BasicEmergencyObstetricandNeonatalCareAssessment

ManufahiandAinaroDistricts

FinalReport

March2012

AnnmarieNolan,BSN,RN,MN

HealthAllianceInternationalUniversityofWashington

AcknowledgementsTheauthorwouldliketothankHealthAllianceInternationalstaff,UnitedNationsPopulationFund’sDr.AngelaBismarkandDr.AmitaPradhanThapafortheirinput,theMinistryofHealthstafffortheirparticipation,andlastlyUSAIDandHealthAllianceInternationalforprojectfunding.

TableofContentsExecutiveSummary………………………………….……………………………...…………………………………………………...1Background……………………………………………………………………………………………………………………………………..3ProblemStatement…………………………………………………………………...…………………………………………………...3Methods…………………………………………………………………………..………………………………………………………….…...4Results

Staffing……………………………………………..………………………………………………………………………………….5CaseSummaries………………………………………………………………………………………………………..……….6ServiceAvailability…………………………………………………………………………………………………...………6StaffKnowledgeLevels……………………………………………………………………………………………………7EquipmentandSupplies………………………………………………………………………………………………….9

Conclusions…………………………………………………………………………………………………………………………………..10Recommendations………………………………………………………………………………………………………………………11 ImmediateRecommendations…………..…………………………………………………………………………11 Long‐termRecommendations…………………………...…………………………………………...……………12Annex1:GovernmentHealthFacilitiesprovidingEmergencyObstetricCareServices…14Annex2:MidwifeAssessmentSupplement…………………………………………………………………………..15Annex3:ServiceAvailabilityandStaffingTable………………………………….…………………………..…..16Annex4:FacilityConditionandStaffing………………………………………………………………………………..17Annex 5: Midwife Knowledge Survey……………………………………………………………………………………….18 Annex6:EquipmentListtoPerformBEmOCbyFacility……………….…………………………………..20

Abbreviations:DemographicandHealthSurvey(DHS)NationalReproductiveHealthStrategy(NRHS)HealthAllianceInternational(HAI)AvertingMaternalDeathandDisease(AMDD)UnitedNationalPopulationFund(UNFPA)MinistryofHealth(MOH)CommunityHealthCenters(CHCs)FamilyHealthPromoters(PSFs)IntegratedCommunityHealthServices(SISCa)Emergencyobstetriccare(EmOC)Emergencyobstetricandneonatalcare(EmONC)Basicemergencyobstetriccare(BEmOC)

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ExecutiveSummaryTheTimor‐Lestegovernmenthasfoughttoreducematernalmortalityusingsafemotherhoodstrategiesonanationalscale.Despiteeffortstoreducematernaldeaths,the2009/10DemographicandHealthSurvey(DHS)foundthatthematernalmortalityratioremainshighat557per100,000livebirths.InJanuaryandFebruaryof2012,HealthAllianceInternational(HAI)assessedbasicemergencyobstetriccareinmid‐levelhealthfacilitiesinthedistrictsofAinaroandManufahi.Thepurposeoftheassessmentwastomonitorthescale‐upofbasicemergencyobstetriccareinruralareasandtoassistthedevelopmentofMobileMoms,amaternalhealthprojectaimingtoimprovehealthandcare‐seekingbehaviorsofpregnantwomenandtheirnewborns.AUnitedNationalPopulationFundsurveytoolenhancedwithadditionalinterviewquestionswasusedtoassesssevendistrictandsub‐districtlevelhealthfacilitiesandseventeenmidwives.ResultswerecomparedbetweenfacilitiesandWorldHealthOrganizationemergencyobstetriccare(EmOC)policiesandrecommendations.Thefindingsshowthat: Serviceavailabilityvariesthroughoutthetwodistricts,withthemostremote

facilitieshavingthefeweststaffmembersavailableinhibiting24hoursperdaycoverage.Supervisoryphysiciansareoftentemporarilyplacedinfacilities,causinginconsistenciesintechnicalsupportandteammanagementstyles.

Therecontinuetobeweaknesseswithinthegovernmentsurveillancesystem.Withinfacilities’monthlyrecordstherewereinconsistenciesincasenumbersandmissingdata.AmajorityofthehealthfacilitiesmanagedfewobstetriccomplicationsandmidwiveslackanadequatecaseloadtopracticeandmaintainbasicEmOCskills.

OtherthantheMaubisseReferralHospital,midwivesfromthePrinceofMonacoII

MaternityHouseweretheonlyinterviewedwhoperformedallbasicEmOCsignalfunctionsinthepastthreemonths.Skillconfidencevariedacrossfacilities,withsomemidwivesacknowledgingincreasedconfidencewithteamcaremanagementapproaches.

EquipmentisnotconsistentlyavailabletoprovidehighqualitybasicEmOC.Basic

equipmenttomonitoranddetectearlycomplicationswasmissingfromnumerousfacilities.EquipmenttoperformbasicEmOCfunctionwasmissingorstafflackedknowledgeonpropermaintenance.Atthetimeofassessment,medicineswerewelldistributed,butstaffadmittedtoexperiencingfrequentshortages.

Whileimprovementshavebeenmadesincethe2009nationalEmOCassessment,theManufahiandAinarodistrictandsub‐districtfacilitieshaveyettomeetWorldHealthOrganizationrecommendationsforprovidinghighqualitybasicemergencyobstetriccare.Beforeadditionalemphasisisfocusedonqualityimprovement,effortsneedtotargethealthsystemimprovementsbasedondistrictandindividualfacilitylevelneed.

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KeyRecommendations:Immediate1. Ensurethatfacilitieshaveequipmenttoprovidebasiccaremanagement.

RevamptheMOHequipmentandsupplyrequestprocesstodecreasewaitingperiods.Supervisorystaffshouldbeknowledgeableinandoverseeequipmentmaintenance.

2. Increaseteamapproachestocaremanagement.Inter‐professionalapproachestomanagingmaternalhealthcarehaveshowntobemoreeffectivetoimprovingqualityofcare.Prenatalanddeliverycarestaffandrecordsshouldbelocatedwithinthesamehealthfacilityincreasingcontinuityofcare.

3. ImprovegovernmentmonitoringsystemsbymentoringhealthstaffthroughroutineSafeMotherhoodandEmOCsupervisionandreviewingcasesummaryreporting.

Long‐term4. Supporttherenovationandupgradingofexistingfacilitiestoimprovepower

suppliesandwaterandsanitationsystems.5. Ensureallproviders(midwivesandphysicians)maintaintheirbasicEmOC

certification.Allmidwivesshouldcompletethecertification,prioritizingdistricthealthfacilitystaff.Routinerefreshertrainingsshouldintegratephysicianandmidwivestogethertoreinforceteamcaremanagementapproachesandmaintainskilllevels.UponbasicEmOCcertification,allprovidersshouldbeuniversallyapprovedtoindependentlyperformfunctionsasdescribedbyMOHpolicy.

6. FacilitatethetimelydistributionofUNFPAEmOCkits,ensuringthatallfacilitieshavetheequipmentnecessarytoperformbasicemergencyobstetriccare.Kitsshouldbereviewedwithreceivingstafftoensurepropermaintenanceofequipment.

