EMONC

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Emergency Obstetric and Newborn Care (EmONC)
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LEARNING OBJECTIVES

• At the end of this session, you should be able
  to
• Recall the leading causes of maternal and newborn
  mortality
• Define Emergency Obstetric and Newborn Care
  (EmONC)
• Describe the levels of care under EmONC
• Describe the signal functions of EmONC and the
  life-threatening conditions they address
• Outline the indicators used to monitor EmONC and
  the acceptable levels
• Use EmONC indicators to identify priorities for
  improving the situation for women with obstetric
  complications

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BURDEN OF MATERNAL AND NEWBORN MORTALITY

• The leading causes of maternal death are
  postpartum hemorrhage (PPH), hypertension
  (pre-eclampsia/ eclampsia), infections (puerperal
  sepsis), prolonged/obstructed labor, and
  complications arising from abortion.
• These causes account for over two-thirds of the
  annual global mortalities related to pregnancy
  and childbirth.
• About three-quarters of neonatal deaths are
  attributable to infections, preterm birth, and
  intrapartum complications.

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Emergency Obstetric and Newborn Care (EmONC)

• EmONC is an integrated strategy that aims to
  equip health facilities with the capacity to
  provide evidence-based, cost-effective
  interventions to attend to the leading causes of
  maternal and newborn mortality.
• Developed by WHO, UNFPA and UNICEF
• These top causes of maternal and newborn
  mortality are all largely preventable through the
  effective use of highly cost-effective
  interventions in EmONC.

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LEVELS OF CARE UNDER EmONC

• Two levels of care are recognized under EmONC
• basic (BEmONC)
• comprehensive (CEmONC)
• BEmONC is provided at primary care facilities
  such as dispensaries and health centers
• CEmONC is provided at hospitals

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Signal Functions of EmONC

• Signal functions refer to the medical
  interventions provided under EmONC.
• They are categorized based on the level of care
  in EmONC i.e., BEmONC and CEmONC signal
  functions.
• There are a total of nine (9) signal functions
  and each signal function addresses at least one
  preventable cause of maternal and neonatal death.

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BEmONC signal functions and some conditions
targeted

• BEmONC has seven (7) signal functions
• Administer parenteral antibiotics
• Puerperal sepsis
• Administer uterotonic drugs
• Postpartum haemorrhage
• Administer parenteral anticonvulsants
• Preeclampsia/eclampsia

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BEmONC signal functions and some conditions
targeted

• Manually remove the placenta
• Postpartum haemorrhage
• Puerperal sepsis
• Remove retained products of conception
• Abortion
• Obstetric haemorrhage
• Perform assisted vaginal delivery
• Prolonged labour
• Perform basic neonatal resuscitation
• Perinatal asphyxia

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CEmONC signal functions and some conditions
targeted

• CEmONC covers the seven BEmONC signal functions
  plus two more
• Perform surgery (e.g., Caesarean delivery)
• Obstructed labor
• Preeclampsia/eclampsia
• Obstetric hemorrhage (e.g., APH)
• Perinatal asphyxia
• Perform blood transfusion
• Obstetric haemorrhage

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DETERMINING PROGRESS IN REDUCING MATERNAL AND
NEONATAL MORTALITY USING EmONC INDICATORS

• The indicators for EmONC have been used in more
  than 50 countries to plan programmes and to
  monitor and evaluate progress in reducing
  maternal mortality.
• The indicators have been integrated into routine
  health management information systems to track
  progress at district, regional and national
  levels.

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Indicator 1 Availability of EmONC services

• Measured by the number of facilities that perform
  the complete set of signal functions in relation
  to the size of the population.
• The facility is classified as functioning at the
  comprehensive level when it offers the seven
  signal functions plus surgery (e.g., caesarean)
  and blood transfusion.
• Minimum acceptable level
• For every 500,000 population, the minimum
  acceptable level is five EmOC facilities, at
  least one of which provides comprehensive care.

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Indicator 2 Geographical distribution of EmONC
facilities

• Measured in the same way as the first, but it
  takes into consideration the geographical
  distribution and accessibility of facilities.
• Minimum acceptable level
• To ensure equity and access, 100 of districts
  should have the minimum acceptable numbers of
  EmONC facilities or at least five facilities
  (including at least one comprehensive facility)
  per 500,000 population.

