Planning and implementing a program of renovations of emergency obstetric care facilities: experiences in Rajasthan, India

International Journal of Gynecology and Obstetrics 78(2002) 283–291

0020-7292/02/$ - see front matter� 2002 International Federation of Gynecology and Obstetrics. Published by Elsevier ScienceIreland Ltd. All rights reserved.PII: S0020-7292Ž02.00191-1

Averting maternal death and disability

Planning and implementing a programof renovations of emergency obstetric carefacilities: experiences in Rajasthan, India

H. Dwivedi *, D. Mavalankar , E. Abreu , V. Srinivasana, b,c c d

UNFPA, Jaipur, Rajasthan, Indiaa

Indian Institute of Management, Vastrapur, Ahmedabad, Indiab

Averting Maternal Death and Disability Program, Heilbrunn Department of Population & Family Health,c

Mailman School of Public Health, Columbia University, New York, NY, USAUNFPA, New Delhi, Indiad

Abstract

Even though many governments and donors are now putting resources into upgrading facilities, the study of therenovation process is one of the most neglected aspects of quality improvement in emergency obstetric care(EmOC).In a previous publication, we discussed basic concepts and simple techniques to assess, plan and implementrenovations. Here we focus on actual in-the-field experiences of the renovation process initiated by the health systemin Rajasthan, India and the valuable lessons obtained from it. With the advice of the technical members of theAverting Maternal Death and Disability Program(AMDD) and the United Nations Population Fund(UNFPA), thefacilities achieved noticeable changes in the physical infrastructure. As a result, the quality of EmOC servicesimproved. We analyze these experiences critically and draw out lessons which may be instructive for future renovationefforts.� 2002 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rightsreserved.

Keywords: Renovation process; Emergency obstetric care; India

1. Introduction

In the early 1990s, emergency obstetric care(EmOC) received attention as a means to reducingmaternal mortality in developing countries. Variousdonors and national governments began to supportactivities which would improve the quality ofEmOC services. As a result, many EmOC facilities

*Corresponding author. Tel.:q91-141-382524; fax:q91-141-380277.

E-mail address: [email protected](H. Dwivedi).

are now moving forward with physical infrastruc-ture improvements.Under a grant from The Bill and Melinda Gates

Foundation, the Averting Maternal Death and Dis-ability Program(AMDD) focuses on improvingthe access, quality and use of EmOC services indeveloping countriesw1x. The AMDD Programand several international agencies are collaboratingin efforts to upgrade EmOC facilities.The Integrated Population and Development

(IPD) project supported by United Nations Popu-

284 H. Dwivedi et al. / International Journal of Gynecology and Obstetrics 78 (2002) 283–291

Table 1Summary of the facilities in the project and the facilities undergoing renovations

Name of Population Facilities Facilities Budget allocateddistrict in millions included selected for for renovations

in the renovation Indian Rupees US $project

Alwar 2.99 16 14 3 368 000Bharatpur 2.09 11 10 2 868 000Bhilwada 2.00 13 12 5 028 000Chittorgarh 1.80 9 8 3 293 000Udaipur 2.23 11 10 4 727 000Sawai Madhopur 1.12 12 10 2 403 000Karauli 1.20 12 7 1 697 000

Total 13.43 84 71 23 384 000 498 000

Average per facility 329 000 7000

lation Fund (UNFPA)yIndia, the Department ofMedical and HealthyGovernment of Rajasthan andthe AMDD Program are working together on aproject to improve EmOC facilities in Rajasthan,a state in western India. This paper will look atone component of this project, the renovationprocess initiated by the health system. We willdiscuss the process of renovations, and the achieve-ments and problems encountered at 71 selectedfacilities in seven districts of Rajasthan. The les-sons drawn from actual in-the-field experiencesmay help health planners prepare for renovationsin similar projects in India and other developingcountries.

