EDITORIAL Unlocking the Benefits of Emergency Obstetric Care in Africa

Friday Okonofua, Sanni Yaya, Toyin Owolabi, Michael Ekholuenetale, Bernard Kadio


Emergency Obstetric care (EmOC) is the form of
clinical care that responds to un-expected complications
of pregnancy such as haemorrhage and hypertensive
crisis in pregnancy. In a recent publication, the UNFPA
identified two forms of EmOC1 as including Basic
Emergency Obstetric Care (BEmOC), and
Comprehensive Emergency Obstetric Care (CEmOC).
BEmOC consists of services such as administration of
antibiotics, uterotonic drugs, and anti-convulsants;
manual removal of retained placenta; removal of
retained products following delivery or abortion;
assisted vaginal delivery, possibly with a vacuum
extractor; and basic neonatal resuscitation procedures.
By contrast, CEmOC consists of all the basic functions
enumerated above, but also includes institutional ability
to perform caesarean sections safely and to administer
blood transfusion as well as the provision made for the
advanced treatment and resuscitation of sick babies.
BEmOC are expected to be carried out in primary
health centres, while CEmOC has to be implemented in
secondary or tertiary health care facilities, enabling the
strategic adoption of a systems approach for addressing
the problem.
A UNICEF, WHO and UNFPA joint statement
further recommends that for every 500,000 people,
there must be at least four facilities offering BEmOC,
and at least one facility offering CEmOC services2.
Such facilities must not only be physically available,
but they must also have the required number of trained
and experienced staff, equipment and consumables to
carry out the emergency obstetric treatment needed to
save the lives of women and children.
Unfortunately, for many countries in sub-
Saharan Africa, these basic components of EmOC are
often not available, which in large measure account for
the high rates of maternal, stillbirth and neonatal
mortality in the region. Evidences abound that Phase III
delay (the type of delays that occur after pregnant
women arrive in health facilities)3 accounts for up to
half of the maternal deaths4 that occur from pregnancy
complications in Africa. Phase III delay also acts as a
dis-incentive to women using facility care. Thus, in
aggregate form, Phase III delay appears to be the most
important single type of delay that need to be acted
upon to reduce the high rate of maternal and newborn
mortality in African countries.
Recent data suggests that available BEmOC and
CEmOC in many parts of Africa are not only of low
quality; they are also inaccessible and respond poorly
to the needs of pregnant women. A recent study5 that
investigated 378 health facilities in six developing
countries, including Kenya, Malawi, Sierra Leone and
Nigeria, reported that fewer than one in four facilities
designated to provide CEmOC were able to offer the
nine required signal functions of care, and only 2.3%
provided all seven signal functions. The study
concluded that health facilities in surveyed countries do
not have the capacity to adequately manage emergency
obstetric complications that lead to maternal and
newborn mortality. A paper by Bamgboye and
colleagues in this edition of the African Journal6 also
reports poor quality and inaccessible BEmOC and
CEmOC in Ibarapa Local Government Area in
Southwest Nigeria, which testify to the persistence and
continuity of the problem at the local level.
Maternal mortality reduction in developing
countries was one of the unfinished agenda in the
Millennium Development Goals and remains one of the
key indicators for measuring the attainment of the
Sustainable Development Goals. If the goal of further
reducing the number of maternal deaths is to be
achieved by 2030, now is the time to focus on
improving the quality of emergency obstetric services,
especially within the context of sub-Saharan Africa.
Due to the recognition that women will likely continue
to delay in seeking orthodox maternity care, we hold
the view that the improvement of the quality,
timeliness, and responsiveness of EmOC is one of the
most important interventions that need to be undertaken
to reduce maternal and newborn mortality in the
African region. Oladapo et al7 in a recent study
reviewing 998 maternal deaths and 1451 near-miss
cases in Nigeria made the point that getting to
maternity care centres is not enough: there must be a
purposefully designed action plan and effective
emergency obstetric services to prevent maternal and
neonatal deaths.
It is within this context that the Women’s Health
and Action Research Centre (WHARC), a Nigerian
national non-governmental organization is actively
pursuing a series of implementation research activities
aimed at improving the quality of BEmOC and
Okonofua et al. Emergency Obstetric Care in Africa
African Journal of Reproductive Health March 2016; 20 (1):10
CEmOC in the country. With funding from the World Health Organization8, WHARC has completed a number of quantitative and qualitative formative studies that assess the quality of CEmOC in eight referral facilities in four geo-political zones of the country. The assessment asked the important questions: 1) to what extent do the health facilities meet the WHO criteria for the delivery of CEmOC services? 2) how available in these facilities are the known interventions for preventing maternal and newborn mortality, and how knowledgeable are health providers working in these facilities about the applicability and use of these key interventions?; and 3) how do women respond to existing care, and what do they see as barriers to use of orthodox maternity care? The results of the formative research have now been disseminated and are widely available9, and again illustrate the paucity of the kind of CEmOC needed to deal with a huge problem of this nature.
The good news is that key stakeholders including policymakers and government officials are working with WHARC to design effective interventions to address the identified gaps. The multi-faceted and composite interventions being proposed would be tested for effectiveness in a quasi-experimental research design that would be implemented in randomly selected sites across the country. If proved to be effective, we believe the engagement of policymakers in every phase of the study will help to ensure that the interventions are integrated into policy and scaled throughout Nigeria’s health care system.
A parallel study is also being undertaken by WHARC with funding from the International Development Research Centre (IDRC)10, Canada to improve the use of Primary Health Centres (PHCs) by pregnant women and the quality of BEmOC offered by PHCs in Nigeria. Although PHCs are the entry points to Nigeria’s health care system, these facilities are hardly available for use by vulnerable women, especially those in hard-to-reach rural populations in the country. Most Nigerian rural populations tend not to have secondary and tertiary care facilities; they are often without evidence-based orthodox care, and are then left to use ineffective local remedies provided by traditional birth attendants. To this day, only about 34% of Nigerian women are attended at delivery by skilled birth attendants, with the large majority of pregnant women delivering in their homes or with unskilled traditional birth attendants. Yet, it is known that most maternal deaths occur in these circumstances where women deliver unattended or with unskilled birth attendants. To address this, WHARC is undertaking formative community-based participatory research to identify the demand and supply factors that account for women’s poor use of PHCs for maternal and newborn care in the country. In collaboration with national and international stakeholders at the University of Ottawa, Canada, the Centre hopes to use the results of the formative research to implement a series of interventions to improve women’s use of PHCs linked to effective referral facilities. We believe this would help resolve the present lack of access to orthodox maternal and child health care to majority of rural women in the country.
The clear message in this editorial is that there is a need to evolve an effective health system in African countries that provides composite BEmOC and CEmOC for dealing with obstetric emergencies that lead to maternal and neonatal mortality. Several years ago, Professor Kelsey Harrison in his elegant prospective studies conducted at the Ahmadu Bello University in Zaria, northern Nigeria11 reported that 90% of women who died during pregnancy were “unbooked emergencies”. These were women who had not received antenatal care throughout the pregnancy, who tried to deliver at home but failed to do so, but who then presented as dire emergencies in hospital after experiencing severe complications of pregnancy. After over 30 years, the problem still remains the same, without any substantive effort made to resolve it either in Nigeria or in many other African countries. If the current effort to promote human development through the Sustainable Development Goals is to be achieved, African countries need to focus on strongly positioning the effective delivery of emergency obstetric care as an important equity, human rights and social justice imperative.
Conflict of Interest

Full Text:



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