc. With exhaustive information of mappingof unmet need,in the format showedin the to shifts in national policies – not in the least by by theleast not in – policies national in shifts to rmed, Ministries of Health have reliable information information have reliable of Health Ministries rmed, e countries that participatedin the network: (i)

2.8 millionbirths interventions: 1.4%of need formajorlife-saving Low-end estimateofthe Studies inHealthServices

UON Network - Tackling Unmet Need for Major Obstetric Interventions 7

or the or 15

It is being , 16 ASO F Trop Int Med the development of 13 URKINA B 1998

UON

– EED IN RURAL AREAS OF EED IN RURAL N tetrical interventions in Guéckédou, Guinea (1988-96). the specificity of the country. Country teams produced the safemotherhood programme in Cameroon, BSTETRIC 14 sters in Rutshuru, Democratic Republic of Congo. O tetrical needs, Siem Reap Province, Cambodia. NMET U liable and relevant information than would have been obtained by obtained been have would than information relevant and liable tricaux dans la province de l’Adamaoua (Cameroun) en 1999. Département de la been collected in countries where information systems, hospital files and DEFICITS IN ABSOLUTE NUMBER ABSOLUTE NUMBER DEFICITS IN Medical Officers, researchers, Family/Maternal Health staff in MOH: the ISTRIBUTION OF D

3. IGURE F :1609-1613. (7): 559-565.

351 3

81 to 120 to 81 (16) to 41 80 (9) <= 40 (5) > 280280241 to (1) 240201 to (1) (1) 200161 to (6) 160121 to (11) The national teams have taken the time to discuss the UON concept with all the stakeholders This is not just snapshot information: the UON indicator has been used for assessing the Absolute number Rural deficits Von Schreeb S. 2000. A survey of essential obs Goyaux N. 2000. Les besoins obsté Porignon D, Soron'Gane E. M, Lokombe T. E, Isu D. K, Hennart P, and Van Lerberghe W. 1998. How robust are Van Damme W, De Brouwere V, Boelaert M, and Van Lerberghe W. 1998. The host population can benefit from a Lancet tested for prospective monitoring of program performances in a number of countries. Capacity building Each of the country-studies brought its share of experience and each constituted a learning experience for the research teams, the health district teams and sometimes also for the MOH’s Maternal Health Division. Except in Pakistan (where a research institution led the collection of data and the analysis), all country teams were new to this mix of research, planning and management. Apparently a UON exercise is possible even in countries where research capacities seem almost non-existent at the outset. It is also that data have to note important other records are generally considered weak. The data turned to be surprisingly reliable: most likely the direct involvement of the actual care providers in the research motivated them to make full use of their re more yielding – expertise local alone. researchers’ ‘external (gynaecologists, District composition of various committees is presented in Annex 7) during the preparation for the actual work. This phase took between 7 and 14 months but was crucial for the taking over of the approach and eventually for the adaptation of the protocols to their own documentsreports; and in Benin andNiger medical students madeUONstudy or usedprevious UON data for their thesis (Annex work 1). capacityof a health cope districtto with crisis and disasters Democraticin RepublicCongo. of Vina et du Faro Déo. 52p. district health systems? Coping district health systems? crisis and disa with refugee assistance programme. of major obs A spatial analysis Health repercussions of a refugee assistanceprogramme on the host population in Guinea, 14 15 16 13

the health services coverage in Cambodia,

8 UON Network - Tackling Unmet need for major obstetric interventions results. Meetings comprised scientific gatheringsas results. Meetingscomprised DG DEV, GTZ, UNFPA, UNICEF, WHO and the World Bank (Annex 3). (Annex Bank theWorld WHOand DG DEV,GTZ,UNFPA,UNICEF, EC the Board: oftheAdvisory agencies member the through disseminated was concept UON the Finally, courses. and seminars such through methodology and concept UON on the toinformation exposed been have countries different 25 than frommore demographers) managers, programme midwives, doctors, (medical professionals health 300 Morethan ofBrussels. University Free atthe seminars of number in a Institut at the Health Reproductive in Course Summer the and MDC) and (ICHD courses ITMMaster’s the in taught iscurrently UONapproach 2). The Annex and 1 (Annex circuit academic the in papers fifteen toabout rise gave and meetings scientific of number international collabora and national by the is co-owned that approach of makers a label-free decision national among uptake smoother by compensated well is diffusion 'academic' in delay resulting The circuit. academic in the publication and ownership national ofprivileging a policy maintained (2000). Geneva WHO headquarters at and 1999), and (1998 Measure and at MotherCare 2000), 1997, (Washington, Bank World at the 1997), York, (New lectures. and publications site, meetings, yet. analysed systematically been all not have interviews These interviewed. were countries five in stakeholders 66 exercises, UON the of influence policy the on evidence actual provide care.To obstetric emergency to investments tore-direct ofcases, number a in and, programmes on unmet need as much asthe national officers to ‘accelerate’ theinvestment inmaternalhealth information the used They design. programme and advocacy motherhood safe for interest its understand Localoffice mobilisation. resource for including foradvocacy, tool excellent an itprovided however, Withthisrestriction, atlarge. public the than more the technocrats targeted has level national at the exercises UON from the The feedback Using UONforadvocacy level. atperipheral and atcentral both action and thinking participative of a dynamics generated they Haiti, in and Mali in as met, were all Where services. and policies on impact to failed study the Pakistan), in (e.g. met not were conditions of these or several one When periphery. third,a of thestudy; phase inevery teams of thefield impl inthe itsleadership MOH and of involvement the first, services: health improve to results of use to wants one if met be to have conditions problems. obstetric of management better towards approach’ ‘risk anineffective from shift countries helped This deficits. todecrease plans new setup makers decision and ofthedeficits magnitude forthe asked wait teams district as throughout, agenda policy the on system transport ofemergency development start the of hospitalsthe in reduction ofmaternal mortality. This encouraged programme managers to intensifyor ofdefici magnitude the ago, tenyears inMorocco case the been As had years. two average on took process study the feedback, final tothe initiation From the Policy shifts Considerable institutional pressure notwithstan pressure institutional Considerable The web(http:\\www.uonn.org) site web the channels: main four through disseminated was concept UON the scene, international On the of anumber isthat Ourinterpretation country. inevery asuccess such not was approach The UON s of internationals organisations (UNFPA,UNICEF,WHO)wereto quick ementation of the approach (Annex 3); second, the close collaboration collaboration close the 3); second, (Annex oftheapproach ementation tors, academic and not. Still,th and not. academic tors, provides access to the method provides accesstothe well as seminars on the UON approach at UNICEF at UNICEF approach UON the on seminars as well ding, the coordination of the UON Network has has Network oftheUON coordination the ding, well organised feedback of the national results to the tothe results ofthenational feedback organised well de Démographie of the UCL, it has been discussed discussed been ithas UCL, of the Démographie de s (Burkina Faso, Mali). Safe Motherhood remained remained Motherhood Safe Mali). Faso, s (Burkina ts contributed to the awareness of the crucial role role ofthecrucial totheawareness contributed ts ed for the results of other districts, policy makers makers policy districts, of other results the for ed control over the use of the results of the work for for ofthework oftheresults use over the control e UON approach was presented in a in presented was approach e UON s modules and the case study and thecasestudy s modules UON Network - Tackling Unmet Need for Major Obstetric Interventions 9 ) or to 18 l/year in Malawi for ic services: putting the 'UNic services: visits from the the visits from CAM team story’s lessons on reducing lessons story’s UON indicator to monitor progress (2):105-117. (2):105-117. (1): 63-73; GoodburnE, HusseinJ, Lema V, : 7-34. 74

