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Vision for EmONC Framework

Every death of a pregnant woman,1 every stillbirth, and every death of a newborn is a tragedy for the family and community that experience it. But maternal and newborn mortality are about much more than the health of individual people. These deaths, and the patterns in which they occur across a society and over time, reflect choices made by countries and communities, as well as global health and development institutions, about who matters and what they are willing to do to change the status quo.

In 2024, the world still experiences nearly 300,000 maternal deaths, 2.3 million newborn deaths and 1.9 million stillbirths each year.234 Indeed, maternal and newborn mortality and morbidity remain significant public health problems in low-, middle- and high-income countries, although the character of the problem is very different. In the countries with highest mortality, the health system is typically weak, its reach is scandalously short, the people’s trust in it is justifiably low.56 A large majority of the population lacks access to good quality childbirth and newborn services, especially in case of life-threatening emergencies.7 In countries with dramatically lower death rates overall, maternal and newborn mortality and morbidity patterns often reveal significant racial and ethnic disparities reflecting deep, historically grounded fissures in the broader society. While the health system may be comparatively very well-funded, its reach and quality are not the same for everyone; and for those who feel its blunter edge, trust is exceedingly fragile. While most people can access the services they need and want, some communities, already disadvantaged in social and structural determinants of health, are excluded, unable to access care that is timely, respectful and good quality.8

This contrasting picture of inequities between and within countries shows that the historical roots and multi-dimensional causes of maternal and newborn mortality and stillbirth are complex and varied. Yet, some critical elements of the solutions are very clear. In every population, no matter how affluent its members or how strong its general health status, a significant proportion of women and newborns will experience complications before, during and after childbirth. Therefore, every health system must be able to provide the care needed to address these complications, often on an emergency basis. This is not the only condition countries must meet to reduce maternal and newborn mortality and morbidity, fulfil the rights of their citizens, and achieve global and national goals; but it is an essential and necessary condition.

This Guide supports country-level planners and managers to get a clear, evidence-based picture of a critical part of their health system essential for saving maternal and newborn lives and preventing stillbirths: emergency9 obstetric and newborn care (EmONC). EmONC services include the clinical interventions that are needed to treat the major direct obstetric complications that can occur during pregnancy, the intrapartum period and postpartum;10 prevent a significant proportion of intrapartum stillbirths; and manage small or sick newborns in the postnatal period.111213 The Guide supports decision makers to understand how the EmONC system is actually functioning in practice, and not just how it was designed to work in theory; and to reckon with the interaction the system has with the health professionals who deliver care in its facilities, and with the population those facilities are supposed to serve.

The overall goal of reducing maternal and newborn mortality and morbidity and stillbirths requires that EmONC have smooth linkages with other services across the antenatal-intrapartum-postnatal continuum and with primary health care more generally. It ultimately requires change on deeper, societal levels as well, including transformation toward gender equity, racial equity, and health equity. But at the heart of these necessary changes must be the commitment to one simply stated principle:

Every pregnant woman and every newborn who experiences complications must have access to the right care in the right place at the right time to survive and thrive.

This is the foundational principle of the EmONC Framework.

  1. We acknowledge that not all people who are pregnant or giving birth identify as women. The use of woman/women in this Guide is to be consistent with terminology used in work in most LMICs, but includes gender expansive people. ↩︎

  2. WHO, UNICEF, UNFPA, World Bank Group, UNDESA/Population Division. 2023. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO. ↩︎

  3. UNICEF, WHO, World Bank Group, UN Department of Economic and Social Affairs Population Division, UN Economic Comission for Latin America and the Caribbean, Population Division. 2024. Levels and Trends in Child Mortality – Report 2023. New York: UNICEF, 2024. ↩︎

  4. UNICEF, WHO, World Bank Group, UN Department of Economic and Social Affairs Population Division. 2023. Never Forgotten – The situation of stillbirth around the globe. New York: UNICEF, 2023. ↩︎

  5. Forthcoming. ↩︎

  6. Kruk ME, Kapoor NR, Lewis TP, et al. Population confidence in the health system in 15 countries: results from the first round of the People's Voice Survey. Lancet Glob Health. 2024 Jan;12(1):e100-e111. doi: 10.1016/S2214-109X(23)00499-0. ↩︎

  7. WHO, UNICEF, UNFPA. 2023. Improving maternal and newborn health and survival and reducing stillbirth: progress report 2023. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO. ↩︎

  8. Mohamoud YA, et al. (2023) Vital Signs: Maternity care Experiences – United States, April 2023. Morbidity and Mortality Weekly Report. Vol. 72. No. 35. September 1, 2023. ↩︎

  9. In the context of emergency obstetric and newborn care (EmONC), the term “emergency” refers to the fact that some complications require urgent care. In other contexts, the term “emergency” is used to describe humanitarian settings. That is not the meaning intended for this document, although EmONC is also needed in humanitarian settings. ↩︎

  10. Antenatal and postpartum hemorrhage, severe pre-eclampsia and eclampsia, prolonged and obstructed labor, sepsis, ruptured uterus, complications of abortion, ectopic pregnancy. ↩︎

  11. Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Heal. 2014;2(6):e323-e333. doi:10.1016/S2214-109X(14)70227-X. ↩︎

  12. UNICEF. Never Forgotten - The situation of stillbirth around the globe - Report of the United Nations Inter-agency Group for Child Mortality Estimation. 2023: NY, USA. ↩︎

  13. WHO, UNICEF. Survive and thrive: transforming care for every small and sick newborn. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO. ↩︎