Alternative measures of spatial distribution and availability of health facilities for the delivery of emergency obstetric services in island communities.

International guidelines and recommendations for availability and spatial distribution of emergency obstetric care services do not adequately address the challenges of providing emergency health services in island communities. The isolation and small population sizes that are typical of islands and remote populations limit the applicability of international guidelines in such communities. Universal access to emergency obstetric care services, when pregnant women encounter complications, is one of the three key strategies for reducing maternal and newborn mortality; the other two being family planning and skilled care during labor. The performance of selected lifesaving clinical interventions (signal functions) over a 3-month period is commonly used to assess and assign performance categories to health facilities but island communities might not have a large enough population to generate demand for all the signal functions over a 3-month period. Similarly, availability and spatial distribution recommendations are typically based on the size of catchment populations, but the populations of island communities tend to be sparsely distributed. With illustrations from six South Pacific Island states, we argue that the recommendation for availability of health facilities, that there should be at least five emergency obstetric care facilities (including at least one comprehensive facility) for every 500,000 population, and the recommendation for equitable distribution of health facilities, that all subnational areas meet the availability recommendation, can be substituted with a focus on access to blood transfusion and obstetric surgical care within 2 hours for all pregnant residents of islands. Island communities could replace the performance of signal functions over a 3-month period with a demonstrated capacity to perform signal functions if the need arises.