75 17 . , can survive informally, without institutionalisation now that only the combinationa multitude of of d to aroundd to 1,700€/hospita ween 15 days to 3 months and the data collection ble by the fact that the UON approach necessarily, es: putting the UN guidelines into practice in Malawi. I: 00 € per country including € country including 00 per numbercasesof level at national as well, even after

direct involvement of the field operators. All too often things that have hi worked: ter-country exchanges would benefit each participant participant each benefit would exchanges ter-country ected data without the involvement of the local teams 19 aham W. 2001. Monitoring obstetr ll the same, theexercise itself was pretty fast indeed:

etrics. Washington, D.C. Septemberetrics. Washington, 3-8, 2000. ? Int.J.Gynaecol.Obstet five regional directors use the the use directors regional five This compares well to the cost the monitoring of of UN process indicators 17 COST APPROACH - International Journal of Gynecology & Obstetrics & Gynecology of Journal International ? Studies in Health Services Organisation & Policy EXT N HAT

FAST AND LOW FAST One of the tenets of this network was that the in As a whole, from decision to embark in the UON exercise to the feedback of results to peripheral Still, thereinlocal, a Still, and of change at evidence is Theregoodischancea that the initiative will end here – atformalleast as a operation.timethe For Hussein J, Goodburn E. A, Damisoni H, Lema V, and Gr Van Lerberghe & De Brouwere. 2001. Of and blind alleys XVI FIGO World Congress of and Gynecology Obst since 1999 without extra budgetary provisions. teams, the process lasted between 24 months and 32 months (Annex 5). is This a long period Thisof time. pace was slow indeed, but it permitted to not perturb the routine functioning of the system and teach every district team how to proceed. Those teams who coll went fast but with little lasting effect in the field.A adapting the protocols to the national context took bet itself an average of around 4 months per country. Demographic and HealthSurveys (around 500,000US$ percountry).collection cost of data The per health facility varied from 341 to 1,409 € (compare monitoring UN process indicators). Once the methodological investment is made, cost for routinedata Mali In marginal. becomes collection 18 19 17 For three years the UON project has thus brought together international organisations, research centres, been have results and Methods endeavour. common in a care providers health and health of ministries disseminated for an audience that included students, professionals, academics and civil society. It would be presumptuous to say that this has had a significant and immediate influence on mother’s health throughouttheworld. Since Cairo and Colombok we 5. W different global and local initiatives, among professionals as well as among civil society, stands any chance of really improving the situation. 4. A € to 64,0 10,000 from varied studies of these cost The and the regional meetings. (112,000€ for 22 hospitals covering 5 million inhabitants, during three years in Malawi in terms of capacity building and motivation. Countries did indeed learn from each other, and belonging to the international network brought much appreciated standing and status. This resulted less from using the website or e-mail than from the inter-country meetings and visits and the formal and informal support and guidance. being the Belgian Directorate General for International Co-operation continues to provide some support to and Madagascar Bangladesh, in exercises similar assist – to not but – start to will help This network. the well the approach master Faso Burkina or Cambodia such as teams country of other A number Angola. enough to continue on their own – they concentrate on using the UON indicator for monitoring progress. yearsfewshow willThe next whetheror not the network or support, and continue to contribute its part to making motherhood safer, in the poorest countries too. Damisoniu H, and Graham W. 2001. Monitoring obstetric servic developing the system. Guidelines' into practice in Malawi: 3 years on. 3 Guidelines' into practice in Malawi: years maternal mortality. one forgets that these front-line providers determine what is done locally to improve obstetric care. The best policies can have only a limited effect if the technicians are not on board: winning the hospital battle is decisive for mitigating the inherent risks of childbirth. by its very methodological specification, requires the such a short time. Much of that has been made possi

10 UON Network - Tackling Unmet need for major obstetric interventions Tambekonou J. 2000. Les Besoins Obstétricaux Non Co Non Obstétricaux Besoins Les 2000. J. Tambekonou les Interventions pour Couverts non Obstétricaux Besoins des à l'étude Contribution P I.2000. Mongazi Benin Publications by thecountryteams De Brouwere V, Tonglet R, Van Lerberghe W. « 1997. V, R, Lerberghe Tonglet Van De Brouwere Risque sans Maternité en pays les » dans couverts. non obstétricaux besoins des international Réseau V. 1999. De Brouwere A.et Laabid De Brouwere V, Laabid A,Van Lerberghe W. 1996. Quels besoins en interventions obstétricales? Une Une obstétricales? eninterventions W. besoins 1996. Quels Lerberghe A,Van V, Laabid De Brouwere De Brouwere V, Laabid A,Van Lerberghe W. 1996. Unmet obstetrical need: an operationally relevant problématique la de conscience de prise la couverts: non obstétricaux besoins Les V. 1997. De Brouwere De BrouwereV, Laabidand A. Van Lerberghe W.1996. Couverture desbesoins en interventions Van Lerberghe W & De Brouwere V. 2001. Of blind alleys and things that have worked: history’s lessons lessons history’s worked: have that things and alleys Ofblind V.2001. W&DeBrouwere Lerberghe Van Van Damme, W, De Brouwere V, Boelaert M.and V,Boelaert W, DeBrouwere Damme, Van W.1998. Lerberghe Van V. and De Brouwere care delivery sloppy: too toolate, little, Too W1999. Lerberghe V, Van M,Litt V,DeBrouwere Derveeuw health? reproductive forprivatising Isthereacase W. 2001. AM&VanLerberghe P,Bugalho Ferrinho strategies. and Concepts childbirth: and pregnancy in Referral V.2001. A&DeBrouwere Jahn Belghiti A, De Brouwere V, Kegels G, Van Lerberghe W. 1998. Monitoring unmet obstetric need at district atdistrict need obstetric unmet Monitoring W.1998. Lerberghe G,Van V,Kegels Brouwere A,De Belghiti in mortality maternal reducing for Strategies 1998. W. Lerberghe Van R, V, Tonglet De Brouwere Van Lerberghe W & De Brouwere V. 2001. Should one wait for poverty to disappear before dealing with with dealing before disappear to forpoverty wait one Should 2001. V. Brouwere W&De Lerberghe Van De Brouwere V. and Van Lerberghe W. Motherhood. Safe 1999. V. W,Litt Lerberghe W,Van Damme M, Van V, Derveeuw Brouwere De De Brouwere V & Van Lerberghe W. 2001 Réduire les Risques de la Maternité: Stratégies et Evidence Evidence et Stratégies Maternité: la de Risques les Réduire W.2001 Lerberghe V &Van De Brouwere De BrouwereV &Van Lerberghe W.2001. Safe MotherhoodStrategies: a Review of the Evidence. west in sections forcaesarean Need W. 2002. Lerberghe F,Van D, Richard V, Dubourg De Brouwere Publications by thenetworkcoordination