7. EmOCsupportivesupervisionshouldbeintegratedinsafemotherhoodvisitstosustainlongevityofskillqualityaftertrainingcompletion.Measuresthatcanpreserveskillqualityincludehands‐onpractice,teamapproaches,andfollow‐uptraining,whichcanbeprovidedduringsupervisionvisits.

8. Researchmethodstopreserveskilllevelofremotelyplacedprovidersthatassistwithfewobstetriccomplications.Considerdevelopingarotationforremotemidwivestopracticeobstetricskillswithinfacilitieswithahighernumberofabnormalobstetriccasesprovidingthemthehands‐onpractice.Alternatively,theMOHcanconsideratrialoflowtechnologysimulation‐basedEmOCpractice,suchasthatavailableattheUniversityofWashington’sPRONTOproject.

9. Increaseresourcestotransportpatients,ensuringthattimelycareisaccessible.IncreasefuelsupplyforemergencytransportationandprimarycareSISCa’s.Considermonitoringthereferraltransportationsystemtoensurethatanappropriatenumberofvehiclesareavailabletoservepopulationneeds

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BackgroundTimor‐Lestehasbeeninvestedinhealthsystemstrengtheningsinceindependencein2002.EffortsbytheMinistryofHealthandnon‐governmentagencieshavetargetednumeroussectors,buthavelargelyfocusedinmaternalhealth.Yetthe2009/10DemographicandHealthSurvey(DHS)foundthatthematernalmortalityratioremainshighat557per100,000livebirths.1Behindthisstatistic,italsofoundthat70percentofbirthsarenotassistedbyaskilledattendantandonly22percentofdeliveriesoccurwithinahealthfacility.The2004Timor‐LesteNationalReproductiveHealthStrategy(NRHS)providesafour‐strategyapproachtomakepregnancysafer.2TheseSafeMotherhoodapproachesincluded1)increasingtheknowledgelevelinthegeneralpopulationonissuesrelatedtopregnancyandchildbirth;2)improvingthequalityandcoverageofprenatal,delivery,postnatal,andperinatalhealthcare;3)improvingemergencyobstetriccare(EmOC)throughrecognition,earlydetection,andmanagementorreferralofcomplicationsofpregnancyanddelivery;and4)integratingeffectivedetectionandmanagementofSTIcasesintomaternalandperinatalcare.HealthAllianceInternational(HAI)iscurrentlylaunchingafour‐yearprojectaimedatsupportingtheSafeMotherhoodcomponentoftheNRHS.TheMobileMomsprojectusesanintegratedapproachinworkingwithdistrictandsub‐districtMOHhealthfacilitiesdowntoFamilyHealthPromoters(PSFs),whoprovideaccesstotheindividualhouseholds.ThehealthstaffstrengtheningcomponentoftheMobileMomsprojectaimstoimproveskillsofhealthteamstoprovidequalitymaternalcareservicesthroughsupportivesupervisionofmidwivesinmaternalcareservicesandtraininginbasicemergencyobstetricandneonatalcare.ProblemStatementTheoverallgoaloftheHealthAllianceInternationalprojectMobileMomsistoimprovethehealthandcare‐seekingbehaviorofpregnantwomenandtheirnewborns.Asapartofthiseffort,HAIaimstosupportgovernmenthealthfacilitiestoensurethatpregnantwomenandtheirnewbornsreceivehighqualitycare.ThisaimwillbeaccomplishedthroughtechnicalsupportinSafeMotherhoodandemergencyobstetricandneonatalcare(EmONC).In2008,theUnitedNationalPopulationFund(UNFPA)conductedanationalEmOCneedsassessment.ThisassessmentfoundmultiplelimitationstoprovidingqualityEmOCinTimor‐Leste,suchaspoorinfrastructure,lackofmaternityspace,inadequateequipmentandsupplies,poortransportationandcommunicationschemes,weak

1 NationalStatisticsDirectorate(NSD)[Timor‐Leste],MinistryofFinance[Timor‐Leste],andICFMacro.2010.Timor‐LesteDemographic andHealth Survey2009‐10.Dili, Timor‐Leste:NSD [Timor‐Leste] andICFMacro.2MinistryofHealth[Tmor‐Leste].2011.NationalHealthSectorStrategicPlan.2011‐2030:TowardsaHealthEastTimoreePeopleinaHealthTimor‐Leste.

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logisticsystem,andlackofconfidenceoftrainedmidwivestoperformsomesignalfunctions.3In2010,HAIfield‐testedabasicEmOCsupervisionassessmentformwiththeMinistryofHealth(MOH)inManatutoandAinarodistrictcenters.4In2012,UNFPAandtheMOHinitiatedEmONCsupervisionvisitsinalldistrictandsub‐districtCommunityHealthCenters(CHCs)withafocusonbasicEmONCidentifiedsites.SeeAppendix1foralistofEmOCsites.ToappropriatelysupporttheAinaroandManufahimidwiveswithintheMobileMomsproject,HAIassessedcurrentbasicEmONCconditionswithinthetwodistricts.ResultsfromtheassessmentwillbeusedtoincreaseEmONCcapacitywithinthetwodistrictsandcanbeappliednationally.MethodsThisbaselineassessmenttargetedgovernmenthealthfacilitieswithintheManufahiandAinarodistricts.TomeasuretheavailabilityofBEmONCthroughoutthisgeographicregion,districtandsub‐districtCHCsandMaternityHousesweretargetedforassessment.Districtandsub‐districthealthfacilitieshavebeenidentifiedbytheMinistryofHealthandUNFPAtobedevelopedintoBEmONCfacilitiesby2015.AUniversityofWashingtongraduatenursingstudent,assistedbyHAItechnicalstaff,visitedeightsitesbetweenJanuary17thandMarch2nd2012.Thosesitesincludedhealthfacilitiesinallfoursub‐districtsinManufahi,andthreesub‐districtsinAinaro(seeTable1).Approvalfromdistrictgovernmentstaffandindividualconsentwasreceivedpriortosurveyinitiation.TheBEmONCassessmentwasconductedusingamixedmethodapproach.MultipleindicatorsweregatheredfromhealthfacilitiesusingaMOHapprovedUNFPAquestionnaire;indicatorsincludedstaffing,casesummaryreports,serviceavailability,staffknowledgelevels,equipment,supplies,anddrugs.5Thesequantitativeresultswerecompiledintoanexceldatabase.

3MinistryofHealth[Timor‐Leste].2004.NationalReproductiveHealthStrategy2004–2015.Dili,Timor‐Leste:MinistryofHealth.4MinistryofHealth[Timor‐Leste],andUnitedNationsPopulationFund(UNFPA).2008.EmergencyObstetricCare(EMOC)NeedsAssessment.Dili,Timor‐Leste:NSD[Timor‐Leste]andUNFPA.5 MinistryofHealth[Timor‐Leste],andUnitedNationsPopulationFund(UNFPA).2008.EmergencyObstetricCare(EMOC)NeedsAssessment.Dili,Timor‐Leste:NSD[Timor‐Leste]andUNFPA.

