THE "UNMET OBSTETRIC NEED" APPROACH

There is a growing consensus on what health services could do to prevent and mitigate the consequences of problems that occur during pregnancy and delivery. Under the label of “Essential Obstetric Care", there is now a realistic strategy towards safer motherhood, built around a core of profes-sional care during pregnancy and delivery. This includes major interventions during labour to treat conditions that are a direct- threat to the mother’s life.
The problem, however, is operationalisation, triggering will-ingness and capacity for change among policy makers as well as operators in the field. The starting point for this is awareness of the magnitude of the problem. Over the last decade champions of maternal health have relied heavily on Maternal Mortality survey results to get maternal health on the policy agenda. This has met with some success, but clearly we need more than aggregate national estimates to generate enough commitment for both local and nation-wide action.
Maternal mortality is an avoidable tragedy. The response to this tragedy has to be a response of society. Not all of it can be reduced to failures of health care delivery systems, but a sizeable portion is vulnerable to a more adequate – and more accountable – response of health professionals.
Health professionals who place little value on a poor woman’s life will not respond effectively. Professionals who are concerned often do not do so either because they do not realise how big the problem is in their own community, or how this problem can be addressed concretely.
The Unmet Obstetric Need network does not pretend to change the status of women in a given country. But it does try to provide well-meaning professionals with the informa-tion needed to start improving their performance – and to give society the ammunition to pressurise professionals into more accountable behaviour.
If we want to make sure that the problem is actually ad-dressed at policy level, by the multitude of health profes-sionals and by lay pressure groups, we need more than estimates of national mortality ratios. We need them to real-ise and be confident that something can be done about it. This starts from knowing where and how the vast amount of unmet need for obstetric care can be tackled: where the women are who need care and are not getting it.
The Unmet Obstetric Need network tries to do that. It tries to kick-start Essential Obstetric Care through “UON-exercises”. Starting with the mapping of unmet obstetric needs and re-sources, this is a cheap and fast way to start both local and national level discussion and change, with full involvement of all actors at the different levels.

THE STARTING POINT: THE “UNMET OBST ETRIC NEED” EXERCISE

A UON-exercise starts with putting together two pieces of information: an inventory of resources and a mapping of Unmet Obstetric Need. This shows, district per district, the number of women who should have benefited from a major obstetric intervention but did not. This is done by comparing the interventions done – information that one can get from hospital registers – with a benchmark of minimal needs.

The exercise is limited to major obstetrical interventions for a limited number of maternal indications that are unques-tionably life-threatening conditions. This is done for two rea-sons. First, by doing so one cannot avoid involving all field professionals (because the indications of each intervention have to be verified, and this cannot be done without discus-sion with the doctors and midwives in the hospitals and health centres), resulting in pressure for local change. Sec-ond, it makes it possible to aggregate local data and make meaningful inter-district comparisons, and thus provides elements for priority setting.

A UON-exercise takes a few weeks for local adaptation of the protocol and a few months of data-collection. It can be completed for some 50,000 € per country, depending on population size. The resulting maps and databases will not change things by themselves. Put in the hands of sensitised professionals they can be powerful levers to pressure for local change as well as for better strategies and resource mobilisation at national level.

THE NETWORK
Morocco was the first country to perform a nation-wide UON-exercise in 1991 – with a significant impact on its ma-ternal health policies. At the end of 1998 the “UON-Network” was created with the support of the European Commission. This network brings together ministries of health, develop-ment organisations, scientific institutions and practitioners in a number of countries that have started a “UON-exercise”: Burkina Faso, Tanzania, Mali, Niger, Haiti, Benin, and Paki-stan.
The co-ordination is based at the department of Public Health of the Institute of Tropical Medicine in Antwerp, which provides technical back up to national teams and fa-cilitates exchange of results and experiences.
The common characteristics of the countries involved is are that they have a high level of maternal mortality, that a number of key players are looking for a way to introduce change, and that they are not just interested in improving maternal health, but in ameliorating the overall functioning of their health care system. Leadership and system vision are a condition for success. This being said, experience shows that a small team of dedicated people may be enough to launch the process, although initial technical backstopping is recommended.
Manuals, protocols and country reports can be found at the UON-Networks web-site: www.uonn.org