Maternal mortality is a global public health burden . Globally in 2015, 303,000 maternal deaths occurred. Over ninety nine percent of these annual maternal deaths occur in low and middle income countries while 66% in particular occurred in Sub-Saharan Africa .About 75% of these maternal mortalities are caused by haemorrhage, sepsis, unsafe abortion, pre-eclampsia/ eclampsia, ruptured uterus, obstructed labour and its sequelae, and extra-uterine pregnancy [1–3]. Life threatening complications will occur in about 15% of pregnant women, they cannot be predicted accurately or prevented completely during pregnancy, delivery or immediate postpartum [4, 5]. Although these complications are highly unpredictable and less preventable, they can be treated by prompt, available and quality emergency obstetric and newborn care (EmONC) services [3–8]. The National Demography and Health Survey (NDHS) data showed that Nigeria’s Maternal Mortality Rate (MMR) is high and stands at 576 per 100,000 live births . In Irrua Specialist Teaching Hospital (ISTH), Okunsanya and co showed that the maternal mortality rate was 1747 per 100,000 live births, of which in about 77.8% of cases they were associated with delays .
Although several efforts have been strategized to reducing maternal mortality, the three most indispensable requirements that are strongly evidence based are the access to available and quality EmONC services, family planning and care of a skill birth attendant during all deliveries [2,4,5]. It has been estimated that with the availability of EmOC services 60% of maternal mortality, 45% of neonatal deaths and 45–75% of still birth could be avoided[2,4]. Paxton et al, 2004 in a systematic review acknowledged the difficulty in measuring maternal mortality, which in turn limits assessment of the impact of EmOC services and also the ethical dilemma in doing a randomized study. Despite these limitations, they concluded that there is a strong reason to suggest that EmOC should be a key element in any policy for reducing maternal death . Universal access to EmONC is considered essential to reducing maternal mortality and it should be available to all pregnant women and newborns (WHO, 2014). No wonder that provision of EmOC service is one of the components of the World Health Organization(WHO)‘Making Pregnancy Safer’ programme which is a newer term for safe-motherhood initiative aimed at reducing maternal mortality [9,13–16]. Rana et al (2007) in Nepal upgraded eight health facilities by providing infrastructure, equipments, training, data collection, policy advocacy and community information activities, found improved met need for EmOC from 1.9 to 16.9% and a reduction in obstetrics case fatality from 2.7 to 0.3% . This showed the positive impact of EmONC effectiveness in reducing maternal mortality. Dumont et al (2013) in a cluster randomized controlled trial, after a base line survey of EmOC facilities, provided an intervention in the form of an interactive workshops and educational outreach on maternal death review and provision of quality EmOC services. He also found a marked reduction in maternal death in the intervention hospital than the control . Holmar et al (2015) in a systematic review observed an inverse relationship between met need for EmOC and maternal mortality and correlate proportionally with available skilled birth attendant .
In Nigeria, the Federal Ministry of Health (FMOH) conducted a national survey on essential obstetrics care and found that only 20% of health facilities studied performed the signal functions . These are mainly tertiary health facilities with few of the secondary and primary health facility providing EmOC services . This is not different from most developing countries. Babatunde et al (2012) in his facility based review of the status of EmOC in a LGA within South—South, Nigeria found that none of the facilities that should serve as B-EmOC facilities were able to do so and only one could perform C-EmOC services . This is not different from a similar survey in Uganda by Wilunda et al, he found out that none of the facilities for B-EmOC services is qualified as such, with operative vaginal delivery and manual vacuum aspiration were the commonest missing functions . The met need for EmOC was 9.9% while absolute obstetric case fatality was 3.0% which is higher than the UN recommendation [18, 19, 23]. Pearson et al, 2004 in a multinational EmOC survey by AMDD including Uganda found adequate C-EmOC services but lesser facility for B-EmOC services . His findings also showed that between 0.6–8.8% of all deliveries occurs in EmOC facility while only 2.1–18.5% of all absolute obstetrics complications were treated, thus showing limited access to women in need of life- saving services. Almost all the surveys on availability of EmOC at National and Sub- National levels showed gross inadequacy of B-EmOC services. In particular, they lack materials for evacuation of retained products of conception (MVA) [22,25,26–30, 32–51,54–57] Most surveys since 1997 have showed that in over 40 countries there are available comprehensive EmOC as recommended by UN / WHO; however there are inadequate or none availability of B-EmOC [2,4,6].
In order to monitor the availability and quality of EmONC services, experts from the Mailman School of Public Health at Columbia University, with Support and adoption by the United Nation’s Children Funds (UNICEF) and the World Health Organization (WHO) formed a guidline [18,19]. This guideline uses eight different care packages, referred to as ‘signal functions’, which were described as lifesaving to major causes of maternal death [18,19]these care packages includes; parenteral antibiotics, parenteral oxytocic, parenteral anticonvulsants, manual removal of placenta, removal of retained products, assisted vaginal delivery, provision of surgery (caesarean section) and safe blood transfusion services. The first six care packages constitute B-EmOC while the whole eight make up the comprehensive emergency Obstetric care (C-EmOC). Six EmONC indicators, as well as the type of data required calculating these indicators with the lowest and/or highest acceptable standards were also established. The guideline was reviewed and updated in 2009, now incorporating basic neonatal resuscitation to the B-EmOC and thus was renamed Emergency Obstetrics and Newborn Care (EmONC) [2, 3,11,16–19].
Quality EmOC services is technically difficult to define because of its complex nature; however it involves alertness that will enable a health center to respond appropriately and timely to women with obstetrics emergencies in a manner that fulfils the needs of the patient with almost technical competency[20,21].
Nigerian federal ministry of health in its plan of health for all ages proposes to use Primary Health Care Centres (PHC) as their centre of focus. The Nigeria health care system is built on the foundation of three tiers: primary, secondary and tertiary health care centers. The primary health care is under the control of the local government, the secondary health care under the state government, while the tertiary hospitals are under the federal government. It is expected that the B-EmOC be available at the primary health care centers while the C-EmOC is expected in the secondary and tertiary health centres. Esan Central LGA is thus a privileged environment to have a federal teaching hospital, state general hospital and several registered primary health centers; however the maternal mortality is still very high .
The importance of EMOC need assessment cannot be over emphasized as it helps to identify gaps and problems through qualitative and quantitative data on the adequacy and quality of EMOC services [18,19,49].It provide a critical steps in improving equitable access to EmOC services and help strengthens overall health systems [18,19]. These will help guide policy decisions, planning and budgeting to reform and strengthens the health system most especially with this era of global agenda of Sustainable Development Goals (SDG)–2030. This study therefore aimed to assess the availability and quality of emergency obstetric and newborn care in Esan Central LGA, Edo state.
1. Reducing maternal death; are there adequate emergency obstetric care services in Esan central LGA?
2. Reducing maternal death, if there are adequate EmONC services: what are their qualities in Esan central LGA
To assess the availability and quality of Emergency Obstetric and Newborn Care (EmONC) Services in Esan Central LGA of Edo State.
1. To determine the number of health center offering maternity services in proportion to the population of Esan Central LGA.
2. To determine the number of health centers with adequate facilities for EmONC services in proportion to the population of Esan Central LGA.
3. To determine the preparedness of health facilities to offer quality EmONC services in Esan Central LGA.
4. To determine the Perception on the quality of EmONC services in Esan Central LGA.