Measuring unmet obstetric need at district level: how an epidemiological tool can affect health service organization and delivery.

A national retrospective survey on the unmet need for major obstetric surgery using the Unmet Obstetric Need Approach was carried out in Mali in 1999. In Koutiala, the district health team decided to carry on the monitoring of the met need for several years in order to assess their progress over time. The first prospective study, for 1999, estimated that more than 100 women in need of obstetric care never reached the hospital and probably died as a consequence. This surprising result shocked the district health team and the resulting increased awareness of service deficits triggered operational measures to tackle the problem. The Unmet Obstetric Need study in Koutiala district was implemented without financial support and only limited external technical back-up. The appropriation of the study by the district team for solving local problems of access to obstetric care may have contributed to the success of the experience. Used as a health service management tool, the study and its results started a dialogue between the hospital staff and both health centre staff and community representatives. This had not only the effect of triggering consideration of coverage, but also of quality of obstetric care.