2. The project setting

The AMDD technical staff met with governmentofficials and visited some facilities in Rajasthan,as identified by the government. They agreed tofocus on improvement of EmOC services at a totalof 84 facilities (district hospitals, sub-district hos-pitals and selected primary health centers) in sevendistricts: Alwar, Bharatpur, Bhilwada, Chittorgarh,Udaipur, Sawai Madhopur and Karauli—coveringa total population of 13.4 million. The criteria forfacility selection included location, catchment area,number of deliveries and staff availability.

3. Assessment

At each facility, a needs assessment(conductedin 1999–2000) identified those areas that needed

improvement in order to achieve a fully function-ing EmOC service. A team consisting of thedistrict Reproductive and Child Health(RCH)officer, the deputy project coordinator and themedical officer reviewed the needs assessmentsand visited the sites. On the basis of the informa-tion gathered, they selected 71 facilities, whichwould undergo renovations(see Table 1).

4. Planning and implementing the renovationsat the selected facilities

The planning and implementation of the reno-vation process is important to the overall successof service deliveryw2x. In this project, the districtRCH society established by the health systemdetermined the agency which would oversee therenovations. In the majority of cases(51 out of 71institutions), the Public Works Department(PWD)handled the renovation process. The other agenciesof choice were the District Rural DevelopmentAgency (in 14 institutions), the Panchayat Samitior local self-government(in five institutions) andthe municipality(in one institution).Many of the facilities in this project were more

than 50 years old and poorly maintained. For themost part, the facilities faced challenges in thefollowing areas: (1) the labor room(LR) andoperating room(OR); (2) the sterilization equip-ment and utility room;(3) the treatment of thefloors, walls, ceilings, doors and windows;(4)

285H. Dwivedi et al. / International Journal of Gynecology and Obstetrics 78 (2002) 283–291

Table 2Steps in renovation process and average time for completion

Steps in the renovation process Average time tocomplete eachstep

Orientation of staff for needs assessment 1 weekNeeds assessment carried out 4–5 weeksby doctorsyRCH

Compilation of needs assessment and 4–5 weekspreparation of report

Identification of agency overseeing the 2 weeksRenovations

Preparation of specifications and detailed 3 weeksEstimates

Tendering process and invitation of bids 3 weeksAward of contracts 2 weeksContractor procures materials, hires staff and 2–4 weeksthen begins renovation

Implementation of renovation and monitoring 24–40 weeksby district officers

Final measurement of the civil work, 1 weekcertification of work done and handingover to the facility

Fixtures(water, electrical, etc.) 2 weeksMove furniture into new space 1 weekInstallation of equipment 1 weekHospital is officially inaugurated Variable(only when major new construction is done)

Total time required to complete the renovation 11–17 monthsprocess

availability of toilets for female patients;(5) elec-tric, water and sewage systems; and(6) patientprivacy in examination rooms.In preparation, all the district officers and facil-

ity heads received guidelines on both the imple-1

mentation of EmOC services and the physicalinfrastructure of a facilityw3,4x. UNFPA providedstandard designs to those facilities requiring thenew construction of a LR andyor OR. The Gov-ernment of Rajasthan developed these designs foruse in the World Bank assisted India PopulationProject (IPP) IX, which also had a constructioncomponent. The PWD or the other agencies devel-

This project benefited from the recommendations of Dr Z.1

Gill and D. Potter. Dr Z. Gill is a technical and implementationexpert at the AMDD Program, Mailman School of PublicHealthyColumbia University, based in New York. D. Potter isan architect working on the DFIDyHMG Nepal Safer Moth-erhood Project in Nepal(managed by Options ConsultancyServices based in London).

