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Providing Emergency Obstetric and Newborn Care to All in Need
An emphasis on making emergency obstetric and newborn care available to all women who develop complications is central to UNFPA’s efforts to reduce maternal mortality.
This is because all five of the major causes of maternal mortality – haemorrhage, sepsis, unsafe abortion, hypertensive disorders and obstructed labour – can be treated at a well-staffed, well-equipped health facility. In such settings, many newborns who might otherwise die can also be saved.
In the long term, this means that all births should take place in appropriate health facilities, as is the case in all countries that have managed to significantly reduce their maternal mortality. In the interim, before such a long-term goal can be reached, universal access to emergency obstetric care requires that all women and newborns with complications should have rapid access to well-functioning facilities, whether that is a mobile health unit, a district hospital or an upgraded maternity centre (see standards, below).
Obviously it is better if the delivery takes place in or very near to a facility capable of providing at least the basic emergency obstetric and newborn care. In some areas where rapid access to such a facility is impossible, women spend the days or weeks before delivery in ‘waiting homes’ so that emergency obstetric care is readily accessible.
More than 80 percent of maternal deaths worldwide are due to five direct causes:
Basic emergency obstetric and newborn care, provided in health centres, large or small , includes the capabilities for:
- Administration of antibiotics, oxytocics, and anticonvulsants
- Manual removal of the placenta
- Removal of retained products following miscarriage or abortion
- Assisted vaginal delivery, preferably with vacuum extractor.
- Newborn care
Comprehensive emergency obstetric and newborn care, typically delivered in district hospitals, includes all basic functions above, plus Caesarean section, safe blood transfusion and care to sick and low birthweight newborns, including resuscitation. Guidelines jointly issued in 1997 by WHO, UNICEF, and UNFPA, recommended that for every 500,000 people there should be four facilities offering basic and one facility offering comprehensive essential obstetric care. These Guidelines are being revised in 2007 to allow flexibility in the implementation and to add new features.
To manage obstetric complications — the life-saving component of maternity care — a facility must have at least two skilled attendants covering 24 hours a day and seven days a week, assisted by trained support staff. To manage complications requiring surgery, the facilities must have a functional operating theatre, more support staff and must be able to administer blood transfusions and anaesthesia.
Existing facilities (district hospitals and health centres) can often, with just a few changes, be upgraded to provide emergency obstetric and newborn care.
Timing proves to be critical in preventing maternal death and disability: Although post-partum haemorrhage can kill a woman in under two hours, for most other complications, a woman has between 6 and 12 hours or more to get life-saving emergency care. Similarly, most perinatal deaths occur during labour and delivery, or within the first 48 hours thereafter.
The ‘three delays’ model (see below) has proved to be a useful tool to identify the points at which delays can occur in the management of obstetric complications, and to design programmes to address these delays.
The first two "delays" (delay in deciding to seek care and delay in reaching appropriate care) relate directly to the issue of access to care, encompassing factors in the family and the community, including transportation. The third "delay" (delay in receiving care at health facilities) relates to factors in the health facility, including quality of care. Unless the three delays are addressed, no safe motherhood programme can succeed. In practice, it is crucial to address the third delay first, for it would be useless to facilitate access to a health facility if it was not available, well-staffed, well equipped and providing good quality care.
UNFPA works at many levels to expand access to obstetric care – from advocating health reform policies and upgrading health facilities to mobilizing communities to prepare for and respond to obstetric emergencies. With funding from the Columbia University’s Averting Maternal Death and Disability programme, UNFPA has initiated activities focusing on improvements in the availability, accessibility and quality of emergency obstetric care in India, Morocco, Mozambique, Senegal and Nicaragua. While this programme is under evaluation, other countries have started to integrate similar approaches in their country programmes. UNFPA is also an active member of the new Partnership for Maternal, Newborn and Child Health (PMNCH), aiming at harmonizing, galvanizing and supporting investments in maternal, newborn and child health.
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