de docteur en médecine, 154 p. 154 enmédecine, de docteur l'obtention du grade de docteur en médecine, 137 p. 137 en médecine, docteur de grade du l'obtention ObstétricalesMajeures dansdépartements les l'Ouemé dePlateau du et (Bénin). Thèse pour développement: les leçons de l’histoire. l’histoire. de lesleçons développement: Publique au Maroc". déficits des spatiale l’analyse sur fondée approche (DGXII). Development Research forScience Commission ITM&European (eds). Antwerp: concept. In UniversitéCatholique de Louvain. (PhD).Louvain-en-Woluwe: Publique Santé en Doctorat de Thèse Maroc. au maternelle santé de la Antwerp: ITGPress,Belgium. obstétricales au Maroc. Maroc. au obstétricales on reducing maternal mortality. 351 assistanceprogramme on hostpopulation inGuinea asmeasured byobstetric interventions” in Africa.[Letter] thinking. wishful and evidence Patchy & Policy Organisation Services Health level in Morocco. International Health countries western of history from learn we can what ? countries: developing L’Harmattan. médecin du Cahiers MotherCare maternal mortality? [Letter] Scientifique. Studies in Health Services Organisation & Policy & Organisation Services Health in Studies Africa. [Letter] : 1609-13. 354 , 44 : 2085. : 2085. Networking for Research in Reproductive Health Reproductive in Research for Networking

Studies in Health Services Organisation &Policy Organisation Services in Health Studies Matters, (2):111-124. Lancet Lancet Tropical Medicine and International Health International and Medicine Tropical , Studies in Health Services Organisation & Policy Organisation Services Health in Studies , 3 8 2 , : 771-782. 359 (1): 8-9 (16): 43-46. , Archives of Public Health ofPublic Archives 353 (16): 974-975. 974-975. (16): : 409. : 409. . Studies in Health Services Organisation & Policy & Organisation Services Health in Studies A

NNEX , Studies in Health Services Organisation & Policy Organisation& Services inHealth Studies 1999. 17 : 229-246. : 229-246. Studies in Health Services Organization and Policy, Policy, and Organization Services in Health Studies 1.

Les besoins obstétricaux non couverts non obstétricaux besoins Les Unmet Obstetric Need Unmet

P UBLICATIONS , n° , 53 Van Lerberghe W. 1998. “Effects ofarefugee- “Effects W.1998. Lerberghe Van uverts au Bénin, Thèse pour l'obtention du grade dugrade pour l'obtention Thèse au uverts Bénin, 18 (Suppl 1): 33. , ITGPress:Antwerp.

, . De Brouwere V. and Van Lerberghe W. W. Lerberghe Van and V. Brouwere . De 3 , n° (7): 584-591. 584-591. (7): Revue d’Epidémiologie et de Santé de Santé et d’Epidémiologie Revue 18 , ITGPress:Antwerp ,

17 (UON) for Major Interventions for (UON) : 1-6. : 1-6. Tropical Medicine and , 17 : 7-34. . 229 p. Paris: p.Paris: . 229 , . 17

: 343-370. : 343-370. Studies in Lancet, Lancet n° Les Les 6 , .