oped the specifications for the minor repairs andrenovation work. The renovation plans allowed formodifications, in order to fit the local needs. Theagency overseeing the work developed the budgetfor the repairs and renovations.There are many steps in planning and imple-

menting renovations in government. Each takestime and can lead to much delay if the process isnot followed-up properly. Table 2 lists these stepsand the average time it can take for each one.Since many of the facilities had poor and dete-

riorating infrastructure, the renovations tended tobe more extensive and proceeded slower thanexpected. Overall, approximately 5 months elapsedfrom the time of identifying the facility’s needs tobeginning the actual construction work. However,after 12 months, only 80% of renovation workwas completed.The renovation was planned in two phases. For

Phase 1, initially 60% of the renovation money


was allocated. During this process, many sitesfaced new problems and needs. These were largelyattributed to: the under-identification of the needsin the first phase, unearthing of some problemswhile the work was in progress, a change in plans,lack of space, the contractor did not follow theagreed specifications andyor the contractor leftwithout finishing the work. As a result, the originalplans required modifications. More renovationwork, with the remaining 40% of the budget, isscheduled for Phase 2.

5. Monitoring the renovations

The renovations at the 71 facilities started afterthe required approvals from the government, inJanuary of 2001. At most locations, the renovationwork progressed as indicated in Table 2.During 2001, the technical staff of AMDD and

UNFPA visited the facilities. They assisted inmonitoring the progress of the repairs and reno-vations. In joint efforts, the AMDD and UNFPAteams focused attention on the following areas:

● patient, staff and material flow;● patient privacy and comfort;● adequacy of space and how to improve thespace for critical functions such as LR, OR,utility rooms;

● ease of cleaning;● proper waste disposal;● storage, furniture and equipment placement;● water and electrical systems;● ventilation and lighting;● communication;● overall condition of the building(surface finish-es of walls, floor, ceilings); and

● coordination between inputs of various projectsin the same facility and district to avoidduplication.

After the site visits, the AMDD and UNFPAteam discussed the findings with the district levelgovernment officers, the district health authority(responsible for the renovation work at the facili-ty), the government engineering staff, the districtcollector (executive head of the district adminis-tration), and the facility directors and staff(doc-tors, nurses, midwives). Based on the teams’

observations, corrective action was taken toimprove the quality of the renovations.

6. General observations

Simultaneously renovating 71 facilities within a12-month period in a bureaucratic, centralizedgovernment system was a major undertaking anda challenge to the organizational capacity ofUNFPA and the Government. In some facilities,the improvement was not to the desired level andat some other places there were a few mistakes inthe renovation process. However, for many of thefacilities, the AMDD and UNFPA staff found thatthe repair and renovation work generally was ofgood quality and performed at a reasonable cost.The average cost of renovating a facility was onlyUS$ 7000(see Table 1).Most important, it improved the functionality

(physical conditions and staff morale) of the facil-ities w5,6x. Overall, there was progress in thefollowing areas:

● the flow of patients, staff and materials into andfrom the EmOC area;

● OR and LR flooring and walls, design andspace use;

● overall cleanliness;● water supply;● waste disposal;● availability of toilets;● electricity supply system, with back-upgenerators;

● patient privacy in examination rooms, laborrooms and wards; and

● use of spaces and rooms.

Interestingly, the LR, which was consideredunimportant and often thought as socio-medicallydirty or polluted, received the greatest attention inthis project. Careful planning of the LR workspa-ces, as well as the location of equipment andinstruments, improved functionality and safety.

7. Learning from the experiences in Rajasthan,India

In this section, we will discuss some commonin-the-field operational and managerial problems


encountered during the renovation process inRajasthan, India, the lessons that emerge andsuggestions for improvementsw6x. We hope thatsharing this practical experience may be of benefitto those planning similar EmOC facility renovationprojects.

7.1. Conduct a thorough needs assessment

7.1.1. ExperienceIn many facilities, several things that needed to

be done to improve the quality of infrastructuredid not appear in the first needs assessment. Therewas little focus on the details of physical infra-structure. For example, most of the facilities over-looked the flow of patients and materials, spacereorganization, provision of utility room, privacyarrangements for patients, waste disposal, adequatesinks for hand-washing and infection prevention.

