Monitoring obstetric services: putting the 'UN Guidelines' into practice in Malawi: 3 years on

The maternal mortality ratio is difficult to use for monitoring short-term progress in safe motherhood programs. UNICEF/WHO/UNFPA have proposed alternative process indicators monitoring the availability, utilization and quality of obstetric services. There is little experience in the large-scale use of these indicators as part of routine health information systems in developing countries. The Malawi Safe Motherhood Project, which covers a population of over 5 million, was one of the first large projects to implement the new process indicators. At the end of 2000 data were available from the new monitoring system for 3 consecutive years. In 1998, availability of comprehensive emergency obstetric care was adequate but availability of basic emergency obstetric care was very poor. Although institutional delivery rates were over 30%, the met need for obstetric care was only 19.8% and the cesarean section rate was only 1.6%. The mean case fatality rate in District hospitals was nearly 5%. By the end of 2000, improvements in availability, utilization and quality of obstetric care were observed. Participation in developing the monitoring system had also created a strong sense of ownership and interest in analyzing and using the data. Several issues have emerged from routine use of the process indicators. In particular, it has been difficult to be certain that obstetric complications have been recorded correctly. The results confirm that a focus on improving emergency obstetric care in Malawi was justified and that process indicators for obstetric care can be successfully introduced in developing countries. The monitoring system has provided data that are of immediate relevance to service providers, managers, and policy makers and provide many lessons useful for similar programs in other settings.