Table1.BEmOCAsssessmentSites

NumberofMidwives

NumberofEmOCCertifiedMidwives

CompletedFacilityAssessments

NumberofCompletedMidwifeAssessed

Manufahi CHCSame 2 x ‐ ‐PrinceofMonacoMaternityHouse 7 5 1 6TuriscaiMaternityHouse 1 0 1 1FatuberlihuMaternityHouse 3 2 1 1CHCAlas 1 0 1 1HPBetano 1 1 ‐ 1

Ainaro

CHCAinaro 3 2 1 3

CHCHatudu 1 1 1 1

CHCMaubisse 1 0 ‐ ‐

RSUMaubisse 5 4 1 3

CHCHatubelico 1 1 ‐ ‐

Total: 26 15 7 17

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MidwifecapacitywasassessedusingaUNFPAindividualstaffknowledgelevelquestionnaireenhancedwithadditionalinterviewquestions.Thistoolaimedtomeasurethefrequencyandconfidenceoftreatingobstetriccaseswhilegatheringadditionalbackgroundinformation.QualitativequestionsinquiredonbarrierstoprovidingBEmONC,qualityofhomedeliveryassistance,andearlycomplicationidentificationandcare.SeeAnnex2fortheinterviewsupplement.ThisindividualassessmentwasdistributedtoseventeenmidwivesintheAinaroandManufahidistricts,fromeverylevelofMOHfacilitiesrangingfromtheMaubisseReferralHospitaltoaManufahihealthpost.Thenumberofmidwivesinterviewedatonefacilityrangedbetweenoneandsixmidwives.Midwives’nameswerenotused,howeversurveyidentificationnumberswerelinkedtofacilityassessmentsallowingstaffandfacilitydatatobecombined.ResultsThefacilityandmidwifeassessmentresultswerecollectedandenteredintoseparateexceldatabases.Datagatheredprovideageographicrepresentationofthetwodistricts,withsurveysitesdistributedoversevenoftheeightsub‐districts.OneplannedAinarosub‐districtCHCwasnotvisitedduetotimeconstraints.Thefollowingresultsareseparatedintostaffing,casesummaryreports,serviceavailability,staffknowledgelevels,equipment,supplies,anddrugs.StaffingFacilitiesrangedinhumanresourcesupport.Fourofthesub‐districthealthfacilities(CHCsandMaternityHouses)haveonlyonemidwifeprovidingobstetricservices.Onlytwoofthefacilitiesadmittedtohavingmidwivespresenttwenty‐fourhoursaday,everyday.Onaverage,midwivesinterviewedassistwithonlysevenbirthsamonth.WhilephysicianswerenotincludedintheMOHquestionnaire,midwivescommentedontheirpresencewithinhealthfacilitiesduetotheirsupervisoryrole.TheMaubisseReferralHospitalistheonlyfacilitywithapermanentobstetricianphysicianposition.DistrictCHCshavegeneralphysicians,however,mostpositionsarefilledwithinternationalsundercontractthatleavethefacilityafterayearortwo.

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CaseSummaries

Table2.2012FacilityCaseSummaries(#)

Obstetriccases Complications Referral

Antenatalcare

consultations

Totaldeliveries

Livebirths

New

bornswithnormal

birthw

eight

Hom

ebirths

Facilitybirths

Totalobstetric

admissions

Hem

orrhagecases

Dystociaorprolonged

birthcases

Post‐partuminfection

cases

Eclampsiacases

Abortioncases

Referredobstetric

cases

Receivedobstetric

cases*

PrinceofMonacoMaternityHouse

2339 329 329 319 12 317 396 27 1 1 7 18 49 x

TuriscaiMaternityHouse

402 95 92 92 85 7 7 0 0 0 0 0 1 0

AlasMaternityHouse 438 63 63 62 33 30 30 0 0 0 0 2 10 0

FaterberlihuMaternityHouse

514 108 108 108 31 77 77 5 3 0 0 6 2 0

MaubisseReferralHospital

1567 188 184 163 13 175 194 9 6 11 23

15 4 137

AinaroCHC 844 186 186 177 64 122 122 0 1 0 1 8 2 x

HatudoCHC 686 89 89 87 37 52 52 1 0 0 0 1 1 0

*x=thesefacilitiesdidnotrecordthenumberofobstetriccasesreceived

2011casesummarydatawascollectedfromsevenfacilities(seeTable2).ThePrinceofMonacoIIMaternityHouseperformsanotablyhighernumberofbirths,evenwhencomparedtothereferralhospitalorAinarodistrictCHC.TheTuriscaiMaternityHouseistheonlyfacilitythatperformssubstantiallymorehomethanfacility‐basedbirths.Itisanewadditiontothatsub‐district,sofacility‐basedbirthsareexpectedtorisein2012.Whilethematernityhouseshaveincreasedaccesstofacility‐baseddeliveriesacrossthetwodistricts,therehasbeennoevidentshiftofhometofacility‐basedbirthsduring2011.Additionally,thefrequencyofreportedobstetriccomplicationsremainslowinmostfacilities.FewobstetricpatientswerereferredfromtheTuriscai,Alas,andHatudofacilities,reinforcingtheinfrequencyofcomplicationcasesmanagedbyhealthprofessionals.Indicationsofobstetricreferralsweredifficulttomonitorasmanyreferralswereexcludedfromfacilitycomplicationcasereports.Also,recordsdidnotuniformlydocumentcauseofreferral.Referralcasesweredifficulttotrackthroughfacilitiesandinconsistencieswithinfacilityformssuggestedsomeerroneousreporting.ServiceAvailabilityAllfacilitiesreportedhavingmidwivesavailableon‐callasneeded.Midwiveslivedinvaryingproximitiestohealthfacilitiesandinconsistenttransportationsometimescausedadelayofservices.TheMaubisseReferralHospitalandthedistrictCHCshadotherhealthstaff(nurses,midwivesandnurseassistants)availabletwenty‐fourhoursadayifskilledassistancewasrequiredduringeveningornighthours.Medicinesareavailableduringeveninghoursatallmonitoredfacilities,faultingTuriscai,whichwasnotmeasured.MaubisseReferralHospitalwastheonlyfacilitywithlaboratorytechniciansavailableatnight,howevernumerousmidwivesclaimedtoindependently

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testformalariaifneeded.Overall,veryfewlaboratorytestsareconductedatruralsites.SeeAnnex3foracompletelistofserviceavailabilityandstaffing.StaffKnowledgeLevelsSixteenoftheseventeenmidwivesinterviewedassistedwithdeliveriesin2012.Quantitativedataisbasedonthesixteenmidwivescurrentlyprovidingmaternitycare.QualitativedataincludestheseventeenthmidwifewhoprovidesantenatalintheMaubisseReferralHospital.Eight(47.1%)ofthemidwivesinterviewedworkinMaternityHouses.Five(29.4%)midwivesworkinCHCs,oneinahealthpost,andthree(17.6%)inahospital.SeventyonepercentofthemidwivesinterviewedareEmOCcertifiedbytheMinistryofHealth.

WHOcategorizesaBEmONCfacilitybydeterminingifallsignalfunctionswereperformedinthelastthreemonths.6Everymidwifewhoassistedwithdeliveriesadministereduterotonicdrugswithinthelastthreemonths.Eleven(68.8%)administeredparenteralantibiotics,nine(56.3%)removedretainedproducts,eight(50.0%)performedamanualremovalofplacenta,whileonlyfive(31.3%)administeredparenteral

anticonvulsants.Assistedvaginaldeliveryandnewbornresuscitationwasassessedduringasix‐monthdurationandnotincludedinTable4.Additionally,midwivesweregivenaquestionnaireonforty‐fiveobstetricskills,inquiringwhethertheywereconductedinthelastsixmonthsandifthepractitionerfeltconfidentinperformingthatfunction.Skillsvariedfornormalassessments,treatingabnormalcases,andBEmONCskills.Whilemanymidwivesreportedthattheyhadnotconductednumerousfunctionsinthelastsixmonths,theyclaimedtofeelconfidentinperformingthem.