7.1.2. RecommendationAn experienced medical facilities consultant

should conduct the needs assessment. And if notavailable locally, then an outside expert(familiarwith the standard guidelines for OR and LR)should be contacted. A detailed checklist can becreated to assess the needs for renovation.

7.2. Obtain input from various stakeholders andcoordinate them to complement each other

7.2.1. ExperienceIn some facilities, the stakeholders(such as the

staff, community, etc.) did not play a role in therenovation planning. At times the staff was activein the decision-making process. However, they didnot envision major renovation work and only askedfor minimal changes. They were also not aware ofthe key technical concepts in renovating the ORand LR w4x, and therefore could not make techni-cally appropriate suggestions.Two cases in particular demonstrate the impor-

tance of community participation. A district healthauthority decided not to renovate the maternitydepartment of an old district hospital since theentire hospital was being moved to a new buildingon the outskirts of the town. However, the com-munity wanted the maternity services to remain in

the 100-year-old district hospital building, whichwas conveniently located. As a result of publicpressure, the district health authority had to devel-op renovation plans for the maternity ward, LRand OR in the old district hospital, so that thematernity services could be improved there. Atanother location, the community objected to theconstruction of toilets attached to the LR. Theybelieved that they should have been consulted inthe planning of new toilets since the LR wasconstructed through community donations.In some cases, there was lack of coordination

between the input from various donors and gov-ernment supported improvement efforts. Duplica-tion occurred at some sites, at the same time othersites in the same district were neglected. Forexample, one site planned to receive support forthe renovation of the OR and LR from bothAMDD and the World Bank. However, a projectteam visiting the facility noted that an OR complexhad been built with World Bank support. Hence,AMDD support was instead focused on theimprovement of the LR, wards and utilities.

7.2.2. RecommendationRenovation planning should incorporate the

needs of the stakeholders. Good communicationbetween all stakeholders(especially plannersymanagers, engineers and users of the facility) willensure that the needs of all are taken into accountin the renovation.In general, the facilities did not have input from

the patients and overlooked the importance ofpatient privacy and provisions for the relatives.One way of attaining input from patients is toorganize a number of small focus groups, eachrelating to a specific topicw7x. Recent patientscould be contacted and invited to discuss theirexperiences with respect to, for example, the carethey received during the treatment of specificobstetric complications.Also, it is beneficial for the facilities and district

health offices to integrate the available inputs fromvarious projects. In this way, the overall function-ing of the hospital and access to care is improvedin the whole district. For example, the input underAMDD is quite flexible and hence supplementedand complemented the input under the World Bank


assisted India Population Project and Reproductiveand Child Health Project, which also providedsupport for OR and LR upgrades. To avoid dupli-cation it is recommended that each district developa map showing the locations of facilities and whichprojects are providing support at each location.Such maps should be used for planning newrenovations or upgrades.

7.3. Develop detailed renovation plans which areunderstandable to the facility staff

7.3.1. ExperienceAt times, the renovations were misguided. Often

this occurred when the renovation guidelines werenot clear, plans made for renovation were notdetailed enough or the hospital managers and staffdid not understand the renovation plans. For exam-ple, one facility installed ceramic tiles on the wallsup to 6–7 feet. Ceramic tiles are not necessary inthe wards. Tiles are better used in other areas,such as around sinks and in the dirty utility room.A gloss or enamel oil-based paint would be anappropriate wall surface finish in the wardsw4x.At other locations the local doctors could notunderstand what was specified in the contractdocuments and only part of the renovations werecarried out.At another facility, the work was not done as

per specification. The local managers did not knowwhat was specified. Almost no facility planned forthe proper location of electrical, water and otherutility outlets in the LR, OR and other rooms.

