One of the indicators of how effective a health system performs is the maternal mortality ratio – or MMR. In industrialised countries maternal mortality ratios were reduced drastically in the latter part of the past century and the early years of this one through a combination of improve maternal nutrition, pre-natal care and obstetric services to manage complications immediately prior to, during, or immediately following birth. In contrast, MMRs in developing countries remain stable and high, between the range 200 to 950 per 100,000 live births. Recent research has concluded that the main reason for this is the lack of emergency obstetric care services, rather than the lack of pre-natal care.

Until recently, developing countries MMRs have been measured mainly through indirect estimation techniques using data from large scale population sample surveys such as the Demographic and Health Surveys. These have produced more reliable national estimates but have limited direct use for health service planning because they are national averages. They involve extensive surveys of large population samples and are therefore expensive to undertake. Health planners have therefore looked for alternative indicators. There have also been attempts to measure process and output indicators, such as the availability of emergency obstetric care services, and throughput measures, usually involving numbers of hospital maternity services provided. However, none of these indices have provided the information needed by health services policy makers and planners.

One particular tool under development by the Department of Public Health of the Institute for Tropical Medicine, Antwerp, is a measure of Unmet Obstetric Need or UON. This measure compares the need for obstetric care with the capacity of the health service to provide this care. The measure has the potential to provide data on the obstetric health service situation in particular geographical areas of various sizes, it can be used for planning and monitoring health service improvements and can be a starting point for national, regional and local policy dialogue.

The concept of UON refers to the discrepancy between what the health care system should provide to deal with obstetric problems in a given population, and the care it actually provides. Operationally, UON is expressed in terms of women who should have benefited from an obstetric intervention, but for whom this intervention did not take place. UON makes it possible estimate the actual need for major obstetric interventions for obstetric emergencies without resorting to major investments in large scale population surveys. Indications of obstetric emergencies are: severe antepartum haemorrhage , severe post-partum haemorrhage, foetopelvic disproportion shoulder or transverse lie and brow presentation.

These estimates can be used to compare need and availability in different geographic areas, identify those where UON is highest, and so target expenditures on service improvements. UON also allows planners to monitor progress in service development and impact on maternal health over time.

Unmet obstetric needs can thus serve as a lever for interventions much more than as a measuring tool. The gathering of data and the analysis of unmet obstetric needs in any country can therefore –

  • help to create a political awareness of the need to promote maternal health;
  • readily provide the information necessary for planning and prioritising the development of services, and
  • lead to action for the reduction of maternal mortality at local level by changing certain attitudes, mobilising resources and more effectively adapting professional practices to the needs of patients.
  • The use of unmet obstetric needs as the point of entry for launching or revising a strategy for the reduction of maternal mortality can yield numerous benefits: for example –
  • encourage community discussion and political pressures for the mobilisation of resources and the formulation of strategies for improving obstetric care;

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Comparison of Met Need indicators