6 WorldHealthOrganization(WHO).2009.MonitoringEmergencyObstetricCare:aHandbook.WHOPress,Geneva,Switzerland.

Table3.MidwifeEmOCEducation(N=17)# %

EmOCcertified 12 70.6

IncompleteEmOCtraining 5 29.4

Table4.BEmOCSignalFunctionsPerformedinLastThreeMonths(N=16)

# %

Administeredparenteralantibiotics 11 68.8

Administereduterotonicdrugs 16 100.0Administeredparenteralanticonvulsants 5 31.3

Performedmanualremovalofplacenta

8 50.0

Removeretainedproducts 9 56.3

Table5.ObstetricSkillsPerformedinLastSixMonths&ConfidenceLevels(N=16)#%

Managedbleedinginearlypregnancy 12 70.6Confidentinmanagingbleedinginearlypregnancy

14 87.5

Managebleedinginlatepregnancyandlabor 7 43.8Confidentinmanagingbleedinginlatepregnancyandlabor

15 88.2

Managepre‐eclampsia 11 68.8

Confidentinmanagingpre‐eclampsia 14 87.5

Managefeverbeforedelivery(amnionitis) 10 62.5Confidentinmanagingafeverbeforedelivery(amnionitis)

15 93.8

Performedvacuumdelivery† 8 57.1

Con identinperformingvacuumdeliveries† 6 42.9Performednewbornresuscitation 9 56.3Confidentinperformingnewbornresuscitation 15 93.8

†Statisticbasedoffof14midwives

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Fromthequalitativeinterviews,midwiveslistedmultiplebarrierstoprovidingBEmONC.Themostcommonthemefoundwasthelackofsupport.Itwasfrequentlylinkedtothelimitednumberofhealthprofessionals(obstetriciansandmidwives)availabletoassistwithabnormalobstetriccases.Anotherissuethattheypresentedwasinconsistenciesinthesupervisionstylesofcontractphysicians.Somemidwivesreportedthatfacilitypoliciesdeterminingwhetherfunctionscouldbeindependentlymanagedbyamidwifechangedunderdifferentphysiciansdependingontheirobstetricexperiencelevel.Midwivesclaimedtohavereferrednumerousobstetriccasesthattheyweretrainedinandfeltconfidentinmanagingbecausethesupervisingphysicianwasnotconfidentofhisorherskills.ThesecondmostcommonthemeidentifiedwasinadequateequipmentorsuppliestoprovideBEmONCfunctions.Manyfacilitiesreportedhavingrequestedreplacementequipment,butaresubjecttolengthywaitperiods.Thethirdbarriercommonlylistedwaslimitedemergencytransportation.Reasonsbehindthisbarrierincludedalimitednumberofemergencyvehiclesavailable,limitedaccessduetopoorroadconditions,andinadequatefuelavailability.WhenaskedabouttheirabilitytoprovidequalityofBEmONCduringhomedeliveries,midwivesoverallreportedlimitedability.MostmidwivesreportedtransferringpatientstoafacilitypriortoprovidingBEmONC.Theyreportedthatintravenousfluidswouldbeplacedinthehomeifnecessary;however,allothercomplicationsaretreatedatahealthfacility.Additionally,whenmidwiveswererequestedtoprovideskilledassistanceduringanormal,early‐stagehomedelivery,theyconsistentlytransferredthepatienttoafacilitytogivebirth.Veryfew“homebirths”assistedbyfacilitystaffactuallydeliveredwithinthehome.Whenaskedhowthemidwivesmanageobstetriccomplicationsduringtheprenatalperiod,themostcommonresponsewasalistofdiversefactorstakenintoconsiderationtodevelopacareplan.Midwivescommonlylistedacuity,gestation,previousmedicalhistory,andgeographiclocationofthepatient’shomeasfactors.Fewmentionedresourcesusedtodevelopabirthplan,whichincludedteamapproachorEmOCmaterials.Midwivesalsolistedvariouscarestrategies,suchasprovidinginpatientcare,additionalconsultations,andrequestingpregnantmothersintheirninthmonthgestationtostaywithinashortdistancefromahealthfacility.However,nouniversalprotocolwasmentioned.AlmostallmidwivesrequestedcontinuationofEmONCtraining,eitherinitialcertificationorrefreshertraining.OnemidwifereceivedEmOCtrainingasearlyas2006,andmanyrequestedroutineupdatestoensureskillquality.EquipmentandSuppliesTheoriginalequipmentandsupplyquestionnaireincluded172items,withsectionsonfacility,equipmentandsupplies,stafftransportation,referralsystem,laboratoryequipment,infectionprevention,basicmedicalitemsandsupplies,recordsandforms,registries,drugs,anddeliveryequipment.Itemspertinenttogeneralfacilitycondition

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andperformingdirectBEmONCfunctionswerereviewedfirst.Someitemswerenotassessedduetoalackoftimeoravailabilityofstaffduringsitevisits.Thesefindingsshowthatthegeneralconditionsofthedistrictandsub‐districtfacilitieswerenotidealforprovidinghighqualityBEmOC.OnlytheMaubisseReferralHospitalhadaccesstoelectricity24hoursaday.Threefacilitieshadaccesstoelectricityduringlimitedhoursoftheday.Twofacilitiesonlyhadelectricityforspecificelectronics.Onefacility,AlasMaternityHouse,hadnoelectricity.TheonlyfacilitieswithareliablewatersupplydirectlytotheclinicweretheMaubisseReferralHospitalandtheAinaroCHC.Additionally,onlythreefacilitieshadanoxygensupply(MaubisseReferralHospital,AinaroCHC,PrinceofMonacoIIMaternityHouse).SeeAnnex4foralistoffacilityconditionsandbasicmedicalequipmentbyfacility.WorldHealthOrganizationpoliciesformanagingpregnancycomplicationswereusedtodevelopanabbreviatedlistofequipmentusedtoperformBEmONCfunctions(seeAnnex6).Thislistofnecessaryitemswasdevelopedfromthe2007WHOprovidermanual,ManagingComplicationsduringPregnancyandChildbirth:AGuideforMidwivesandDoctors.7ThismanualisusedasatrainingresourceinTimor‐Leste.ThisequipmentlistdoesnotincludebasiccaremanagementsuppliesorequipmentneededtoaddresscomplicationsthatmayarisewhileperformingBEmONC.ThislistwasusedsolelyforanalysisofBEmONCequipment.EquipmentwithinTimor‐LestevariesslightlyfromtheWHOrecommendations,sosomevariationexists.Table6depictsthepercentageofequipmentcurrentlyavailableatfacilitiesduringthe2012sitevisittocompleteBEmONCfunctions.SeeAnnex6forabreakdownofequipmentbyBEmONCfunctionandfacility.Table6showsthatnofacilitieshadacompletesetofequipmenttoprovidehighqualitycare.Ruralsub‐districtsofTuriscai,Alas,andHatudulackedthemostequipment.