7.3.2. RecommendationIt is highly recommended that the facility staff

work very closely with the building designer andbuilding contractor. A mock layout or a plan onpaper with all the furniture, equipment, etc., canbe helpful for the facility staff to visualize therenovated spacew8x. It is important that all stake-holders have a good understanding of what needsto be accomplished. It is suggested that key healthplanners visit a successfully functioning EmOCfacility and see how space is utilized, what equip-ment is needed, which surface finishes are appro-priate, etc.w9x. A video tape or slide show(with

commentary) could be made on the various aspectsof renovation planning.Also, before awarding a construction contract, a

detailed layout plan should be developed whichshows each item of the proposed renovations indetail: the type of flooring, wall surfaces, fixedshelves, wash basins, drains, electrical outlets, theplacement of major equipment, etc. The variousaspects of the renovation should be discussed withthe key staff working in the facility. One personshould be designated to monitor the renovationand report any deviations from the contract. Thiswill enable the staff to keep a check on what isbeing done.

7.4. Obtain expert technical advice on how torenovate facility buildings

7.4.1. ExperienceFor lack of expert technical advice, individual

rooms underwent renovations without plans toimprove the general flow of patients, staff andmaterials or supplies within the building. At someplaces the work proceeded with inappropriatematerials, poor physical design, no considerationfor infection control, patient privacy, etc. Therewas little effort to explore alternate uses of avail-able space and rooms. This reflected the lack oftechnical designyarchitectural capability in thegovernment health and engineering departments.

7.4.2. RecommendationIt is advisable to hire a good, practical building

designer, but not necessarily a famous urban build-ing designer or architect, who may have very highfees for their services and hisyher ideas may notbe most cost-effective for rural areas. A goodbuilding designer can improve patient and staffflow by constructing new doors, changing thefunctions of various rooms, creating connectingcorridors and passages, etc.The facility managers and local engineers should

be familiar with the literature on hospital renova-tions and use them accordingly for each hospitalsituation. In this project, the facilities profited fromapplication of some key, simple principles ofdesign and renovation. A simple list, consisting of


‘dos’ and ‘don’ts for the renovation of the OR andLR, will be helpful in similar projects.

7.5. Work with a building contractor who doesquality work, follows given specifications, and isreliable

7.5.1. ExperienceAt a few of the locations, the work was not

done as per the specifications. For example, at onesite, instead of installing a slab stone floor asspecified, the contractor laid down a cement floor.In general, floors should have a smooth hardsurface which can withstand frequent washing witha germicidal cleaning solutionw4x. Also at somefacilities, the contractor left before completing thework.

7.5.2. RecommendationIt is best to work with a building contractor

who understands the needs and requirements. Therenovation of an EmOC facility is somewhat dif-ferent than renovation of any public building, likea school or post office. Here mistakes and poorquality may cost a woman her life if infectiondevelops. The contractor should be reliable, qualityconscious and ensure good workmanship. Thismay mean that the construction work costs morebut it is worth spending more for reliable and goodquality work.

7.6. Make adequate repairs or renovations to thegeneral facility support systems (water, electricity,housekeeping and biomedical waste disposal)

7.6.1. ExperienceAt times, the renovations did not adequately

rectify the deficiencies in the facility’s utilities.For example, some facilities corrected or replacedthe electrical system only in the maternity wards.Since there were no improvements to the mainelectric supply and distribution system in thehospital, the repairs in the maternity wards provideonly a temporary and inadequate solution. Also,the water system was not adequately improved atseveral facilities. Waste disposal systems were alsoneglected during the renovations.

7.6.2. RecommendationDuring the initial assessments detailed evalua-

tions of water and electric systems must be made.Improvements of these utilities from their sourceto the maternity and OR should be part of therenovation plan. Since the public supply of elec-tricity and water are unreliable in many places inRajasthan, just improving the wiring and piping inthe facility is not sufficient. Installing a back-upsystem is necessary. Thus, it is advisable to planfor electric generators or inverters and water stor-age tanks. The disposal of waste water and bio-medical waste, such as placentas, also needs to beplanned.Large facilities may consider having their own

maintenance staff for preventive maintenance aswell as for minor repairs of support systems.