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Indicator 3 Proportion of all births inEmONC
facilities

• Proportion of all births in an area that take
  place in EmONC health facilities (basic or
  comprehensive).
• The numerator is the number of women registered
  as having given birth in facilities classified as
  EmONC facilities.
• The denominator is an estimate of all the live
  births expected in the area, regardless of where
  the birth takes place.
• Minimum acceptable level
• Varies by country (Tanzania 80)

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Indicator 4 Met need for EmONC

• Met need is an estimate of the proportion of
  all women with major direct obstetric
  complications who are treated in a health
  facility providing EmONC (basic or
  comprehensive).
• Minimum acceptable level
• As the goal is that all women who have obstetric
  complications will receive EmONC, the minimum
  acceptable level is 100.

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Indicator 5 Caesarean sections as aproportion
of all births

• The proportion of all deliveries by caesarean
  section in a geographical area is a measure of
  access to and use of a common obstetric
  intervention for averting maternal and neonatal
  deaths and for preventing complications such as
  obstetric fistula.
• Minimum and maximum acceptable levels
• 5-15

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Indicator 6 Direct obstetric case fatality rate

• The direct obstetric case fatality rate is the
  proportion of women admitted to an EmONC facility
  with major direct obstetric complications, or who
  develop such complications after admission, and
  die before discharge.
• Maximum acceptable level
• The maximum acceptable level is less than 1.

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Indicator 7 Intrapartum and very earlyneonatal
death rate

• The proportion of births that result in a very
  early neonatal death or an intrapartum death
  (fresh stillbirth) in an EmONC facility. This new
  indicator has been proposed to shed light on the
  quality of intrapartum care for foetuses and
  newborns delivered at facilities.
• Maximum acceptable level
• No standard has been set

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Indicator 8 Proportion of deaths due to indirect
causes in EmONC facilities

• The numerator of this new indicator is all
  maternal deaths due to indirect causes in EmONC
  facilities during a specific period, and its
  denominator is all maternal deaths in the same
  facilities during the same period.
• Acceptable level
• No standard has been set

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EXERCISE INTERPRETING EmONC INDICATORS

• District X has a population of 950,000. There are
  3 EmONC facilities in the district (2 BEmONC and
  1 CEmONC) and 2 are located in more urban areas.
  The proportion of all births in EmONC facilities
  is 10 Met need for EmONC is 8 and Caesarean
  Section rate is 0.7.
• Question Provide an interpretation of the state
  of EmONC in District X and identify priorities
  for improving the situation for women with
  obstetric complications.

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EXERCISE INTERPRETING EmONC INDICATORS

• Sample answer
• There are far too few functioning EmONC
  facilities. For a population of nearly 1 million,
  there should be 10 EmONC facilities, at least two
  of which are comprehensive, rather than the
  existing three.
• The functioning facilities are mostly in urban
  areas.
• The first priority is to see which health
  facilities can be upgraded to provide appropriate
  care, especially in rural areas.

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PRACTICE QUIZ

• Click on this link to access the practice quiz
  for this session.
• Use these notes and the materials for further
  reading (next slide) to help you answer the
  questions.
• The results of the quiz do not contribute to your
  continuous assessment, but you are encouraged to
  take it to check your understanding.

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FURTHER READING

• WHO, UNFPA, AMDD, UNICEF. Monitoring Emergency
  Obstetric Care a handbook. Geneva WHO 2009.
  (https//www.who.int/reproductivehealth/publicatio
  ns/monitoring/9789241547734/en/)
• JHPIEGO Guidelines for In-Service Training in
  Basic and Comprehensive Emergency Obstetric and
  Newborn Care 2012 (http//reprolineplus.org/resou
  rces/guidelines-service-training-basic-and-compreh
  ensive-emergency-obstetric-and-newborn-care)
• MEASURE Evaluation Monitoring and Evaluation
  Toolkit for the Scale-Up of Emergency Obstetric
  and Newborn Care in Kenya 2017
  (https//www.measureevaluation.org/resources/publi
  cations/tr-17-150/at_download/document)
• MOHCDGEC The National Road Map Strategic Plan to
  Improve Reproductive, Maternal, Newborn, Child
  Adolescent Health in Tanzania (2016 - 2020) One
  Plan II(https//www.globalfinancingfacility.org/si
  tes/gff_new/files/documents/Tanzania_One_Plan_II.p
  df)