7 WorldHealthOrganization(WHO).2007.ManagingComplicationsinPregnancyandChildbirth:Aguideformidwivesanddoctors.WHOPress,Geneva,Switzerland.

Table6.BasicEmOCEquipmentandSupplies(percentageavailable)

MaubisseHospital

MonacoMaternityHouse

TuriscaiMaternityHouse

AlasMaternityHouse

Fater‐berlihuMaternityHouse

AinaroMaternityHouse

HatuduMaternityHouse

1 Admisterparenteralantibiotics 100.0% 100.0% 81.8% 81.8% 90.9% 100.0% 90.9%

2Administeruterotonicdrugs(i.e.parenteraloxytocin) 91.7% 91.7% 66.7% 75.0% 83.3% 91.7% 91.7%

3Administerparenteralanticonvulsantsforpre‐eclampsiaandeclampsia 81.8% 81.8% 63.6% 54.4% 63.6% 81.8% 72.7%

4 Manuallyremovetheplacenta 100.0% 87.5% 62.5% 87.5% 93.8% 100.0% 87.5%

5 Removeretainedproducts(vacuumextraction,dilationandcurettage)

90.0%,93.8%

90.0%,87.5%

60.0%,62.5%

65.0%,81.3%

75.0%,68.8%

90.0%,93.8%

55.0%,62.5%

6Performassistedvaginaldelivery(i.e.vacuumextraction) 83.3% 83.3% 33.3% 50.0% 50.0% 100.0% 33.3%

7Performbasicneonatalresuscitation(i.e.withbagandmask) 100.0% 100.0% 75.0% 87.5% 100.0% 100.0% 0.0%

BasedonWorldHealthOrganization'sprovidermanual"ManagingComplicationsinPregnancyandChildbirth:AGuideforMidwivesandDoctors"

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ConclusionIn2002,theNationalPlanningCommitteeelegantlysummarizedthestateofmaternalhealth,statingthat“womenbearanunacceptableburdenofmortalityandmorbidity,withmaternalmortalityratesat350‐800per100,000livebirths”.8Eightyearslater,womencontinuetobesubjecttothisheavyburden.Since2002,emergencyobstetricserviceshaveimproved.However,AinaroandManufahifacilitiesprovideincompletebasicservices,especiallyatruralsub‐districtsites.IdentifyingandtargetingindividualfacilityweaknessisthemosteffectivestrategytoincreasingdistrictBEmONCcapacity.9,10,Thisassessmentfoundmanyofthelimitationslistedinthe2008UNFPAEmOCNeedsAssessmentstillexistandrequireadditionalfocusandresources.TheframeworkontherightisColumbiaUniversity’s“AvertingMaternalDeathandDisability”(AMDD)tooltomeasureEmOCimplementation.11Thisbuildingblockframeworkbreaksdownhoweachactivityrelatestotheothersandinwhatsequencetheymustbeinitiated.Thebottomtworowsarethefoundationtoprovidingsustainable,highqualityemergencyobstetriccareandmake‐upthepreparationstage.AMDDandUNFPAagreethatdevelopingstronghealthsystemsprecludesEmONCqualityimprovementinterventions.12Focusingontheframework’sbottomlevel:whilethehealthfacilitieshavemadeimprovementsinrenovations,facilitysetup,suppliesandequipmentsincethe2008EmOCassessment,manyweaknessesarestillevident.Additionaleffortisstillneededtoimprovefacilityconditions,equipmentmaintenance,suppliesandequipment,andimprovetheaccuracyofdatacollection.EquipmentandsupplieswerewellstockedandfunctioningintheMaubisseReferralHospital.However,otherfacilitiesaresubjecttolongwaitingperiodsforequipmentandsupplyreplacementandrestock.Basicmedicalequipmentneededforcareofroutineandemergencyconditionsweremissingfromnumerousfacilities,especiallythemostremotesites.Bettermaintenanceandsupplyofequipmentisneededtodetectandconfirmearlyobstetriccomplications.

8 NationalPlanningCommittee.2002.NationalDevelopmentPlan.Dili,EastTimor.9Freedman,L.P.,Graham,W.J.,Brazier,E.,Smith,J.M.,Ensor,T.,Fauveau,V.,Themmen,E.,Currie,S.,Agarwal,K.2007.Practicallessonsfromglobalsafemotherhoodinitiatives:timeforanewfocusonimplementation.Lancet,370:1383–91.10AvertingMaternalDeathandDisability.2006.AvertingMaternalDeathandDisabilityProgramReport1999‐2005.ColumbiaUniversity,NewYork,USA.11Campbell,O.M.R.andGraham,W.J.2006.Strategiesforreducingmaternalmortality:gettingonwithwhatworks.Lancet,368:1284–99.12Freedmanetal.2007.

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Thesefirst‐layeractivitieswithinthetoolsupportthesubsequentpreparationstagelayer.RoutinerefreshertrainingsonEmONCandsafemotherhoodneedtobeintegratedintohealthprofessional’scareers.IncreasingstaffingwouldprovidemidwivessupporttoprovideBEmONCinruralsitesduring24hoursperday.Teambuildingtrainingsandexerciseswouldincreaseinter‐professionalapproachesandqualityofcare.UsingtheAMDD’sframeworkshowsaneedfortheMOHtofocusonimprovinghealthsystemissuesbeforeBEmONCqualitycanbefullyaddressed.Whileworkingonthesefoundationalissues,theMOHcanplanhowtoaugmentthefirstlayeroftheservicedeliverystage,consistingofcontinualreadinessandconstantemergencyobstetriccare.Obstetriccomplicationsatsub‐districtfacilitiesareinfrequentandthesecasesareoftenreferredtothedistrictorreferralhospitallevelbasedonacuity.Withcurrentlevelsofhealthcareutilization,remotelyplacedmidwiveslackasufficientnumberofopportunitiestopracticetheirBEmONCskills.RecommendationsManyinterventionsaddressingmaternalmortalitywereintegratedintothenationalplanfromtheSafeMotherhoodinitiative.Communityoutreachefforts,suchasSISCa(IntegratedCommunityHealthServices)andPSFsincreasedtheuseofhealthfacilityandtrainedstaffservices.Whilequalityofcarehasbeensupportedthroughspecialtytrainingsandsupervisionvisits,furtherhealthsystemimprovementsareneededtoprovideauniversalstandardofcareacrossfacilitylevels.Globally,therehasbeenanincreasedfocusontheimplementationofinterventionswithevidence‐basedscale‐upstrategies.13Duetoinconsistenciesinfacilityconditions,supplies,serviceavailability,andstaffing,basicsystemlevelfactorsatthedistrictandsub‐districtlevelhealthfacilitieshavetoimproveasaconditionofexpandingEmOCservices.Additionally,byaddressingsystemlevelissues,benefitswilloccuracrossabroadspectrumofhealthconditionsincludingpreventivecare.Thefollowingisalistofimmediatesystemlevelchangessuggestedandlong‐termrecommendationsfocusingonEmOC.Recommendationsweredevelopedfromassessmentresults,aliteraturereview,andinterviewswithfieldexperts.ImmediateRecommendations

1. Ensurethatthefacilitieshavethebasicequipmentnecessarytoprovidecaremanagement.RevamptheMOHequipmentandsuppliesrequestprocesstodecreasewaitingperiods.Frequentequipmentallotmentshouldbeanticipatedanddistributedinatimelymanner.Equipmentmustbeavailableforcomplicationstobedetectedearlyandappropriatemanaged.