7.7. Monitor the progress of repair and renovationwork

7.7.1. ExperienceIn some places, the work did not proceed as

specified because of poor understanding regardingsome construction items, the contractors were notreliable, the local doctors made their own modifi-cations, and mistakes occurred. There are severalexamples illustrating this. A waste disposal pit wasconstructed like a water tank with cement liningfrom all sides instead of open to the earth fromthe bottom and sides so that waste materials coulddecompose in it. The contractor used inappropri-ately large stone slabs in the LR. The windows inthe OR and LR were below eye level, thus com-promising privacy. Toilets were constructed in aninappropriate place.

7.7.2. RecommendationThere should be regular inspections by the

medical and engineering personnel as the work isbeing done. Any deviations from the specificationsshould be discussed and resolved. By carefullysupervising and monitoring the renovations, inap-propriate or poorly executed work can be reducedor eliminated.


7.8. Expect changes and delays during the reno-vation process and provide solutions as they arise

7.8.1. ExperienceIn many cases, the original plan was changed

as new needs were identified. This required newapprovals. At times, the project office or districtoffice stopped the work because it was not as perspecifications. These resulted in considerabledelays. At a few sites, a more serious problemoccurred as the building contractors left theirprojects before completion. At other sites, moremoney was needed than originally planned. Insome districts delays occurred because the districtlevel officers were not proactive and did not pushthe needed procedures from their end.

7.8.2. RecommendationThe renovation plan should be somewhat flexi-

ble to accommodate some last minute changes,which may arise as the work is in progress. Somefunds should be set aside for such additional work.To minimize delays, it is best to hire specialisedagencies with the required capacity to plan andcarry out the construction work and to complywith agreed upon list of criteria. Periodic reviewof the work helps to identify delays and deviations.There should be a mechanism to solve the identi-fied problems so that delays are minimized.

7.9. Plan for possible disruptions of EmOC serv-ices at the facility

7.9.1. ExperienceMost of the facilities did not plan how to

mitigate the effects of additional dust and noise,which are generated during renovations as con-struction materials, workers and machinery arebrought in and out of the facility. Some facilitiestried to provide continuous coverage, other facili-ties planned the renovations in phases or shiftedthe EmOC services to another area. No facilitytried to inform the community or the lower levelhealth centers(such as primary health centers)when the EmOC services were shut down forrenovation.

7.9.2. RecommendationThe facility should have a plan for situations

when EmOC services must be suspended. When-ever the utilities need to be temporarily shut downin order to carry out construction, repair or main-tenance work, the staff should be notified inadvance(if possible) so that alternative measurescan be takenw10x. Disturbances to the patients andthe operations of the facility should be minimal.When the services are completely halted, the facil-ity should give public notice. All efforts should bemade to limit the shut-down period and makealternate arrangements for EmOC. This wouldeliminate delays in getting emergency cases toalternate locations.

8. Summary

In the past, managers of various health projects(financed by government and donor agencies) didnot fully realize the importance of good design,layout and space utilization; and the maintenanceand repair of facility buildings has not beenemphasized. In addition, many believed that oldstructures had poor designs, which could not beimproved. Considerable sums of money supportedthe construction of new buildings rather than therepair and maintenance of existing facilities.The project in Rajasthan, India demonstrated

that with relatively small amounts of money(US$7000 per facility), many existing facilities can berenovated and the EmOC services upgraded. Italso showed that on the spot supervision and asuccessful working relationship between the facil-ity managers, government engineers and a multi-disciplinary technical team of project partners canfurther improve the quality of the renovation.Through technical support of AMDD and UNFPAit was possible to identify and rectify variousexisting and potential problems. The authors wouldalso highlight the need for health system to put inplace sustainable mechanisms to maintain the ren-ovated institutions.In-the-field observations stress the importance

of the stakeholders having a good understandingof the basic concepts and techniques in assessing,planning and implementing renovations. The expe-rience of this renovation effort in Rajasthan dem-


onstrates that with proper assessment, goodplanning and design, minor changes and renova-tions can, in a substantial way, improve the EmOCservices at large numbers of facilities in a relativelyshort period of time.