UON Network - Tackling Unmet Need for Major Obstetric Interventions 11 erts, Rapport final, erts, Rapport draft,.15 p. du systèmeréférence/évacuation du de du es, et des pratiqueses, mortalité de lutte contrela et des pratiqueses, mortalité de lutte contrela l'équipe scientifique: Adaptation des définitions définitions des Adaptation scientifique: l'équipe -Ouest, Octobre 1998-Septembre 1999), Rapport final de restitution des résultats, Rapport, 16 p. r les Besoins Obstétricaux Non Couverts, 29 p. bonite, Nord, Nord Besoins Obstétricaux Besoins Obstétricaux Non Couv liale et Communautaire1998. Evaluation Cercle de Bougouni, 36 p. p. 36 Bougouni, de Cercle obstétricaux, 24 p. p. 58 Niger, du Publique Santé la de Ministère Couverts, , 18 p. départements du Borgou du et Zou, 4 p. p. 6 Cové en 1998, Majeuresde au CSSP provisoire, 44 p. Majeure.Documentation des politiques, desstratégi final, 38 maternelle. Rapport p. Majeure.Documentation des politiques, desstratégi maternelle.Proposition service. de p. 14 en Haïti, (Département Arti (draft): 60 p. maternelle,Mars-DécembreHaïti, 2000, 17 p. p. 6 processus, du critique Revue 2000, Mars-Décembre Haïti, 2000. maternelle Couverts Haïti 2000, Atelier de synthèse et IMA, IOM, Taux de référence, 14 p. Couverts: Protocole d'étude, 16 p. Mali, Rapport final, 94 p. stratégies et des pratiques de lutte contre la mortalité maternelle au Mali, 4 p. Obstétricaux Non Couverts à Kayes, 6 p. Obstétricaux Non Couverts à Koulikoro, 6 p. Obstétricaux Non Couverts au Mali, 7 p. octobre 1998 – janvier 2000, Rapport provisoire pour la réunion d'Abidjan, 8 p. mai 1998 – juin 1999, 2 p. données dans la région de Ségou, Résultats préliminaires, 26 p. Division SantéFamiliale etCommunautaire ().Une stratégie pour améliorerla qualité dessoins Niger Ministère de la Santé 2001. Les Besoins Obstétricaux Non Couverts au Niger en 1998, Rapport final, Non Obstétricaux Besoins les sur recherche de BONC Protocole 1999. l'étude de pilotage de Comité de la Santé 2000. Les Ministère Ministère de laSanté 2000. Protocole d'étude su PADS 1999. Point sur l'état actuel de la recherche sur les Besoins Obstétricaux Non Couverts dans les Houeto D.J, Sognigbe H, Gbehou J, Kotchofa 1998, I.S. Étude du taux Interventions des Obstétricales Burkina Faso Ministère de la Santé 2001. Besoins Obstétricaux Non Couverts, Expérience du Burkina Document Faso. Ouedrago I. 2000. Approche des Besoins Obstétricaux Non Couverts pour les Interventions Obstétricales Ouedrago I. 2000. Approche des Besoins Obstétricaux Non Couverts pour les Interventions Obstétricales Haiti Ministère de la Santé Publique et de la Population 2000. Etude des Besoins Obstétricaux Non Couverts mortalité la contre lutte de des pratiques et stratégies des politiques, des Documentation 2000. C. Roenen C Roenen, Documentation des politiques, des stratégies et des pratiques de lutte contre la mortalité Ministère de la Santé Publique et de la Population 2000. Etude sur les Besoins Obstétricaux Non de préliminaire Rapport UON 2000. scientifique Comité Ministère de la Santé Publique et de la Population 1999. Etude sur les Besoins Obstétricaux Non Mali Division SantéFamiliale Communautaire et 2000. L'approche des besoinsobstétricaux couverts non au Division Santé Familiale et Communautaire 2000. Synthèse de la documentation des politiques, des Division Santé Familiale et Communautaire 2000. Rapport de restitution régionale sur les Besoins Division Santé Familiale et Communautaire 2000. Rapport de restitution régionale sur les Besoins DivisionSantéFamiliale et Communautaire 2000. Rapportrestitutionde nationale sur lesBesoins Division Santé Familiale et Communautaire 2000. Rapport sur les Besoins Obstétricaux Non Couverts, Division Santé Familiale et Communautaire 2000. Rapport sur les Besoins Obstétricaux Non Couverts, Bamba, S. 1999. Les Besoins Obstétricaux Non Couverts: Mission d'appui à la collecte et à l'analyse des Sangaré, M.1999. Protocole de recherche sur les Besoins Obstétricaux Non Couverts au Mali, 10p. Division Santé Fami

12 UON Network - Tackling Unmet need for major obstetric interventions Dumont A, de Bernis L, Bouvier-Colle M. H, and H, and M. L,Bouvier-Colle Bernis A,de Dumont RonsmansC, VanDamme W,FilippiV,Pittrof R.2002. N Soumaila Aminatou 2000. Etude desBesoinsObst 2000. Soumaila Aminatou Dumont A,de Bernis L, Bouvier-Colle M-H, Bréart G. Bagna Beidou Aminaou 1999. Etude Bagna BeidouAminaou Obstétricaux Besoins des surl'approche basée foeto-maternel dupronostic Analyse 2000. Tezere Patale Prual A, de Bernis L, Ould ElJoud D. 2002. Santé maternelle en Afrique francophone. Rôle potentiel de la totheUONapproach Literature referring Bangladesh project (UON) ObstetricNeeds Unmet first 6months Progress-report G.2001. Dieltiens a se on ofthefirstmeeting Report G,2001. Dieltiens Tassadaq F,Zaidi, Sahela A.R.1999. Estimating the Tassadaq Farook 1999. Report of DataCollection at DistrictJehlum,2 p. p. 5 15-20.11.99, Pakistan, Islamabad, to UON mission on the Report A.1999. Jahn Punjab & Jehlum, Attock of Districts the in Needs Obstetrical Unmet 2000. & al Rehman Abdur Saleha Pakistan Dieltiens G,2001. Report ofthe secondary analysis Need 2000. Unmet Bashir I. Bangladesh 1999. en (Cameroun) l'Adamaoua de province la dans obstétricaux besoins Les N. 2000. Goyaux Cameroun 7p. Cambodia. Province, Reap Siem needs, obstetrical ofessential Asurvey 2000. S. von Schreeb Cambodge provide to services health of capacity of the Assessment M. 2000. Derveuw E, Almeida de E, J,David Lilia Mozambique to visit a country on Report –UONN- Network Need Obstetric Unmet international The A. 1999. Jahn (Draft). Tanzania in assessment (UON) Need Obstetrics Unmet for Proposal A.2000. S,Jahn Massawe 2001 /July June of results: dissemination First year 2000 Nov/Dec report three-month Second 2000 reportNovember First three-month Tanzanie p. 17 visittoPakistan, of apreparatory Report V.1998. V,DeBrouwere A,Litt Jahn Lancet indication in sub-Saharan Af insub-Saharan indication 31 population de femmes enceintes d'Afrique de l'Ouest (enquête MOMA). francophone. Estimation du taux attendu de césariennes pour indications maternelles dans une pour l'obtention du grade de Docteur en médecine, 91 p. 91 en médecine, Docteur de grade du l'obtention pour thèse Tillabéri, de département le dans et Niamey de urbaine communauté la dans Couverts Non p. 82 en médecine, Docteur de grade du l'obtention pour thèse Niamey, sub-saharienne. consultation prénatale dans la lutte 6p. 2001). 08, July – 08 (January 8 need. p. obstetric unmet the estimate to (ACPR), Bangladesh in services care obstetric emergency of use and p. 79 Pakistan, Province, p. 76 en médecine, Docteur de grade du l'obtention pour thèse Niamey, (ACPR) in order to estimate (un)met n order toestimate(un)met (ACPR) in Bangladesh in Complexes Health Upzilla and Hospitals District in services care obstetric emergency p. p. 52 Déo. Faro et du Djerem du Vina, de la Départements p. 19 assessment. needs ofthe report Final Mozambique. province, inTete care obstetric essential 9 p. Tanzania. 17 p. p. 31 ofPakistan, province the Punjab (1): 107-112. (1): , 359 (16): 974. (16): J Gynecol ObstetReprod Biol for Major Obstetric Interventions in rural Bangladesh. Research protocol.47 rica: a systematic review. rica: asystematic des Besoins Obstétricaux Non C Besoins ObstétricauxNon des contre la mortalité maternelle et la mortalité néonatale en Afrique eedspecialised for obs

31 et le groupe MOMA. 2002. Santé maternelle en Afrique Breart G. 2001. Caesarean section rate for maternal rate for maternal section G. 2001. Breart Caesarean Unmet Obstetric Need at districts Attock & Jehlum in Attock &Jehlum at districts Need Obstetric Unmet (1):90-99. condary analysis of the 1999 Review of availability ofavailability Review the1999 of analysis condary étricaux NonCouverts eed for caesarean sections inWest Africa. [Letter] of theof 1999 Reviewof availability and useof Lancet

tetric care. 8 p. tetric care.8 358: 1328-1333. ouverts dans laCommuneIIIde ouverts J Gynecol Obstet Biol Reprod J GynecolObstetBiol dans la Commune III de dans laCommuneIII

UON Network - Tackling Unmet Need for Major Obstetric Interventions 13

77

(5): 78

(1): 63-73. Organ : 514-521. : 514-521.

