The strength of the evidence is high in several studies with a design that places them in the second and third tier in the quality of evidence ranking system. No studies were found that are experimental in design that would give them a top ranking, due to the measurement challenges associated with maternal mortality, although many of the specific individual clinical interventions that comprise EmOC have been evaluated through experimental design. There is strong evidence based on studies, using quasi-experimental, observational and ecological designs, to support the contention that EmOC must be a critical component of any program to reduce maternal mortality.

Upgrading maternities, health centers and hospitals to at least basic EmOC status would be a major contributing step towards maternal mortality reduction in resource-poor countries.

The EmOC process indicators have been used successfully in a wide variety of settings. They describe vital elements of the health system and how well that system is functioning for women at risk of dying from major obstetric complications.

These data can help governments allocate their budgets appropriately, help policy makers and planners identify systemic bottlenecks and prioritize solutions. Monitoring the performance of the functions informs us of the capacity of the health system to provide key interventions when obstetric emergencies occur.

a b s t r a c t a r t i c l e i n f oObjective: Policy, regulation, training, and support for cadres adopting tasks and roles outside their historical domain have lagged behind the practical shift in service-delivery on the ground. The Health Systems Strengthening for Equity (HSSE) project sought to assess the alignment between national policy and regulation, preservice training, district level expectations, and clinical practice of cadres providing some or all components of emergency obstetric care (EmOC) in Malawi and Tanzania. Methods: A mixed methods approach was used, including key informant interviews, a survey of District Health Management Teams, and a survey of health providers employed at a representative sample of health facilities. Results: A lack of alignment between national policy and regulation, training, and clinical practice was observed in both countries, particularly for cadres with less preservice training; a closer alignment was found between district level expectations and reported clinical practice. There is ineffective use of cadres that are trained and authorized to provide EmOC, but who are not delivering care, especially assisted vaginal delivery. Conclusion: Better alignment between policy and practice, and support and training, and more efficient utilization of clinical staff are needed to achieve the quality health care for which the Malawian and Tanzanian health ministries and governments are accountable.