Acknowledgments

The authors are grateful to the Government ofRajasthan, Department of Medical and Health andthe Indian Institute of Management, Ahmedabad.This work was supported by the AMDD Programat the Heilbrunn Department of Population andFamily Health, Joseph L. Mailman School ofPublic Health, Columbia University, with fundingfrom The Bill and Melinda Gates Foundation.

References

w1x Rosenfield A, Maine D. Making safe motherhood areality. Grant proposal to the Bill and Melinda GatesFoundation. 1999.

w2x Mavalankar D, Abreu E. Planning and implementing aprogram for renovations of an emergency obstetric carefacility: part 1—concepts and techniques. Int J GynecolObstet 2002; in press.

w3x Gill Z. Handout: Implementing emergency obstetric carein developing countries. First Annual AMDD ProjectWorkshop: Marrakech, Morocco, February. 2001.

w4x Abreu E, Potter D. Recommendations for renovating anoperating theater at an emergency obstetric care facility.Int J Gynecol Obstet 2001;75(3):287–294

w5x Mavalankar D. Trip report: Rajasthan, India. AMDDProgram, 25–28th September. 2001.

w6x Dwivedi H. Trip report: Rahasthan, India. UNFPA IPDProgram, 20–22nd December. 2001.

w7x Hagland M. Blueprint for a 21st century hospital: acasebook in strategic and operational planning. Strate-gies Healthcare Excellence 2000;13(4):1–6

w8x Gehrki B. OR design & construction: part 1—NewMayo ORs allow for rapid change. OR Manager2001;17(12):13–15, 19

w9x OR design & construction: part 2—OR directors sharetheir advice for surviving a building project. OR Man-ager 2002;18(1):1, 13–14

w10x Gehrki B. OR design & construction: part 3—lessonslearned through OR renovation. OR Manager2002;18(2):21–22.

Editor’s CommentThe voice of experience is compelling. Renovationsshould be planned to the last detail. As this articlemakes clear, both training and experience in this areais lacking in hospitals or health planning districts inmany developing countries. While the most meticu-lously planned renovation can encounter glitches andnasty surprises, failure to plan adequately makes theminevitable.At the present time quite a few emergencyobstetric care facilities are undergoing renovation tobetter to meet the needs of patients with obstetricemergencies and those who care for them. The greatmajority of these are on a relatively small scale.Hospital directors and those involved in safe moth-erhood projects are learning just how complex theprocess of upgrading emergency obstetric care is,even in a small hospital. We are grateful to DrDwivedi and his colleagues for sharing their experi-ence and the lessons it provides to others preparingto undertake similar renovations.J.A. FortneyFamilyHealth InternationalResearch Triangle Park, NC,USA

Call for Papers for the Adverting MaternalDeath and Disability SectionPapers can be sub-mitted via e-mail to [email protected] inhard copy to Dr. J A Fortney, AMDD Program,Mailman School of Public Health, Columbia Uni-versity, 60 Haven Avenue, New York, NY 10032,Papers should be in MicroSoft Word, follow thestyle of this journal, and must address the issuesof access to, or quality of, emergency obstetriccare.

The fully text of all articles and editorial com-ments published in the Adverting Maternal Deathand Disability Section are available on the ElsevierWomen’s Health Resource(WHR) website:http:yywww.womenshealth-elsevier.comyijgo_frm.htmlor through the FIGO website: www.figo.org

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Planning and implementing a program of renovations of emergency obstetric care facilities: experiences in Rajasthan, India