Emergency Obstetric and Newborn Care (EmONC) EmONC Toolkit Appendix 2 Background: Emergency Obstetric and Newborn Care (EmONC)

Global Situation: Maternal and Newborn Health (MNH) Maternal deaths 293,000 per year* 99% in developing countries Maternal morbidity: 5.1– 10.2 million Still birth 3.3 million per year Neonatal Deaths 2.1 million per year* 75% first week of life *GBD 2013 Mortality and Causes of Death Collaborators, Lancet 2014

Situation in Kenya Maternal mortality ratio: 488/100 000 live births (KDHS, 2008-2009) Causes: bleeding, sepsis, pre-eclampsia, eclampsia Neonatal mortality rate: 22/1000 live births (KDHS, 2014) Causes: birth asphyxia (29%), prematurity (28%), sepsis (23%) Uptake of PMTCT: 90% (KAIS 2012) Facilities offering all 7 basic emergency obstetric and newborn care (BEmONC) signal functions: 3% (SARAM, 2013) Skilled birth attendance: 62% (KDHS, 2014)

County Situation

County MNCH Overview Indicator Estimate MMR 350/100,000 live births IMR 30/1000 live births TFR 3.0 per woman ANC 1st visit 97.4% SBA 85.5% CPR 68.9% Source: KDHS 2014; DHIS 2014/2015

Strategies to Reduce Maternal Mortality Access to skilled birth attendance Access to EmONC The Three Delays Model EmONC Decision to seek care Identifying and reaching health facility Receipt of adequate and appropriate treatment Complication Recovery/Death Source: Maine, D., et al. (1997). The design and evaluation of maternal mortality programs. New York, NY, USA: Columbia University.

EmONC Signal Functions BEmONC 1 Administer parenteral antibiotics 2 Administer uterotonic drugs 3 Administer parenteral anticonvulsants 4 Perform manual removal of the placenta 5 Remove retained products of conception 6 Perform assisted vaginal delivery 7 Perform basic neonatal resuscitation Comprehensive EmONC (CEmONC): All seven BEmONC Signal Functions plus 8 Perform Caesarean delivery 9 Provide blood transfusion

Standards for EmONC Coverage World Health Organization’s recommended minimum: 5 health facilities providing EmONC per 500,000 population (4 basic and 1 comprehensive) Coverage of EmONC facilities in Kenya: 1.2/500,000 population Services should be available every day, all day Equitable distribution of facilities and services

Signal Function 1: Administer Parenteral Antibiotics Puerperal sepsis accounts for 8% of global maternal deaths and 33% of maternal deaths in Kenya.* Effectively managed with injectable antibiotics IV Pencillin G 2MU every 6 hours Plus Gentamicin 5 mg/kg body weight IV every 24 hours Plus Metronidazole 500mg IV every 8 hours *World Health Organization’s multicountry Survey on Maternal and Newborn Health Analysis of Maternal Mortality and Mortality Kenya Statistical Report [In press]

Signal Function 2: Administer Uterotonic Drugs Postpartum hemorrhage accounts for 15% of global maternal deaths Up to 33% of maternal deaths in Kenya* Effectively managed through active management of third stage of labor (AMTSL) IM oxytocin within 1 minute of delivery *World Health Organization’s multicountry Survey on Maternal and Newborn Health Analysis of Maternal Mortality and Mortality Kenya Statistical Report [In press]

Signal Function 3: Administer Parenteral Anticonvulsants Severe pre-eclampsia and eclampsia account for 10% of global annual maternal deaths. Hypertensive disorders account for 35% of maternal deaths in Kenya.* Effectively managed through use of parenteral anticonvulsants Parenteral magnesium sulphate *World Health Organization’s multi-country Survey on Maternal and Newborn Health Analysis of Maternal Mortality and Mortality Kenya Statistical Report [In press]

Signal Function 4: Manually Remove Placenta Retained placenta: A major cause of postpartum hemorrhage and puerperal sepsis – both leading causes of maternal mortality Managed through manual removal of the placenta; requires elbow-length sterile gloves

Signal Function 5: Remove Retained Products of Conception Complications from abortion account for 15% of global annual maternal deaths. Managed effectively through manual vacuum aspiration or medical evacuation using misoprostol Postabortion care provides an opportunity to prevent further unplanned pregnancy by promoting contraceptive use.

Signal Function 6: Perform Assisted Vaginal Delivery Obstructed labour accounts for 6% of maternal deaths. Assisted vaginal delivery, using forceps or vacuum extraction, when done appropriately, can avert unnecessary hospital referral and caesarian delivery.

Signal Function 7: Perform Basic Neonatal Resuscitation Perinatal asphyxia is a leading cause of child mortality, accounting for 11% of global under-five deaths annually.* Severe forms are associated with serious long-term complications. Effective newborn resuscitation can reduce morbidity and mortality associated with perinatal asphyxia. *Liu, L., et al. (2014). Global, regional, and national causes of child mortality in 2000–13, with projections to inform post-2015 priorities: An updated systematic analysis. The Lancet, 385 (996): 430-440.

Signal Function 8: Perform Caesarean Delivery Caesarean section is a life-saving procedure required when vaginal delivery places the life or health of the mother or baby at risk. It is the first of two additional signal functions required in facilities designated to provide CEmONC.

Signal Function 9: Provide Blood Transfusion Blood transfusion is a life-saving procedure for women suffering from postpartum hemorrhage – the leading single cause of maternal mortality. Facilities providing CEmONC are required to provide blood transfusion.

Summary Maternal and newborn mortality are major global and local public health challenges. EmONC is a package of interventions targeting the leading causes of maternal and newborn mortality. The Government of Kenya and partners seek to ensure universal access to EmONC.

Key References World Health Organization, United Nations Population Fund, UNICEF, Columbia University Mailman School of Public Health. (2009). Averting maternal death and disability. Monitoring emergency obstetric care: a handbook. Geneva, Switzerland: World Health Organization. GBD 2013 Mortality and Causes of Death Collaborators. (2015). Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013. The Lancet, 385(9963):117-171.

MEASURE Evaluation PIMA is funded by the U. S MEASURE Evaluation PIMA is funded by the U. S. Agency for International Development (USAID) through associate award AID-623-LA-12-00001 and is implemented by the Carolina Population Center at the University of North Carolina at Chapel Hill, in partnership with ICF International; Management Sciences for Health; Palladium; and Tulane University. The views expressed in this presentation do not necessarily reflect the views of USAID or the United States government. www.measureevaluation.org/pima