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 altern ative process indicators monitoring the availability, utilization and quali ty of obstetric services. There is little experience in the large-scale use of these indicators as part of routine health information systems in devel oping countries. The Malawi Safe Motherhood Project, which covers a populat ion 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 ne w monitoring system for 3 consecutive years. In 1998, availability of compr ehensive emergency obstetric care was adequate but availability of basic em ergency obstetric care was very poor. Although institutional delivery rates were over 30%, the met need for obstetric care was only 19.8% and the cesa rean section rate was only 1.6%. The mean case fatality rate in District ho spitals was nearly 5%. By the end of 2000, improvements in availability, ut ilization and quality of obstetric care were observed. Participation in dev eloping the monitoring system had also created a strong sense of ownership and interest in analyzing and using the data. Several issues have emerged f rom routine use of the process indicators. In particular, it has been diffi cult to be certain that obstetric complications have been recorded correctl y. The results confirm that a focus on improving emergency obstetric care i n Malawi was justified and that process indicators for obstetric care can b e successfully introduced in developing countries. The monitoring system ha s provided data that are of immediate relevance to service providers, manag ers, and policy makers and provide many lessons useful for similar programs in other settings. (C) 2001 International Federation of Gynecology and Obs tetrics. All rights reserved.