System Changes to Improve Care for Mothers and Newborns

March 2024

In a global effort to increase access to quality emergency care for mothers and newborns, Peter Acker, MD an associate professor of emergency medicine is helping to improve emergency referrals. 

Early in his career, Acker was working in a rural health facility in Cambodia when he learned that a woman had been sent to the facility with postpartum hemorrhage. She arrived after many delays and needed surgery and a blood transfusion, which that facility couldn’t provide. She died soon after. 

“I thought a lot about that woman and her family, her newborn baby, her parents, and the long-lasting impact on her community,“ says Acker. “All of it could have been avoided if the system had the ability to rapidly refer her to a facility with the capacity to address her clinical needs. It struck me that the necessary changes wouldn’t require a large infusion of money. We just needed the existing components of the system to work together more efficiently.”

Each year an estimated 15 percent of women develop complications during pregnancy or after giving birth, leading to the deaths of 287,000 women and 3 million newborns. The vast majority of the world’s maternal deaths occur in developing countries where health systems are working to overcome many barriers to provide effective and timely emergency obstetric and newborn care.

The Emergency Obstetric and Newborn Care Needs Assessment Toolkit

The Emergency Obstetric and Newborn Care (EMONC) Needs Assessment Toolkit created in 1999 and updated in 2009 has been employed across 80 countries to try to identify and address emergency care gaps. The Toolkit was developed by a group called Averting Maternal Death and Disability (AAMD) at Columbia’s Mailman School of Public Health.

However, a critical aspect of the care continuum was not included in the needs assessment: emergency transport. 

To address this gap, AMDD reached out to an international community of practice to develop new criteria for assessing transport systems. Acker, the only emergency medicine physician in the group, shared his insight as a clinician and as a global emergency medicine expert with extensive experience in low-resource settings.

“Emergency care thinks about the whole system across patient categories,” Acker notes. “This is a somewhat different perspective. Until recently, funding, and as a result, many projects addressed a specific condition or targeted a particular patient group. But you can have a tremendous impact by working to improve systems to better address emergencies.”

Acker and his colleagues in the community of practice conducted extensive research on emergency referral indicators, refining ideas and formulating a program for real-world testing.

Unveiling the New Readiness Assessment Guidelines

At the 2023 International Maternal and Newborn Health Conference in South Africa, AAMD unveiled proposed updates to the EMONC tool that included measures for emergency referrals. 

The new measures, which enable health systems to evaluate their ability to refer mothers and newborns experiencing emergencies, are expected to profoundly impact global and maternal care, acting as a catalyst for governments and funders worldwide. “We hope that by having novel insights into emergency care and referral performance, these areas will be prioritized for ongoing improvement and receive the resources needed to do so,” Acker notes.

As the only emergency medicine physician in the community of practice that created the new assessment guidelines, Dr. Acker relied on his years of clinical practice, teaching, and systems changes in low- to middle-income countries.