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Geographic distribution of EmOC facilities

The assessment by map or interactive geographic information system (GIS) of the actual geographic distribution, distances, and travel time to emergency obstetric care (EmOC) facilities. Optimally, basic EmOC facilities should be located so they can be accessed within a maximum of two hours, and comprehensive EmOC facilities should be accessible within a maximum of 12 hours UNFPA (2004).

Basic EmOC service facilities are defined by the performance of the complete set of these seven signal functions (WHO et al., 2010):

  1. Administer parenteral antibiotics
  2. Administer uterotonic drugs (i.e. parenteral oxytocin)
  3. Administer parenteral anticonvulsants for preeclampsia and eclampsia
  4. Manually remove the placenta
  5. Remove retained products (e.g. manual vacuum extraction, dilation and curettage)
  6. Perform assisted vaginal delivery (e.g. vacuum extraction, forceps delivery)
  7. Perform basic neonatal resuscitation (e.g., with bag and mask)

The facility is classified as functioning at the comprehensive EmOC level when it offers the seven signal functions plus surgery (e.g. caesarean) and blood transfusion.  For additional background on this indicator and basic and comprehensive EmOC, see WHO et al, (2010); UNFPA (2004); and AMDD (2003).

This indicator is calculated as:

The number and distribution of basic EmOC service facilities, and/or estimates of the proportion of the population within two hours travel time from a facility, calculated using maps or a GIS mapping system for subnational areas, such as districts, subdistricts, and urban areas. 

Alternatively, the minimum acceptable number of comprehensive EmOC facilities for an area can be estimated by dividing the subnational area population by 500,000. The resulting number is multiplied by five to calculate the overall minimum number basic and comprehensive facilities for the area. To calculate the percentage of the recommended minimum number of facilities that is available to the district population, divide the number of functioning EmOC facilities by the recommended number and multiply by 100. To ensure equity and access, all of the district and urban areas should have the minimum acceptable numbers of EmOC facilities or at least five facilities (including at least one comprehensive facility) per 500,000 population (WHO et al., 2010).

Spatial analysis conducted with the use of GIS mapping for the distribution of facilities and for estimates of the proportion of households within two hours of a basic EmOC facility. Alternatively, estimates can be made of minimum acceptable numbers of EmOC facilities within subnational areas using lists of the numbers and locations of basic and comprehensive EmOC facilities. Data on EmOC facilities in subnational areas can be stratified by public, private, and non-governmental types of facilities.

If targeting and/or linking to inequity, classify the facilities by location (poor/not poor) and disaggregate by location.

GIS mapping systems; maps and listings with locations of basic and comprehensive EmOC facilities

This indicator measures access to EmOC services based on geographic distribution and travel time to facilities. Simply having sufficient numbers of EmOC facilities is not enough; their geographic distribution must also be considered.  For example, if all comprehensive EmOC facilities are clustered in urban areas, a large number of women, especially those living in rural areas, will not be able to access services in a timely manner. Women’s access to basic and comprehensive EmOC services is vital to achieving Millennium Development Goals #5. improve maternal health #4. reduce child mortality.

In settings with rugged terrain, traveling even relatively short distances may take a very long time with the journey often made on foot, horseback or by donkey cart. Thus, a companion indicator for the proportion of households within a given travel time for a woman to reach a basic or comprehensive EmOC facility is useful. Ideally, all women should live within two hours of a basic EmOC facility. This time frame was selected as a maximum limit because hemorrhage, the most rapidly fatal complication of pregnancy, can kill a mother in two hours. Therefore, in order to save the maximum number of lives, facilities must be able to treat pregnant women within two hours. Hemorrhage can be treated at a basic EmOC facility, although some cases may need to be referred to a comprehensive facility for blood transfusions. An optimal geographic distribution of facilities would ensure that all women live within two hours of a basic EmOC facility and within twelve hours of a comprehensive one (UNFPA, 2004). The creation and dissemination of maps that show the EmOC status of facilities, the distance of communities from basic and comprehensive facilities (both in travel time and in relation to road networks), population dispersion and density and other features that show inequities in terms of access to care can be effective advocacy and planning tools.

While this indicator measures physical access, it does not address other barriers to access at EmOC facilities, such as stockouts of necessary drugs, lack of available trained staff, or inadequate equipment and supplies. This indicator is best measured by performing spatial analysis with the use of maps or GIS (which requires the appropriate software and expertise using it).  In many developing countries, the terrain is rough and communications, roads and transportation are poor, making estimates of the travel time difficult. The alternative estimation of minimum acceptable numbers of facilities per subnational area (WHO et al., 2010) does not provide information on actual distances or travel times to the closest facilities.  

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

AMDD Program, 2003, Using the UN Process Indicators of Emergency Obstetric Services: Questions and Answers, Columbia University, New York; AMDD.   

UNFPA, 2004, Program Manager’s Planning Monitoring and Evaluation Toolkit, Part II: Indicators for Reducing Maternal Mortality, New York: UNFPA.  

WHO, UNFPA, UNICEF, AMDD, 2010, Monitoring Emergency Obstetric Care: A handbook, Geneva: WHO.