2. Ensurestaffisknowledgeableinequipmentmaintenance,i.e.sterilizationofmanualsuctionmachine.Supervisingstaffshouldberesponsibleforensuringequipmentmaintenanceandstandardsofcare.Adequatecareofequipmentincreasesitslongevityandqualityofcare.

13 Freedmanetal.2007.

12

3. Encourageteamapproachestopatientcaremanagementduringsupervisionvisitsandtrainings.Inter‐professionalapproachestomanagingmaternalhealthcarehaveshowntobemoreeffectivetoimprovingqualityofcare.14

4. ImprovegovernmentmonitoringsystemsbymentoringhealthstaffthroughroutineSafeMotherhoodandBEmONCsupervisionindistrictandsub‐districthealthfacilitiesandreviewingcasesummaryreporting.15WHO,UNFPA,UNICEFandAMDDpromotetheintegrationoftheEmONCindicatorsintohealthmanagementinformationsystemsasanefficientwayofmonitoringtheavailabilityanduseofsuchcareovertime.16Additionally,itestablishesthecapacityofafacilitytotrackitsownprogressandtofocusattentiononproblemareas.17

5. Provideafour‐wheeldriveemergencyvehicletotheAinarodistricthealthfacility.Despitethisfacilityservingalargegeographicregionwithroughterrain,itlackedavehiclethatcouldnavigateroadsduringheavyrains.

Long‐termRecommendations1. Supportforrenovationandupgradingofexistingfacilitiestoimprovewater

andsanitationsystemsandpowersupply.2. EnsureallmidwivesarecertifiedinBEmONC,prioritizingdistricthealth

facilitystaff.UponBEmONCcertification,allmidwivesshouldbeuniversallyapprovedtoindependentlyperformfunctionsasdescribedbyMOHpolicy.Inconsistenciesinmidwife’sindependencelevelsresultsinconfusion.

3. MOHshouldcontinuetrainingphysicianstounderstandmidwifecapacityandwhichprocedurestheycanandareauthorizedtoindependentlyperformaccordingtoMOHpolicy.AnyphysiciansnotalreadycompetentinEmONCproceduresshouldbetrainedforthoseskills.

4. FacilitatethetimelydistributionofUNFPAEmONCkits,ensuringthatallfacilitieshavetheequipmentnecessarytoperformbasicemergencyobstetriccare.Kitsshouldbereviewedwithreceivingstafftoensurepropermaintenanceofequipment.

5. Developandimplementapolicyonroutinerefreshertrainingstomaintainskilllevelofobstetriccare(EmONCandSafeMotherhood).Thishands‐onpracticeandfollow‐uptrainingsincreasequalityofskilllevelovertime.18

6. EmONCsupportivesupervisionshouldbeintegratedinSafeMotherhoodvisitstosustainlongevityofskillqualityaftertrainingcompletion.Measures that can preserve skill quality include hands-on practice, team approaches, and follow-up training, which can be provided during supervision visits.19

7. Developarotationforremotemidwivestopracticeobstetricskillswithinfacilitieswithahighernumberofabnormalobstetriccasesprovidingthemthehands‐onpractice.Alternatively,theMOHshouldconsideratrialoflow‐

14Freedmanetal.2007.15Campbell,O.M.R.andGraham,W.J.2006.16WorldHealthOrganization.200917AvertingMaternalDeathandDisability.2006.18vanLonkhuijzen,L.,Dijkman,A.,vanRoosmalen,J.,Zeeman,G.,Scherpbier,A.2010.Asystematicreviewoftheeffectivenessoftraininginemergencyobstetriccareinlow‐resourceenvironments.InternationalJournalofObstetrics&Gynaecology117:777–787.19vanLonkhuijzenetal.2010.

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technologysimulation‐basedEmOCpractice,suchasthatavailableattheUniversityofWashingtoninthePRONTOproject.

8. IntegrateprenatalcareintoMaternityHousestofacilitaterecordsharingandcontinuityofcare.Midwivespracticingprenatalcareshouldbebasedoutofthematernityhouses.

9. Increaseresourcestotransportpatients,ensuringthattimelycareisaccessible.IncreasefuelsupplyforemergencytransportationandprimarycareSISCa’s.Monitorthereferraltransportationsystemtoensurethatanappropriatenumberofvehiclesareavailabletoservepopulationneeds.

14

Annex1:GovernmentHealthFacilitiesprovidingEmergencyObstetricCareServicesinEastTimorBasicEmOCServiceFacilities;Functioningin20081. LosPalosDistrictCHC2. ViquequeDistrictCHC3. ManatutoDistrictMaternityHouse4. SamePrinceofMonacoIIMaternityHouseBacisEmOCServiceFacilities;Plannedfor20151. Alldistrictandsub‐districtmaternalhealthfacilitiesComprehensiveEmOCServiceFacilities;Functioningin2012:1. BaucauReferralHospital2. MaubisseReferralHospital3. NationalDiliHospital

15

Annex2:MidwifeAssessmentSupplement Please answer the following questions about EmOC in your health facility?

What do you perceive as barriers to providing quality basic emergency obstetric care?

How well can you provide basic emergency obstetric care while managing home births?

Are special care plans used for pregnant women with known complications?

Comments

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Annex3:ServiceAvailabilityandStaffingTable

ServiceAvailability&Staffing

MonacoMaternityHouse

TuriscaiMaternityHouse

AlasMaternityHouse

Fater‐berlihuMaternityHouse

MaubisseReferralHospital

AinaroMaternityHouse

HatuduMaternityHouse

ImmediateServiceAvailabilityDuring24HoursaDay

Laboranddeliveryservicebymidwife √ ‐ ‐ ‐ √ ‐ ‐Laboranddeliveryservicesbyotherhealthstaff √ ‐ ‐ ‐ √ √ ‐EmOCmedications √ x √ √ √ √ √Laboratoryservices ‐ ‐ ‐ √ √ ‐ ‐

StaffingMidwives

Total 6 1 1 3 5 3 1Present24hoursperday 1 0 0 0 2 0 0EmOCcertified 4 0 2 2 5 2 1

PharmacistTotal 1 1 1 1 3 2 xPresent24hoursperday 0 0 0 0 1 0 x

LabtechnicianTotal 1 1 1 1 4 1 1Present24hoursperday 0 0 0 1 1 0 0

MidwifeAssistantorNursingAssistantTotal 0 1 0 0 6 x xPresent24hoursperday 0 0 0 0 x x x

PhysicianTotal 5 x x x 4 2 xPresent24hoursperday 0 x x x x 0 x

AmbulanceDriverTotal 2 1 1 1 x 2 1Present24hoursperday 1 0 0 0 x 2 0

CleanerTotal 3 1 1 1 17 5 1Present24hoursperday 0 0 0 0 2 0 0x=notreportedbyfacilities

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Annex 4: Facility Condition and Basic Equipment Supply

