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.

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:  

Setting standards for emergency obstetric and newborn care

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.

Reducing life-threatening delays

Timing proves to be critical in preventing maternal death and disability: Although post-partum haemorrhage can kill a woman in less than 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.

Protecting Mothers in Risky Situations

In a crisis or refugee situation, one in five women of childbearing age is likely to be pregnant. Conflicts and natural disasters put these women and their babies at risk because of the sudden loss of medical support, compounded in many cases by trauma, malnutrition or disease, and exposure to violence. UNFPA seeks to make motherhood as safe as possible during crisis situations by helping those who want to delay or avoid pregnancy and by providing care before, during and after delivery.

Family planning

Pregnancy and childbirth are always risky in many parts of the developing world. This is especially so during and after emergencies. Many couples would prefer not to risk pregnancy or childbearing during this period but lack the means to postpone pregnancy when family planning services become unavailable.

Neglecting family planning can have other serious consequences, including unsafe abortions resulting from unwanted pregnancies. Restoring access to safe, effective contraception protects the lives and well-being of women and children and enables crisis-affected couples to manage scarce family resources more effectively.

UNFPA is able to ship male and female condoms and other family planning supplies within hours of an emergency. When the situation stabilizes, UNFPA conducts rapid assessments to determine local needs and preferences and supports efforts to make a wide range of modern methods available so that couples have access to the contraceptive of their choice.

After the tsunami hit Banda Aceh, for instance, UNFPA helped the National Family Planning Coordination Board to replenish and retrain its staff and ordered a large volume of supplies to meet needs anticipated for the next 12 months. In migrant communities of Thailand that were also hit by the tsunami, UNFPA helped establish family planning and other reproductive health services. At a camp for displaced persons in Darfur, the family planning unit served some 75 women per day.

Safe delivery

Women who die in childbirth leave behind devastated families. Motherless children are far more likely than others to die before reaching adolescence. Those who survive are less likely to complete their education.

When crisis strikes, UNFPA sends emergency supplies and equipment to make deliveries safer and to support medical interventions where necessary. UNFPA emergency response includes rapid shipment of clean delivery kits – including a new razor blade and string for cutting and tying the umbilical cord – to help prevent fatal infections in women who cannot reach a medical facility.

As the situation develops, the Fund sends the equipment, medicine and supplies needed for clinical delivery assistance and emergency obstetric care. The specific response depends on the circumstances: Ad hoc delivery rooms may be set up in damaged buildings, mobile health clinics may be dispatched, and midwives are sometimes provided with motorcycles. More comprehensive services are organized when the worst of the crisis has passed.

Whether the emergency is due to violence, as in Timor-Leste, earthquakes, as in Indonesia and Pakistan , or a hurricane, as in Guatemala, UNFPA stands ready to assist pregnant women in this time of compounded vulnerability.  

Pre- and post-natal care

Health care before and after the crucial time of delivery can save the lives of mothers and babies. It can also serve as an important point of entry for women and their infants to health information and services. This can be especially important during emergency situations, when infant and maternal mortality soars.

Prenatal care can identify general health problems that need to be treated. It can raise awareness of danger signs to look for during pregnancy. Prenatal care should also address the special nutritional needs of pregnant women. Health care providers must be trained to detect anaemia and other vitamin deficiencies that can put the mother and her unborn baby at risk. Good prenatal care and voluntary testing and counselling can also minimize the risk of HIV transmission from HIV-positive parents to their unborn children.

The 48 hours after delivery are critical: Up to 50 per cent of all maternal deaths take place during that period. And the death of a mother poses a high risk for her newborn. Post-partum care can mean the difference between life and death for both. Whether conducted in a health facility or through a visit by a midwife or trained birth attendant, post-partum care can assess the mother’s general condition after childbirth and identify haemorrhage, hypertension, infection and other life-threatening  conditions that may require urgent medical attention.

Post-partum care is also an opportunity for the midwife or health worker to assess the health of the newborn and talk to the mother about infant care, breastfeeding and nutrition. Sensitive counselling is especially important if the mother is HIV-positive and risks transmitting the virus to her child through her breastmilk.

UNFPA emergency health kits include the tools health workers need to provide basic prenatal care for everything from medical examinations to medicines and supplies to prevent malnutrition, malaria and other threats to a mother’s health. UNFPA also provides training for health workers and midwives to make sure women receive the care they need during all phases of pregnancy and childbirth. The Fund also strives to make sure pregnant and lactating women get the extra nutrition they need during this period.

The Fund supports post-partum care through the provision of supplies, medicine, equipment and training to enable health workers to identify and treat life-threatening complications and share information with mothers regarding infant care and family planning. Mini-vans carrying health care workers and supplies deliver maternal and child health services to women in remote, earthquake-affected areas of Pakistan.

A team of obstetricians, general practitioners and midwives visit the camps for those displaced by civil strife in Timor-Leste daily to provide antenatal care, including tetanus vaccinations and supplementary food provided by the World Food Programme. And during Niger’s food crisis, UNFPA’s support encouraged women to seek antenatal care by linking visits to the clinic with supplies of cereal, pulses and oil.

