Using clinical cascades to measure health facilities' obstetric emergency readiness: testing the cascade model using cross-sectional facility data in East Africa

Bridget Whaley, Elizabeth Butrick, Jessica M Sales, Anthony Wanyoro, Peter Waiswa, Dilys Walker, John N Cranmer, Bridget Whaley, Elizabeth Butrick, Jessica M Sales, Anthony Wanyoro, Peter Waiswa, Dilys Walker, John N Cranmer

Abstract

Objectives: Globally, hundreds of women die daily from preventable pregnancy-related causes, with the greatest burden in sub-Saharan Africa. Five key emergencies-bleeding, infections, high blood pressure, delivery complications and unsafe abortions-account for nearly 75% of these obstetric deaths. Skilled clinicians with strategic supplies could prevent most deaths. In this study, we (1) measured facility readiness to manage common obstetric emergencies using the clinical cascades and signal function tracers; (2) compared these readiness estimates by facility characteristics; and (3) measured cascading drop-offs in resources.

Design: A facility-based cross-sectional analysis of resources for common obstetric emergencies.

Setting: Data were collected in 2016 from 23 hospitals (10 designated comprehensive emergency obstetric care (CEmOC) facilities) in Migori County, western Kenya, and Busoga Region, eastern Uganda, in the Preterm Birth Initiative study in East Africa. Baseline data were used to estimate a facility's readiness to manage common obstetric emergencies using signal function tracers and the clinical cascade model. We compared emergency readiness using the proportion of facilities with tracers (signal functions) and the proportion with resources for identifying and treating the emergency (cascade stages 1 and 2).

Results: The signal functions overestimated practical emergency readiness by 23 percentage points across five emergencies. Only 42% of CEmOC-designated facilities could perform basic emergency obstetric care. Across the three stages of care (identify, treat and monitor-modify) for five emergencies, there was a 28% pooled mean drop-off in readiness. Across emergencies, the largest drop-off occurred in the treatment stage. Patterns of drop-off remained largely consistent across facility characteristics.

Conclusions: Accurate measurement of obstetric emergency readiness is a prerequisite for strengthening facilities' capacity to manage common emergencies. The cascades offer stepwise, emergency-specific readiness estimates designed to guide targeted maternal survival policies and programmes.

Trial registration number: NCT03112018.

Keywords: international health services; maternal medicine; obstetrics; quality in health care.

Conflict of interest statement

Competing interests: AW represents his university on the Sexual, Reproductive and Child Health Committee for the Bill & Melinda Gates Foundation. JNC has grants from UNICEF and is an advisory board member for Towards Unity in Health and chair for the Community-Based Primary Health Care working group with the American Public Health Association, International Health Section. DW is on the Board of Directors of PRONTO International, a not-for-profit agency.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.

Figures

Figure 1
Figure 1
Emergency readiness estimates by emergency cascade and stage of care.

