HHFA and EmONC: complementarity along the maternal continuum of care

The Emergency Obstetric and Newborn Care (EmONC) assessment measures the capacity to respond to complications. The Harmonized Health Facility Assessment (HHFA) measures the services that reduce the number of complications and detect them in time: family planning, antenatal care (ANC) and postnatal care.

Justification

Scale of the problem. About 15% of pregnant women develop a potentially life-threatening complication [1]. In Angola, with 36.6 million inhabitants and a crude birth rate of 33.7 per 1,000, this means about 185,000 complications a year [2, 3].

Contraception. It prevents the emergency by preventing the pregnancy. Unmet need for family planning is 37% among women in union and 48% among unmarried women [3]. Contraception averted 44% of maternal deaths worldwide [4].

Antenatal care. It identifies women at risk and allows timely management:

  • pre-eclampsia, detected through blood pressure and proteinuria checks;
  • aspirin for high-risk women;
  • anaemia, malaria and syphilis;
  • a birth plan in a facility able to respond.

In Angola, only 51% of pregnant women have four or more visits [3].

Postnatal period. Obstetric emergencies also occur after discharge, such as late postpartum haemorrhage, puerperal sepsis and postpartum pre-eclampsia. They are identified in the community and at postnatal visits. Most maternal and neonatal deaths occur within 48 hours after birth, yet only 15% of women receive a postnatal check in that period [3]. HHFA measures outpatient postnatal care; EmONC does not.

Limit of prevention. Many complications only arise during labour and cannot be predicted. Emergency response remains essential.

Coverage by stage

Stage HHFA EmONC
Family planning Strong Strong (delivery facilities only)
ANC, prevention of mother-to-child transmission (PMTCT) and syphilis Strong Weak
Emergency referral and transport Weak Strong
Childbirth and signal functions Partial Strong
Newborn Strong Strong
Inpatient postnatal care Strong Partial
Outpatient postnatal care Strong Absent
Women’s experience and costs Absent Strong

Gaps shared by both

Neither instrument measures:

  • preconception care;
  • provision of postpartum contraception;
  • community identification of pregnant women;
  • clinical record review of labour care.

Differences to consider

Universe. EmONC excludes facilities without deliveries (question M1 101).

Place of verification. EmONC checks resources in the maternity ward; HHFA checks them where each service is delivered.

Reference period. Signal functions are asked over 3 months in EmONC and over 12 months in HHFA.

Conclusion

The instruments are complementary. Applied without the HHFA family planning, ANC and postnatal care modules, EmONC leaves the maternal continuum of care incomplete.

References

  1. WHO, Managing complications in pregnancy and childbirth, 2017.
  2. INE, 2024 Census.
  3. INE/MINSA/ICF, Angola IIMS 2023–2024, pp. ix, 17–18, 22–23.
  4. Ahmed S et al. Lancet 2012;380:111–25.

Complications estimate: IIMS crude birth rate × Census population × 15%.