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 UNFPAs 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. 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: Setting standards for emergency obstetric and newborn care 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. Reducing life-threatening delays Timing proves to be critical in preventing maternal death and disability: Although post-partum haemorrhage can kill a woman in less than 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. Protecting Mothers in Risky Situations In a crisis or refugee situation, one in five women of childbearing age is likely to be pregnant. Conflicts and natural disasters put these women and their babies at risk because of the sudden loss of medical support, compounded in many cases by trauma, malnutrition or disease, and exposure to violence. UNFPA seeks to make motherhood as safe as possible during crisis situations by helping those who want to delay or avoid pregnancy and by providing care before, during and after delivery. Family planning Pregnancy and childbirth are always risky in many parts of the developing world. This is especially so during and after emergencies. Many couples would prefer not to risk pregnancy or childbearing during this period but lack the means to postpone pregnancy when family planning services become unavailable. Neglecting family planning can have other serious consequences, including unsafe abortions resulting from unwanted pregnancies. Restoring access to safe, effective contraception protects the lives and well-being of women and children and enables crisis-affected couples to manage scarce family resources more effectively. UNFPA is able to ship male and female condoms and other family planning supplies within hours of an emergency. When the situation stabilizes, UNFPA conducts rapid assessments to determine local needs and preferences and supports efforts to make a wide range of modern methods available so that couples have access to the contraceptive of their choice. After the tsunami hit Banda Aceh, for instance, UNFPA helped the National Family Planning Coordination Board to replenish and retrain its staff and ordered a large volume of supplies to meet needs anticipated for the next 12 months. In migrant communities of Thailand that were also hit by the tsunami, UNFPA helped establish family planning and other reproductive health services. At a camp for displaced persons in Darfur, the family planning unit served some 75 women per day. Safe delivery Women who die in childbirth leave behind devastated families. Motherless children are far more likely than others to die before reaching adolescence. Those who survive are less likely to complete their education. When crisis strikes, UNFPA sends emergency supplies and equipment to make deliveries safer and to support medical interventions where necessary. UNFPA emergency response includes rapid shipment of clean delivery kits including a new razor blade and string for cutting and tying the umbilical cord to help prevent fatal infections in women who cannot reach a medical facility. As the situation develops, the Fund sends the equipment, medicine and supplies needed for clinical delivery assistance and emergency obstetric care. The specific response depends on the circumstances: Ad hoc delivery rooms may be set up in damaged buildings, mobile health clinics may be dispatched, and midwives are sometimes provided with motorcycles. More comprehensive services are organized when the worst of the crisis has passed. Whether the emergency is due to violence, as in Timor-Leste, earthquakes, as in Indonesia and Pakistan , or a hurricane, as in Guatemala, UNFPA stands ready to assist pregnant women in this time of compounded vulnerability. Pre- and post-natal care Health care before and after the crucial time of delivery can save the lives of mothers and babies. It can also serve as an important point of entry for women and their infants to health information and services. This can be especially important during emergency situations, when infant and maternal mortality soars. Prenatal care can identify general health problems that need to be treated. It can raise awareness of danger signs to look for during pregnancy. Prenatal care should also address the special nutritional needs of pregnant women. Health care providers must be trained to detect anaemia and other vitamin deficiencies that can put the mother and her unborn baby at risk. Good prenatal care and voluntary testing and counselling can also minimize the risk of HIV transmission from HIV-positive parents to their unborn children. The 48 hours after delivery are critical: Up to 50 per cent of all maternal deaths take place during that period. And the death of a mother poses a high risk for her newborn. Post-partum care can mean the difference between life and death for both. Whether conducted in a health facility or through a visit by a midwife or trained birth attendant, post-partum care can assess the mothers general condition after childbirth and identify haemorrhage, hypertension, infection and other life-threatening conditions that may require urgent medical attention. Post-partum care is also an opportunity for the midwife or health worker to assess the health of the newborn and talk to the mother about infant care, breastfeeding and nutrition. Sensitive counselling is especially important if the mother is HIV-positive and risks transmitting the virus to her child through her breastmilk. UNFPA emergency health kits include the tools health workers need to provide basic prenatal care for everything from medical examinations to medicines and supplies to prevent malnutrition, malaria and other threats to a mothers health. UNFPA also provides training for health workers and midwives to make sure women receive the care they need during all phases of pregnancy and childbirth. The Fund also strives to make sure pregnant and lactating women get the extra nutrition they need during this period. The Fund supports post-partum care through the provision of supplies, medicine, equipment and training to enable health workers to identify and treat life-threatening complications and share information with mothers regarding infant care and family planning. Mini-vans carrying health care workers and supplies deliver maternal and child health services to women in remote, earthquake-affected areas of Pakistan. A team of obstetricians, general practitioners and midwives visit the camps for those displaced by civil strife in Timor-Leste daily to provide antenatal care, including tetanus vaccinations and supplementary food provided by the World Food Programme. And during Nigers food crisis, UNFPAs support encouraged women to seek antenatal care by linking visits to the clinic with supplies of cereal, pulses and oil.