EDITORIAL: Unlocking the Benefits of Emergency Obstetric Care in Africa

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 None

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