Facility condition Clean water

supply directly inside

clinic

Electricity and/or power source Radiant warmer/work

surface for newborn

resuscitation

Operating oxygen

source with flow meter

Clock with second hand

visible from the delivery table

Working refrigerator

24 hrs daily

Only a few hours daily

Only for specific appliances

Prince of Monaco II Maternity House - - √ - √ √ √ √

Turiscai Maternity House - - - √ - - - √ Alas Maternity House - - - - - - - √ Faterberlihu Maternity House - - - √ √ - - √ Maubisse Referral Hospital √ √ - - √ √ √ √ Ainaro CHC √ - √ - √ √ √ √ Hatudo CHC - - √ - - - - -

Basic Equipment

Blood pressure

apparatus

Stethoscope

Therm -o- meter

Ambubag with mask Scales

Plastic or rubber aprons

Povidone iodine 10% antiseptic (Betadine)

Sterile gloves (fitted) Adult Fetal Adult

Neo-nates Adults Infant

Prince of Monaco II Maternity House √ √ √ - √ √ √ √ √ √ √

Turiscai Maternity House - √ √ √ - √ √ √ √ √ √ Alas Maternity House - √ √ - √ - - √ √ √ √ Faterberlihu Maternity House √ √ √ √ - √ √ √ √ √ √ Maubisse Referral Hospital √ √ √ √ √ √ √ √ √ √ √ Ainaro CHC √ √ √ √ √ √ √ √ √ √ √ Hatudo CHC √ √ √ √ - - √ - √ √ √

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Annex 5: Midwife Knowledge Survey

Obstetricskills(lastsixmonths)* #

TotalInter‐viewed

Managedbleedinginearlypregnancy 12 16Confidentinmanagingbleedinginearlypregnancy 14 16Managebleedinginlatepregnancyandlabor 7 16Confidentinmanagingbleedinginlatepregnancyandlabor 15 16Managepre‐eclampsia 11 16Confidentinmanagingpre‐eclampsia 14 16Madeareferralforeclampsia 6 16Confidentinreferringeclampsiacases 13 16Managedafeverbeforedelivery 10 16Confidentinmanagingafeverbeforedelivery 15 16Managedafeverafterdelivery 9 16Confidentinmanagingafeverafterdelivery 14 16Assessedthefetalposition 12 12Confidentinassessingfetalposition 12 12Assessedprogressoflabor 12 12Confidentinassessinglaborprogress 12 12Useapartographcorrectly&completelyuptophase4 14 16Confidentinusingapartograph 16 16Managedanormallabor 12 12Confidentinmanaginganormallabor 12 12Managedabnormalearlylabor 13 15Confidentinmanagingabnormalearlylabor 14 15Managedabnormalactivelabor(firststage) 11 16Confidentinmanagingabnormalactivelabor(firststage) 15 16Managedabnormalactivelabor(secondstage) 11 16Confidentinmanagingabnormalactivelabor(secondstage) 7 16Managedabnormalactivelabor(thirdstage) 7 16Confidentinmanagingabnormalactivelabor(thirdstage) 14 16Inducedlabor 11 16Confidentininducinglabor 13 16Managedanormalbirth 12 12Confidentinmanaginganormalbirth 12 12Performedvacuumdelivery 8 16Confidentinperformingavacuumdelivery 6 16Performedforcepsdelivery 1 16Confidentinperformingforcepsdelivery 1 16Removedofplacenta 8 12Confidentinremovalofplacenta 12 12Performedmanualvacuumaspirationinlast6months 11 14Confidentinperformingmanualvacuumaspiration 13 16Recognizedbreechposition 12 16Confidentinidentifyingbreechposition 12 16Managedprolapsedumbilicalcord 6 16Confidentinmanagingaprolapsedumbilicalcord 5 16Managedmalariaduringlabor&delivery 8 12Confidentinmanagingmalariaduringlabor&delivery 12 12Performedanamniotomy 12 15

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Confidentinperforminganamniotomy 13 15Suturedanepisiotomywithabsorbablestitches 12 14Confidentinsuturinganepisiotomy 14 14Repairedfirstdegreeepisotomytear 12 14Confidentinrepairingfirstdegreeepisiotomytears 14 14Repairedseconddegreeepisiotomytear 10 14Confidentinrepairingseconddegreeepisiotomytears 10 14Repairedthirddegreeepisiotomytear 3 14Confidentinrepairingthirddegreeepisiotomy 3 14Repairedacervicaltear 5 14Confidentinrepairingacervicaltear 7 14Performedmaneuversforshoulderdystocia 9 16Confidentinperformingmaneuversforshoulderdystocia 16 16Managedatwindelivery 9 16Confidentinmanagingtwinsdeliver 16 16Performedmanualremovalofplacenta 10 14Confidentinmanualremovalofplacenta 11 12Performedcurettageorexploration 9 16Confidentinperformingacurettageorexploration 13 16Performbimanualcompression 14 16Confidentinperformingabimanualcompression 14 16Performedabdominalaorticcompressioninlast6months 3 16Confidentinperformingabdominalaorticcompression 12 15Dopostpartumcarevisitsatday1,3,7(BSP)&day3,7andweek6(lisio)

5 5

Confidentinpostpartumcare 5 5PerformedanIUDinsertionafterdeliveryorabortion 4 4ConfidentininsertingIUD 4 4Providedcontraceptionpills(COC/POP) 4 4Confidentinprovidingcontraceptionpills 4 4Injecteddepo‐provera 4 4Confidentininjectingdepo‐provera 4 4Insertednorplantimplant 2 3Confidentininsertingnorplant 3 3Performednewbornresuscitation 9 16Confidentinperformingnewbornresuscitation 15 16Conductedrapidinitialassessmentforemergencies 13 16Confidentinconductingrapidinitialassessmentforemergencies 13 16Managedshockfrombleeding 10 16Confidentinmanagingshockfrombleeding 15 16Managedshockfromsepsis 13 16Confidentinmanagingshockfromsepsis 13 16Implementedinfectionpreventionmeasures 13 13Confidentinimplementinginfectionpreventionmeasures 13 13

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Annex6:EquipmentListtoPerformBasicEmergencyObstetricCareServicesbyFacility(DevelopedfromtheWHOprovidermanual.)

BEmOC Signal Functions and their Equipment According to WHO standards

MonacoMaternityHouse

TuriscaiMaternityHouse

AlasMaternityHouse

Fater‐berlihuMaternityHouse

MaubisseReferralHospital

AinaroMaternityHouse

HatuduMaternityHouse

Administerparenteralantibiotics

Ampicillin1gram/vial √ ‐ √ √ √ √ √

Gentamicin80mg/ampule √ √ ‐ √ √ √ √

Metronidazole500mg/vial √ √ √ √ √ √ √IVtubing √ √ √ √ √ √ √

IVcannulag16and/org20/22/24/28 √ √ √ √ √ √ √Ringer'sLactate √ √ √ √ √ √ √Normalsaline0.9% √ ‐ √ √ √ √ √Sterilegloves √ √ √ √ √ √ √Sterilecottonorgauze √ √ √ √ √ √ √Ringforceps √ ‐ ‐ ‐ √ √ ‐Povidoneiodine10%Antiseptic(Betadine) √ √ √ √ √ √ √