75 4 . , Studies in Health in Studies International Journal of (2): 52-58. , 9-11. East African Medical Journal BullHealth World 19 . International Health International (44): 353-361. Int.J.Gynaecol.Obstet Contact 16 (3): 163-165.

3 , and disasters in Rutshuru, Democratic Republic ck A. 2000. Daily iron supplementation is more in pregnant women in Pakistan in a randomized randomized a in in Pakistan women in pregnant caesarean section as a process indicator of safe- t J. 1999. Use of hospital data for Safe Motherhood Safe for data hospital Use of J. 1999. t 0. Maternity care in rural Nepal:service a health J Health Popul. Nutr J Health Popul. . Tropical Medicine & Medicine . Tropical mortalité maternelle! in Malawi. I: developing the system. (11): 2697-2702. Trop Med Int Health cidence fatalityand case rates. (7): 559-565. : 317-342. : 317-342. (9): 657-665. Health Policy & Planning Coping with crisis 3 130 5, , 17 . , , r Stuyft P. Geographical 1998. information systems (GIS), gimmick or (2): 105-117. 74 J Nutr , (10): 799-810. 6 Saint-Marc Sus à la , Trop Med & Int Health & Int Trop Med Trop Med & Int Health Int Trop Med & Programmes in South Kalimantan, Indonesia Kalimantan, in South Programmes 593-602. tool for health district management? obstetric causes in West Africa: in district maternity referral systems. Gynecology & Obstetrics motherhood programmes: the case of Kenya. Services Organisation & Policy putting the UN guidelines into practice robust are district health systems? double- blind clinical trial. putting the 'UN Guidelines' into practice in Malawi: 3 years on. effective than twice weekly iron supplementation (11): 599-607. of Congo. Evaluation of a comprehensive home-based midwifery programme in South Kalimantan, Indonesia. Trop Med Int Health analysis. Ronsmans C, Achadi E, Sutratikto G, Zazri A, McDermot Zazri G, C, Achadi E, Sutratikto Ronsmans Boelaert M, Arbyn M, and Van de Prual A, Bouvier-Colle M. H, de Bernis L, and Breart G. 2000. Severe maternal morbidity from direct Murray S. F, Davies S, Kumwenda Phiri R, and Ahmed Y. 2000. Tools for monitoring the effectiveness of Gichangi Apers P, L, and Temmerman M. 2001. Rate of RonsmansC. 2001. How can we monitor progress towards improved maternal health? Goodburn E, Hussein J, LemaV, Damisoniu H, and Graham 2001. W. Monitoring obstetric services: Porignon D, Soron'Gane E. LokombeM, T. E, Isu D. K, Hennart P, and Van Lerberghe W. 1998. How Hussein J, Goodburn E. A, Damisoni H, Lema V, and Graham W. 2001. Monitoring obstetric services: Luck M. 2000. Safe Motherhood Intervention Studies in Africa: a review. Mumtaz Z, Shahab S, Butt N, Rab M. A, and DeMuyn Ngwakum P. 2001. Haïti: Ronsmans C, Endang A, Gunawan S, Zazri A, McDermott J, Koblinsky and M, Marshall T. 2001. Jahn A, Dar Iang Shah M, U, and Diesfeld H. J. 200

14 UON Network - Tackling Unmet need for major obstetric interventions De Brouwere V. Insufficien De Brouwere on Consultation Technical perspective. historical an Mortality: V.Maternal Brouwere W,De Lerberghe Van De Brouwere V, Van Lerberghe W. Unmet Obstetrica W. Unmet V, Lerberghe Van De Brouwere De à l’INAS, Conférence historique. perspective une Maternelle W.Mortalité Lerberghe V, Van De Brouwere Hill. Chapel Series, Summary Workshop 1999. May Measure/Evaluation, V. De Brouwere Health. Perinatal and Maternal in Evaluation and Monitoring Improving V.Towards De Brouwere WHO-UONN Meeting. Discussion on De Brouwere V, Laabid A, Van Lerberghe W. La couverture des besoins en interventions obstétricales au au obstétricales interventions en besoins des couverture W. La Lerberghe A, Van V, Laabid Brouwere De obstetric for need of coverage MMR: to alternative W.An Lerberghe Van A, V, Laabid De Brouwere health. maternal toimprove Astrategy Need. Obstetrical V.Unmet Brouwere W,De Lerberghe Van VanLerberghe W,De Brouwere V.Unmet Obstetrical Need. Astrategy to improve maternal health. World

