EmONC indicators

The indicators in Domain 1 are based on the fundamental principle that to achieve low maternal and newborn mortality in line with global and national goals, a health system must have the kind of facilities that, in a time-sensitive emergency, are ready and able to identify, manage and, if needed, refer any woman or newborn who presents with a complication. In this Guide, we call these EmONC facilities and they can collectively be understood as a country’s EmONC system.

Certainly lives can be saved outside of the EmONC system. For example, trained village health workers have successfully managed neonatal sepsis.¹ But many obstetric and newborn complications require a level of medical care that can only be delivered in a health facility having a particular level of skilled provider, specific drugs and appropriate equipment. For health system planners and managers, the challenge is to determine the right number of such facilities needed in their country, given various demographic, geographic and other factors; and then to ensure that these facilities function in a consistent, sustained way to handle emergencies, providing good quality of care, 24 hours a day, 7 days a week; and finally, to ensure that all mothers and newborns can access EmONC when needed without delay. The structure indicators in Domain 1 are designed to help planners and managers tackle that challenge.

Availability (info)	1a. Progress toward long-term goal for EmONC availability
	1b. Progress toward interim goal for scaling up EmONC availability
Adequate conditions to provide good-quality care (“readiness”) (info)	2. Basic infrastructure
	3. Equipment, drugs & supplies
	4. Health workforce adequate for caseload
	5. Emergency referral readiness
Accessibility (info)	6. Home to Comprehensive EmONC within 1hr

Availability of EmONC

This Guide proposes a two-step way for each country to set its own availability goals: The first step is to set a long-term (±10-year) goal, and the second step is to set a medium-term (3-5 year) milestone target by designating a subset of facilities for targeted support. These two goal-setting processes are described briefly in Instructions for using the Long-term EmONC Calculator and How to use the EmONC Framework: Step by step implementation. They provide the foundation for calculating the two indicators that help planners and managers measure EmONC availability in their health system.

Adequate conditions to provide good-quality care (“readiness”)

Indicators in this section highlight the fundamental conditions needed to provide good quality EmONC in a sustained, consistent way. Taken together, they provide a picture of whether facilities are ready to provide EmONC.

Accessibility

Beyond having enough facilities that perform EmONC under adequate conditions, women and newborns with complications must be able to access those facilities. The indicator in this section focuses on geographic accessibility, but financial and social/cultural accessibility of EmONC services are also factors that planners and managers should consider.

In the ideal health system all women and newborns receive the right care in the right place at the right time. From the perspective of efficiency of the overall EmONC system, ideally no facilities are overcrowded and no facilities are underused. From the perspective of users, care is respectful, good quality, and does not cause financial hardship.

The indicators included in Domain 1 (Structure: Equitably distributed, well-functioning EmONC facilities) generate information to assess whether there are enough facilities in the right locations, and whether they are ready to provide good quality care. The indicators in Domain 2 examine how people interact with that system. Together they depict a dynamic system, in which “active patients” are ideally making choices, interacting with providers and, where necessary, receiving needed care. Without this information, it is impossible to see how and whether the EmONC system is actually meeting the needs and legitimate expectations of the people.

Place of delivery (info)	7. Institutional delivery rate
Met need (info)	8. Met need for emergency obstetric care
Clinical appropriateness of care (info)	9. Cesarean section as a proportion of all expected births
Experience of care (info)	10. Person-centered maternity care
	11. Togetherness - 24h/7d family access to inpatient newborn care unit
Health workforce wellbeing (info)	12. Health workforce wellbeing

Place of delivery

Women and their families actively make decisions about where they go to receive services, often seeking out facilities that they believe will provide the best possible quality of care, even when that means by-passing the closest facility.² These decisions may be constrained by financial, geographic, and other considerations, but they represent people’s preferences given the limitations they face. Their preferences are key to planning a people-centered EmONC system.

Met need

Beyond having enough facilities providing EmONC, it is important for managers and planners to broadly assess whether women with complications are using these facilities, and whether their overall need for EmONC is being met.

Clinical appropriateness of care

As institutional delivery continues to increase globally, it is critical that countries monitor the appropriateness of the care that women and newborns receive in health facilities, ensuring that they receive care that is neither “too little, too late” nor “too much, too soon.”³

Experience of care

Disrespect and abuse and other forms of mistreatment lead to lack of, delayed, inadequate, unnecessary, or harmful care, which undermines health gains for mothers and babies.⁴ Mistreatment deters women from giving birth in health facilities and undermines trust in the health care system.⁵⁶ Conversely, respectful care has positive effects on health outcomes through timeliness, effective communication, patient engagement, safety, trust, improved psychosocial health, and patient and provider satisfaction.⁷⁸

Health workforce wellbeing

Monitoring the health workforce’s wellbeing is critical to ensuring a person-centered health system that respects health workers and is able to deliver respectful, good-quality EmONC services to patients.

The EmONC Framework proposes impact indicators to track change over time. These indicators are specific to EmONC and raise red flags to underscore where there might be particular problems.

Impact on maternal mortality in health facilities (info)	13. Institutional maternal mortality ratio
	14. Direct obstetric case fatality rate
Impact on stillbirths and newborn mortality in health facilities (info)	15. Intrapartum stillbirth and very early neonatal death rate
	16. Neonatal inpatient mortality rate

Impact on maternal mortality in health facilities

Determining how many maternal deaths occur in the health system and tracking changes over time is an important way to gauge whether the health system’s strategies and programming are having the desired impact: a reduction in maternal mortality.

Impact on stillbirths and newborn mortality in health facilities

Tracking changes in stillbirths and newborn mortality is central to understanding the impact of EmONC service delivery.