Administeruterotonicdrugs(i.e.parenteraloxytocin)Oxytocin10Units/ampule ‐ √ √ ‐ √ √ √Methylergometrine0.2mg/ampule √ ‐ ‐ √ √ √ √Salbutamol4mg/tablet √ √ √ √ √ √ √Salbutamol1mg/ampule √ ‐ ‐ √ ‐ ‐ √IVtubing √ √ √ √ √ √ √IVcannulag16and/org20/22/24/28 √ √ √ √ √ √ √Ringer'sLactate √ √ √ √ √ √ √Normalsaline0.9% √ ‐ √ √ √ √ √Sterilegloves √ √ √ √ √ √ √Sterilecottonorgauze √ √ √ √ √ √ √Ringforceps √ ‐ ‐ ‐ √ √ ‐

Povidoneiodine10%Antiseptic(Betadine) √ √ √ √ √ √ √

21

Annex6:Continued‐EquipmentListtoPerformBEmOCbyFacilityBEmOC Signal Functions and their Equipment According to WHO standards

MonacoMaternityHouse

TuriscaiMaternityHouse

AlasMaternityHouse

Fater‐berlihuMaternityHouse

MaubisseReferralHospital

AinaroMaternityHouse

HatuduMaternityHouse

Administer parenteral anticonvulsants for pre-eclampsia and eclampsia Magnesium sulfate 50% solution √ √ - - √ √ √ Magnesium sulfate 20% solution - √ - - - - -

Diazepam 10mg/2ml √ - √ √ √ √ √

Calcium gluconate 10% - - - - √ - -

IV tubing √ √ √ √ √ √ √ IV cannula g16 and/or g20/22/24/28 √ √ √ √ √ √ √

Sterile gloves √ √ √ √ √ √ √

Sterile cotton or gauze √ √ √ √ √ √ √ Ring forcepts √ - - - √ √ - Povidone iodine 10% Antiseptic (Betadine) √ √ √ √ √ √ √ Blood pressure apparatus √ - - √ √ √ √

Manually remove the placenta

Diazepam 10mg/2ml √ - √ √ √ √ √ Ampicillin 1 gram/vial and Metronidazole 500mg/vial √ - √ √ √ √ √ Umbilical clamp (artery clamps) √ √ √ - √ √ √ Sterile gloves √ √ √ √ √ √ √

Plastic or rubber aprons √ √ √ √ √ √ √ Oxytocin 10 units - √ √ √ √ √ √ Normal saline 0.9% √ - √ √ √ √ √

Ringer's Lactate √ √ √ √ √ √ √

IV tubing √ √ √ √ √ √ √ IV cannula g16 and/or g20/22/24/28 √ √ √ √ √ √ √

Sterile gloves √ √ √ √ √ √ √ Sterile cotton or gauze √ √ √ √ √ √ √ Povidone iodine 10% Antiseptic (Betadine) √ √ √ √ √ √ √ Ergometrine 0.2 mg IM or prostaglandins Medicine not included on Question- naire

Ovum forceps - - - √ √ √ - Wide curette (Curette small, medium, postpartum) √ - √ √ √ √ -

Blood pressure apparatus √ - - √ √ √ √

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Annex6:Continued‐EquipmentListtoPerformBEmOCbyFacilityBEmOC Signal Functions and their Equipment According to WHO standards

MonacoMaternityHouse

TuriscaiMaternityHouse

AlasMaternityHouse

Fater‐berlihuMaternityHouse

MaubisseReferralHospital

AinaroMaternityHouse

HatuduMaternityHouse

Removeretainedproducts(i.e.vacuumextraction,dilationandcurettage)Vacuumextraction

MVAsyringe √ √ ‐ √ √ √ ‐MVAadaptorsforsize6,7,8,9,10 √ ‐ ‐ √ √ √ ‐Paracetamol500mg/tablet √ √ √ √ √ √ √Oxytocin10Units/ampule ‐ √ √ √ √ √ √IVtubing √ √ √ √ √ √ √IVcannulag16and/org20/22/24/28 √ √ √ √ √ √ √Ringer'sLactate √ √ √ √ √ √ √Normalsaline0.9% √ ‐ √ √ √ √ √Sterilegloves √ √ √ √ √ √ √

Sterilecottonorgauze √ √ √ √ √ √ √Ringforceps √ ‐ ‐ ‐ √ √ ‐Povidoneiodine10%Antiseptic(Betadine) √ √ √ √ √ √ √Vaginalspeculumorvaginalretractor √ √ √ ‐ √ √ √Ringorspongeforceps √ ‐ ‐ ‐ √ √ ‐Cannulaesize6,7,8,9,10,12 √ √ ‐ √ √ √ ‐Curette:small,medium,postpartum √ ‐ √ √ √ √ ‐Vulsellumorsingle‐toothedtenaculum √ ‐ √ √ √ √ ‐Smallbowl √ √ √ √ √ √ √Dilators ‐ ‐ ‐ ‐ ‐ ‐ ‐

DilationandCurettageOxytocin10unitsIM ‐ √ √ √ √ √ √IVtubing √ √ √ √ √ √ √IVcannulag16and/org20/22/24/28 √ √ √ √ √ √ √Sterilegloves √ √ √ √ √ √ √Sterilecottonorgauze √ √ √ √ √ √ √Ringforceps √ ‐ ‐ ‐ √ √ ‐Povidoneiodine10%Antiseptic(Betadine) √ √ √ √ √ √ √VaginalspeculumORvaginalretractor √ √ ‐ ‐ √ √ √Povidoneiodine10%Antiseptic(Betadine) √ √ √ √ √ √ √Ringorspongeforceps √ ‐ ‐ ‐ √ √ ‐Vulsellumorsingle‐toothedtenaculum √ ‐ √ √ √ √ ‐Widecurette √ ‐ √ √ √ √ ‐Dilators ‐ ‐ ‐ ‐ ‐ ‐ ‐Ringforcepsoralargecurette √ ‐ ‐ √ √ √ ‐Paracetamol500mg √ √ √ √ √ √ √

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Annex6:Continued‐EquipmentListtoPerformBEmOCbyFacility BEmOC Signal Functions and their Equipment According to WHO standards

Monaco Maternity

House

Turiscai Maternity

House

Alas Maternity

House

Fater-berlihu

Maternity House

Maubisse Referral Hospital

Ainaro Maternity

House

Hatudu Maternity

House Perform assisted vaginal delivery (vacuum extraction only since forceps are rarely performed)

Tubings/rubber hose for suction √ - - - √ √ -

VE plastic suction cup √ - √ √ √ √ -

Vacuum pump with pressure gauge √ - - - √ √ -

Manual pump - - √ √ √ √ -

Sterile gloves √ √ √ √ √ √ √

Mayo/episiotomy scissor √ √ - - - √ √ Perform basic neonatal resuscitation (i.e. with bag and mask)

Suction machine (manual or electric) √ √ √ √ √ √ -

Ambubag for neonates √ √ √ √ √ √ -

Oxygen mask and tubing for neonates √ √ √ √ √ √ -

Mask for neonates No.0 √ √ √ √ √ √ -

Mask for neonates No.1 √ √ √ √ √ √ -

Blankets/linen √ √ √ √ √ √ -

Clock with second hand in delivery room √ - √ √ √ √ -

Radiant warmer/Work surface for NBR near delivery area √ - - √ √ √ -

24