De Brouwere V, Van Lerberghe W. Séminaire Anthropologie et Sociologie de la santé: risques et et risques santé: la de et Sociologie Anthropologie W.Séminaire Lerberghe V, Van De Brouwere V. Inter-AgencyDe Brouwere Group work. that things and alleys a blind mortality: maternal V.Reducing Brouwere W,De Lerberghe Van XVIFIGOWorld Interventions. Obstetrical Major for Need Unmet on Network W.The Lerberghe Van obstetric formajor need unmet the W,LittV.Estimating Lerberghe V, Van M,DeBrouwere Derveeuw Belgium. Brussels, 2000, November 27-28 Motherhood, on Safer meeting EC Expert 2010. Vision l'histoire. de leçons les maternelle: mortalité la W.Réduire Lerberghe V, Van De Brouwere Cercle le dans Couverts Non Obstétricaux Besoins N.Les A,Keita, Dembele, E, O, Papa, S, Ba, Temé, De BrouwereDe V.Besoinsobstétricaux non couverts:enmise place d'unréseau. RéunionPérinatalité 1997. Brouwere V Unmet Obstetric Need (UON) for Major Inte forMajor (UON) Need V UnmetObstetric Brouwere Safe Motherhood. 18-23 October 1997, Colombo, Sri Lanka. Lanka. Sri Colombo, 1997, October 18-23 Safe Motherhood. Morocco. Latin America Sections Second Opinion Trial. 1 Trial. Opinion Second Sections America Latin Morocco. Belgium. Antwerp, 1998, 15May Day, Scientific Medicine ofTropical Institute VA 98, Arlington, June 1-2 Snow.Inc, MotherCare/John Maroc. 22.09.98, Virginia. Arlington, 1999. 2-4th, March Care. Health Perinatal and Maternal for Source Data a as Registers of Birth Use the on fromaWorkshop Proceedings Geneva. Organisation, Health World 1999. May actions. Maroc. 21° Congrès de l’ADELF, Epidémiologie de la Reproduction. Bruxelles, 3-5 juin 1996. 1996. juin 3-5 Bruxelles, Reproduction. la de Epidémiologie l’ADELF, de Congrès 21° Maroc. 24-27,1996 September Philippines, Manila, ofthePhilippines, –University Institute Population and Health Reproductive on Committee IUSSP Health, Reproductive of Assessment the to Approaches Innovative on Seminar interventions. UNICEF, January 1997,York. New Washington. 1997, January Bank, procréation. Ecole des Hautes Etudes en Sciences Sciences en Etudes Hautes des Ecole procréation. Attendance atDelivery Washington 2000. 9September Bank, World atthe Communication DC. Washington 2000, 3-8, September Obstetrics. an of Gynecology Congress Belgium. Leuven. 24,2000, November Epidemiology, Spatial Research. Health Public in Methods indications. maternal for absolute interventions major obstetric in of deficits presentation ona spatial based anapproach interventions: Mali Bamako 2000,. 7-10mai etnéonatale. maternelle mortalité de la laréduction pour Forum régional Burkina-Faso. Ouagadougou, 2001, December 2001, SAGO du Mali. République de Kadiolo, ASPROCOP: Paris, 25-26 août Paris,25-26 ASPROCOP: 1997 ULB. Brussels: A NNEX 2

C ," 25-272000, April WHO Headquarters, Geneva. t Major Obstetrical Interventions rates rates Interventions t MajorObstetrical ONFERENCES AND ONFERENCES WORKSHOPS ONUNMETOBSTETRICNEEDS harmonisation of the UON activi for Safe for Motherhood, Technical Consultation, "Ensure Skilled . . Sociales et IRD, 13 au 15 mars 2000, Marseille. Marseille. 2000, 15 mars au etIRD,13 Sociales l Need. The best of ITM: Sicentific Highlights. Highlights. ofITM:Sicentific best The Need. l rventions. Maternal Health Indicators Meeting. Meeting. Indicators Health Maternal rventions. st LASSO meeting, 14 October 1997. October 1997. 14 LASSOmeeting, for Absolute Maternal Indications in ties with other Safe Motherhood

UON Network - Tackling Unmet Need for Major Obstetric Interventions 15

country Other regional exercise coordinator National/ countries country regional exercise coordinator National/ Pakistan persons

country ETWORK regional exercise National/ coordinator Bangladesh N EED N DGDEV) then Haiti country DG DEV) regional exercise coordinator National/ DFID) then World Bank) World UNFPA) then then then

BSTETRIC O IN THE DIFFERENT COUNTRIES NICEF Mali Board: Advisory country regional exercise coordinator Coordination Team National/ MOH NMET Scientific secretary:DPH-ITM Network Management & U - J. Liljestrand (WHO Liljestrand (WHO - J. - M. DeBruycker (EU, DGVIII -Fransen L. (EU, DGVIII - L. de Bernis (WHO) Bernis de - L. -Daniels D. (EU, DGI - V. De Brouwere (ITM) Brouwere De - V. - W. Van Lerberghe (ITM) - B. Schmidt-Erhy (GTZ) -Donnay F. (U country Bénin regional exercise coordinator National/ MOH involvement Leadership Extended advisory group: EU, WHO, advisory Extended WB, UNFPA, GTZ, BADC, other agencies TRUCTURE THE OF country S regional exercise coordinator National/

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16 UON Network - Tackling Unmet need for major obstetric interventions 8) Information on the numerator (type ofintervention, (type numerator onthe 8) Information ofreliability. a fairlevel with isknown births) (expected denominator 7) The inall data tocollect 6) Itispossible 5) Itspopulation ishigher than one million inhabitants of 4) Itcomprisesmore area ofthestudy Characteristics team national of the work ofthe quality the guarantees Board, Advisory the to known person, 3) One team. national ofthe charge in as overall identified is clearly person 2) One Monitoring the guarantee to ready andis interest show authorities) health regional (orthe ofHealth 1) TheMinistry Political contextandwillingness to

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UON Network - Tackling Unmet Need for Major Obstetric Interventions 17

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5. Pakistan Pakistan NNEX A Tanzania Launching the survey process Feedback Tanzania

01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 Y 3 Y 2 Y 1

18 UON Network - Tackling Unmet need for major obstetric interventions rnia ate CentreMuraz, Bobo-Dioulasso CentreMuraz, Bobo-Dioulasso 1998 Retrospective CentreMuraz, Bobo-Dioulasso Number ofpersons trained(researchskill Four Main donorforfieldoperations StrongcommitmentthroughtheFamilyHealthDirection notbeeninformed someregionaldirectorshave Weakinvolvement: Principal partner Collaboration witharesearchinstitution ofcare Participation ofproviders Involvement of the MOH at peripheral level MOHatcentrallevel Involvement ofthe PAD Study year Study areaandpopulationsize PADS (Swissco-operation) Type ofstudy 1998 Retrospective CERRHUDProfessor Alihonou Number ofpersons trained(research Str Departmentof Main donorforfieldoperations Trainedfordata collection Principal partner WeaksupportfromcentrallevelofMOH, weak involvementof Collaboration witharesearchinstitution ofcareatperipherallevel Participation ofproviders MOHatperipheral level Involvement ofthe Involvement of the MOH at Study year central level Study areaandpopulationsize Type ofstudy Official report released Technical report, descr report, Technical No nat a through Feedback MinistryofHealth the newnational UONindicatorasaprocessin UNICEF Initiatives taken following 1998 the first study Official reportreleased Feedback atregionallevel No Retrospective Feedback atnationallevel Number ofpersons trained(researchskills) Main donorforfieldoperations Threedepartmentsinhabitants) Principal partner (2,3million partici Strong Strong Collaboration witharesearchinstitution ofcareatperipherallevel Participation ofproviders MOHatperipheral level Involvement ofthe MOHatcentrallevel Involvement ofthe Study year Study areaandpopulationsize Type ofstudy fiilrpr eesd No Yes No study areatotwootherdepartments Extensionofthe study thefirst takenfollowing Initiatives Official reportreleased Feedback atregionallevel Feedback atnationallevel fiilrpr eesd Draft: No No country study totheentire Extensionofthe study thefirst takenfollowing Initiatives Official reportreleased Feedback atregionallevel Feedback atnationallevel Benin