References

    1. World Health Organization . Maternal mortality, 2019. Available: [Accessed 21 Mar 2021].
    1. World Health Organization . Trends in maternal mortality 2000 to 2017: estimates by who, UNICEF, UNFPA, world bank group, and the United nations population division. Geneva: Wrold Health Organization, 2019.
    1. Say L, Chou D, Gemmill A, et al. . Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014;2:e323–33. 10.1016/S2214-109X(14)70227-X
    1. World Health Organization . Mother-baby package: implementing safe motherhood in countries. Geneva, Switzerland: Maternal Health and Safe Motherhood Programme, Division of Family Health, 1996.
    1. World Health Organization . Monitoring emergency obstetric care: a Handbook. Geneva, Switzerland: Department of Reproductive Health and Research, 2009.
    1. Nesbitt RC, Lohela TJ, Manu A, et al. . Correction: quality along the continuum: a health facility assessment of intrapartum and postnatal care in Ghana. PLoS One 2015;10:e0141517. 10.1371/journal.pone.0141517
    1. Paxton A, Bailey P, Lobis S. The United nations process indicators for emergency obstetric care: reflections based on a decade of experience. Int J Gynaecol Obstet 2006;95:192–208. 10.1016/j.ijgo.2006.08.009
    1. World Health Organization . Monitoring the building blocks of health systems: a Handbook of indicators and their measurement strategies. Geneva, Switzerland: World Health Organization, 2010.
    1. Gabrysch S, Civitelli G, Edmond KM, et al. . New signal functions to measure the ability of health facilities to provide routine and emergency newborn care. PLoS Med 2012;9:e1001340. 10.1371/journal.pmed.1001340
    1. Nickerson JW, Adams O, Attaran A, et al. . Monitoring the ability to deliver care in low- and middle-income countries: a systematic review of health facility assessment tools. Health Policy Plan 2015;30:675–86. 10.1093/heapol/czu043
    1. Gill Z, Bailey P, Waxman R, et al. . A tool for assessing 'readiness' in emergency obstetric care: the room-by-room 'walk-through'. Int J Gynaecol Obstet 2005;89:191–9. 10.1016/j.ijgo.2004.12.043
    1. Government of Sierra Leone . Sierra Leone service availability and readiness assessment 2011 report. Ministry of health and sanitation, 2011.
    1. Government of Kenya . Kenya service availability and assessment mapping (SARAM) report 2013. Nairobi, Kenya: Ministry of Health, 2013.
    1. O'Neill K, Takane M, Sheffel A, et al. . Monitoring service delivery for universal health coverage: the service availability and readiness assessment. Bull World Health Organ 2013;91:923–31. 10.2471/BLT.12.116798
    1. World Health Organization . Service availability and readiness assessment (SARA): an annual monitoring system for service delivery. Geneva, Switzerland: World Health Organization, 2015.
    1. Spangler SA. Assessing skilled birth attendants and emergency obstetric care in rural Tanzania: the inadequacy of using global standards and indicators to measure local realities. Reprod Health Matters 2012;20:133–41. 10.1016/S0968-8080(12)39603-4
    1. Brenner S, De Allegri M, Gabrysch S, et al. . The quality of clinical maternal and neonatal healthcare - a strategy for identifying 'routine care signal functions'. PLoS One 2015;10:e0123968. 10.1371/journal.pone.0123968
    1. Bailey P, Paxton A, Lobis S. The availability of life-saving obstetric services in developing countries: an in-depth look at the signal functions for emergency obstetric care. Obstet Gynecol Int 2006;93:285–91.
    1. Collender G, Gabrysch S, Campbell OMR. Reducing maternal mortality: better monitoring, indicators and benchmarks needed to improve emergency obstetric care. research summary for policymakers. Trop Med Int Health 2012;17:694–6. 10.1111/j.1365-3156.2012.02983.x
    1. Gabrysch S, Zanger P, Seneviratne HR, et al. . Tracking progress towards safe motherhood: meeting the benchmark yet missing the goal? an appeal for better use of health-system output indicators with evidence from Zambia and Sri Lanka. Trop Med Int Health 2011;16:627–39. 10.1111/j.1365-3156.2011.02741.x
    1. Cranmer JN, Dettinger J, Calkins K, et al. . Beyond signal functions in global obstetric care: using a clinical cascade to measure emergency obstetric readiness. PLoS One 2018;13:e0184252. 10.1371/journal.pone.0184252
    1. Potter C, Brough R. Systemic capacity building: a hierarchy of needs. Health Policy Plan 2004;19:336–45. 10.1093/heapol/czh038
    1. Gardner EM, McLees MP, Steiner JF, et al. . The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis 2011;52:793–800. 10.1093/cid/ciq243
    1. Morgan MC, Spindler H, Nambuya H, et al. . Clinical cascades as a novel way to assess physical readiness of facilities for the care of small and sick neonates in Kenya and Uganda. PLoS One 2018;13:e0207156. 10.1371/journal.pone.0207156
    1. Otieno P, Waiswa P, Butrick E, et al. . Strengthening intrapartum and immediate newborn care to reduce morbidity and mortality of preterm infants born in health facilities in Migori County, Kenya and Busoga region, Uganda: a study protocol for a randomized controlled trial. Trials 2018;19:313. 10.1186/s13063-018-2696-2
    1. The Partnership for Maternal, Newborn & Child Health . Essential interventions, commodities and guidelines for reproductive, maternal, newborn and child health. Geneva, Switzerland, 2011.
    1. World Health Organization . Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. 3 edn. Geneva, Switzerland, 2015.
    1. Paxton A, Bailey P, Lobis S, et al. . Global patterns in availability of emergency obstetric care. Int J Gynaecol Obstet 2006;93:300–7. 10.1016/j.ijgo.2006.01.030
    1. Carter R, Xiong X, Lusamba-Dikassa P-S, et al. . Facility conditions, obstetric and neonatal care practices, and availability of emergency obstetric and neonatal care in 72 rural health facilities in the Democratic Republic of the Congo: a cross-sectional study. Gates Open Res 2019;3:13. 10.12688/gatesopenres.12905.2

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する