Haiti Faso Burkina tprpea ee Weakparticipation at peripherallevel kls Twomedical doctorsatMOH skills) ) TwomedicaldoctorsfromtheMOH s) OnemedicaldoctorfromthecentralMOH A NNEX 6. about the study about thestudy Family HealthDepartment. MOH directors and with field actors having participated in the study. MOH directorsand havingparticipatedinthe study. withfieldactors reproductive healthpolicy improve themanagementofobstetrical emergencies. causesofdefi reflection onthe collection data carriedout departments gynaecology hospital Responsible of in datacollection Two students in medicine (data collection and analysis) Two studentsinmedicine(datacollectionandanalysis) One medical student fordatacollection One medicalstudent

S ong commitmentfromthehealth departmentdirectors YNTHESIS PERCOUNTRY YNTHESIS S (Swiss co-operation) S (Swissco-operation) regions (3 millions inhabitants) inhabitants) regions (3millions figures without realanalysis commitment throughtheDeputyGeneral Director pation ofhealthdepartment directors whoparticipated Zou(1million)andBorgou iptive and analytical. The analysis involved a Theanalysisinvolved analytical. iptive and ional workshopwithnationalandregional

cits and operational proposalsto cits andoperational UON Network - Tackling Unmet Need for Major Obstetric Interventions 19

re: data collection carried out by The whole study was carried out by this ing regional health managers, hospital staff, ent at the beginning of the process but weak in the of the process ent at the beginning t, descriptive but no in-depth analysis. pation of health regional directors who participated in ons, UON indicator is used as a routine indicator for tive participation of the regional health directors for l report, descriptive and analytical. participation of providers of ca ipation limited of interventions and indications to the definition teams have been trained for data collection. A first preliminary data collection. for teams have been trained A first preliminary hnical report, descriptive. e as monitoring indicator in one district health district teams and social action staff. monitoring progress in obstetric care coverage. and one medical student for data collectionand one medical student system. to take into account research and teaching institution. HSA is supported by GTZ data collection realised analysis of results was teamswith the local just after data collection. gynaecologists from level. the departmental follow-up of the study organisation of data collection. lls) medical student (analysis) Three skills) for the study. the FHD especially by One medical doctor recruited

Pakistan Niger Mali Official report released Initiatives taken following the first study In five regi Technical repor Feedback at national level national at Feedback Feedback at regional level Workshop organised along with a seminar on referral/evacuation In 4 regions, involv Collaboration with a research institution Principal partner Main donor for field operations trained (research skills) Number of persons Feedback at national level GTZ Feedback at regional level Official report released None GTZ Health Services Academy. No No Tec Initiatives taken following the first study No initiative Participation of providers of care at peripheral level Local institution Collaboration with a research Principal partner Main donor for field operations trained (research Number of persons No Belgian Co-operation DSF Collaboration with a research institution Principal partner Main donor for field operations trained (research ski Number of persons Feedback at national level Feedback at regional level Alafia/GTZ Official report released Initiatives taken following the first study OMS Alafia/GTZ – UNICEF - Us Alafia/GTZ Yes No Technica Type of study Study area and population size Study year Involvement of thecentral level MOH at Involvement of the level MOH at peripheral Participation of providers of care at peripheral level Partic None None Two Tehsils (sub-region) 2,2 million inhabitants Retrospective 1998/99 (18 months) Involvement of the level MOH at peripheral Participation of providers level of care at peripheral Weak Administra Type of study Study area and population size Study year Involvement of the MOH at central level Strong commitm Nation wide (10,3 million inhabitants) Retrospective 1998 Type of study Type of study and population sizeStudy area Study year of theInvolvement MOH at central level Involvement of the level MOH at peripheral Strong Strong involvement of the Family Health Division partici Nation wide (except Kidal region) 9,8 million inhabitants Retrospective 1998

20 UON Network - Tackling Unmet need for major obstetric interventions td er 200-2002 fortwodistricts andprospective apilotdistrict Retrospectivefor inhabitants) Twodistricts(2,2million W Tworegional Acti ofcareatperipherallevel Participation ofproviders MOHatperipheral level Involvement ofthe MOHatcentrallevel Involvement ofthe Study year Study areaandpopulationsize Type of study fiilrpr eesd Quarterly andannualrepor Unknown Two workshops planned in2001andone2002, attheend of the Department of MedicalCentre ChiefofObstetric&Gynecology GTZ Official report released Unknown Feedback atregionallevel GTZ Feedback at national level Number ofpersons trained(researchskills) Main donorforfieldoperations Principal partner Collaboration witharesearchinstitution ntaie ae olwn h is td UN niao is indicator UON study thefirst takenfollowing Initiatives Tanzania (2000 –2002) collected in health facilities facilities in health collected meetings) study (noinformationaboutthe actualorganisation ofthese Muhimbili maternal mortality enquiry in the study area. maternal mortalityenquiryinthe indicatorbya The Tanzanian teamenvisagesvalidatingthe under study. of themhasbeensenttotheCAMteamAntwerp. eak, participationatthepreparatoryworkshop

ve participation active of practitioners,dataare routinely activeof ve participation co-ordinatorsaremembers oftheresearch team. used for maternal health activities in the district healthactivitiesinthedistrict usedformaternal ts plusafinalreportareexpected.None UON Network - Tackling Unmet Need for Major Obstetric Interventions 21

TASK FORCES TEAMS RESEARCH AND , de santéfamiliale la direction à départementale du istiques, études,planification documentation et la à service de statistiques, documentation et recherche du servicestatistiques, de études,planification et atistiques, documentationrechercheet opérationnelle OMMITTEES C CIENTIFIC S int focal de l’étude à la DSF mité de pilotage et point focal du ministère de la santé, ONSTITUTION OF C

7. NNEX A Zou Mme Amadou Sylvie, Sage femme, service de santé familiale la à direction départementale du Borgou M. Benjamin Dady, Statisticien, chef du service de stat direction départementaleBorgou du Dr Léon Legba, Médecin de santé publique, chef Benin Scientific Committee Professeur Eusèbe Alihonou, chef de service de gynécologie - obstétrique au CNHU de Cotonou, chef du département santé publique mère enfantet à la faculté des Sciences de la Santé Dr Jacob Houéto, Gynéco-obstétricien,chef du service documentationla directionà départementaleZou du Docteur Félix Ahouandogbo, Epidémiologiste, chef du opérationnelle au ministèrede la santé M. Fatchéoun Tchobo,Statisticien au service de st du ministère de la santé EstherDr Traoré, Pédiatre, chefservicedu santéla de maternelleinfantile et à la directiondesanté la familiale du ministère de la santé Task force Dr Esther Traoré, membre du co Le directeur départemental du Zou Le directeur départemental du Borgou Le coordonateur du programme bénino-suisse Le coordonateur du programme bénino-allemand (PBA/SSP) Le responsable du programme santé de l’UNICEF en charge du Zou et du Borgou Le responsable du programme PROSAF (USAID) en charge du Zou et du Borgou Research team est réalisée l’étude lesquelles dans sanitaires zones des Cadres Médecinscoordonnateurs de zones Gynécologues et/ou chirurgiens, sages-femmes responsables des maternités Une Etudiante en médecine Burkina Faso Scientific Committee Pr. Bibiane Koné, Gynécologue, Faculté des Sciences de la santé Pr. Blaise Sondo, Médecin de santé Publique, Faculté des Sciences de la santé Pr. François Tall, Pédiatre, Directeur de la santé de la famille, Ministère de ma Santé OMS Ouagadougou Bureau Publique, Santé de Médecin Bamba, Dr. Azara Dr. Flavia, Médecin de santé Publique, UNICEF Ouagadougou FNUAP Ouagadougou Sociologue, Zeba, Thérèse Madame Ouagadougou Publique, Santé de Médecin Zina, Dr. Yacouba des Pays-bas Ambassade sage-femme, Sebgo, Pascaline Madame Dr. Philippe Van De Perre, Médecin de santé Publique, Directeur du Centre Muraz, Bobo Dioulasso Dr. Sosthène D. Zombre, Médecin de santé Publique, Direction Régionale de la Santé de Ouahigouya N’Gourma. Fada de santé la de régionale Direction Publique, santé de Médecin Kara, Dr. Daniel Research team l’étude de général Coordonnateur Famille, la de Santé la de Directeur Tall, Pr. François principal Chercheur Ouagadougou, de Université Publique, santé de Médecin Ouédrago, Dr. Laurent Dr. Zénabou Derme, Médecin, Po Dr. Germain Traoré, Gynéco-obstétricien à la DSF, Ouagadougou, de Université Gynéco-obstétricienne, Thieba, Dr. Blandine Dr. Jule Bazie, Gynéco-obstétricien, hôpital de Bobo-Dioulasso, Dr. Kaboré, Gynéco-obstétricien à l’hôpital de Ouahigouya, Dr. Josianne Diall, Médecin, maternité de l’hôpital de Fada N’Gourma, DSF, la de Personnel Nougtara, Jeanne Mme Mr. Emmanuel Sawadogo , Interne en médecine, Enquêteur

22 UON Network - Tackling Unmet need for major obstetric interventions Le chargé du Système d'Information Sanitaire Sanitaire d'Information Système du Le chargé hôpitaux des maîtresses femmes Les sages hôpitaux des chefs Les médecins régionales directions des Les sages-femmes régionaux hôpitaux des oules chirurgiens Les gynécologues Un étudiant en médecine DSFC familiale dela planification La chargée DSFC périnatalité cellule à la recherche de L'assistant Un médecin spécialement engagé pour cetterecherche DSFC) ( etCommunautaire Familiale Santé Division de la Le chef team Research de Bamako V Commune la de référence de desanté du centre externe gynécologique consultation la de chargée La sage-femme VdeBamako Commune la de de référence santé de ducentre chef aumédecin L'adjoint de Bamako V Commune la de référence de santé de centre du (gynécologue) chef Le médecin G Point du l'hôpital de médecine de duservice L'infectiologue La sage-femme maîtressede gynéco obstétrique G Point du de l'hôpital obstétrique gynéco de declinique chef L'assistant G Point du l'hôpital de obstétrique gynéco de du service Le chef périnatalité cellule à la recherche de L'assistant DSCF Familiale Planification de La chargé DSFC de Périnatalité duProgramme La chargée (DSFC) etCommunautaire Familiale Santé division de la Le chef Publique Santé la de National directeur Le Committee Scientific Mali deshôpitaux / gynécologie d'obstétrique des services médecin) et/ou (nursing Responsables dans l'étude impliqués hôpitaux des Directeurs Epidémiologiste départemental départementaux. Les directeurs team Research UNICEF FNUAP OPS/OMS Reproduction. la de Santé de la Service Task force Prince. au dePort Jeanty Isaïe la Maternité de Un représentant d'Haïti d'Etat l'Université de del'Hôpital gynécologie de et d'obstétrique duservice Un représentant et deGynécologie d'Obstétrique Haïtienne la Société de Un représentant de médecine la faculté de Un représentant Des spécialistes de la discipline (gynéco-obstétrique) Deux représentants de l'équipe de recherche Committee Scientific Haïti UON Network - Tackling Unmet Need for Major Obstetric Interventions 23

planners

and

or Mtwara site administrators

Niger Scientific Committee Trois représentants de la Directionde la Santéde la Reproduction (DSR) Deux représentants du Système National d’Information Sanitaire (SNIS) Un représentant de l’école nationale de santé publique Trois représentants de la Faculté des sciences de la santé Un représentant du projet Alafia GTZ La présidentecomité du chargé l'élaborationde du programmenational SR de Research team Trois membres de la DSR Un représentant du SNIS Un Médecin de la maternité Gazoby Un membre du projet Alafia GTZ Les gynéco-obstétriciens et/ou médecins des hôpitaux concernés Les sages-femmes des hôpitaux concernés Pakistan Scientific Committee Seven obstetricians from both districts and all sectors. Research team Prof. Aimé De Muynck GTZ/HSA technical advisor Dr. Saleha Abdur Rahman HSA researcher Dr. Tausif Janjua HSA researcher TassadaqDr. researcher Farooq HSA Dr Zaidi .HSA researcher Tanzania Scientific Committee Dr SN Massawe UNO national co-ordinator Dr A Thomas assistant co-ordinator Dr Fred Mtatifikolo representative Tanga region Ms H Kitundu representative Mtwara region Dr Kuellker Rainer GTZ Tanga Research team Dr Mtatifikolo co-ordinator Tanga site co-ordinat Kivo Dr Dr Bischof co-ordinator Masasi site Midwives and doctors working in the maternity unit ward and theatre Hospitals