Beyond signal functions in global obstetric care: Using a clinical cascade to measure emergency obstetric readiness

Abstract

BackgroundGlobally, the rate of reduction in delivery-associated maternal and perinatal mortality has been slow compared to improvements in post-delivery mortality in children under five. Improving clinical readiness for basic obstetric emergencies is crucial for reducing facility-based maternal deaths. Emergency readiness is commonly assessed using tracers derived from the maternal signal functions model.Objective-methodWe compare emergency readiness using the signal functions model and a novel clinical cascade. The cascades model readiness as the proportion of facilities with resources to identify the emergency (stage 1), treat it (stage 2) and monitor-modify therapy (stage 3). Data were collected from 44 Kenyan clinics as part of an implementation trial.FindingsAlthough most facilities (77.0%) stock maternal signal function tracer drugs, far fewer have resources to practically identify and treat emergencies. In hypertensive emergencies for example, 38.6% of facilities have resources to identify the emergency (Stage 1 readiness, including sphygmomanometer, stethoscope, urine collection device, protein test). 6.8% have the resources to treat the emergency (Stage 2, consumables (IV Kit, fluids), durable goods (IV pole) and drugs (magnesium sulfate and hydralazine). No facilities could monitor or modify therapy (Stage 3). Across five maternal emergencies, the signal functions overestimate readiness by 54.5%. A consistent, step-wise pattern of readiness loss across signal functions and care stage emerged and was profoundly consistent at 33.0%.SignificanceComparing estimates from the maternal signal functions and cascades illustrates four themes. First, signal functions overestimate practical readiness by 55%. Second, the cascade’s intuitive indicators can support cross-sector health system or program planners to more precisely measure and improve emergency care. Third, adding few variables to existing readiness inventories permits step-wise modeling of readiness loss and can inform more precise interventions. Fourth, the novel aggregate readiness loss indicator provides an innovative and intuitive approach for modeling health system emergency readiness. Additional testing in diverse contexts is warranted.

Clinical cascades as a novel way to assess physical readiness of facilities for the care of small and sick neonates in Kenya and Uganda

“…At each step of the cascade (e.g., diagnosis, linkage to care), patients may be lost to follow-up and, as a result, fail to access or benefit from available health interventions. The cascade approach has subsequently been applied to other areas of public health, including PMTCT [ 29 ], hepatitis C [ 30 ], diabetes [ 31 ], hypertension [ 32 ] and, most recently, emergency obstetric care [ 33 ]. The latter introduced the clinical cascade model, which highlights the fact that multiple resources are required sequentially or simultaneously in order to provide real-time patient care [ 33 ].…”

“…The cascade approach has subsequently been applied to other areas of public health, including PMTCT [ 29 ], hepatitis C [ 30 ], diabetes [ 31 ], hypertension [ 32 ] and, most recently, emergency obstetric care [ 33 ]. The latter introduced the clinical cascade model, which highlights the fact that multiple resources are required sequentially or simultaneously in order to provide real-time patient care [ 33 ]. For example, a provider can effectively treat a sick neonate requiring immediate care only when all resources needed to identify and treat the underlying condition are simultaneously present in the facility.…”

“…For example, a provider can effectively treat a sick neonate requiring immediate care only when all resources needed to identify and treat the underlying condition are simultaneously present in the facility. In the obstetric cascade study, Cranmer and colleagues assessed 44 primary care facilities in Kakamega County, Kenya and found that 39–100% had the resources required for identification, 7–57% had resources for treatment, and 0–2% had resources to monitor or modify treatment across five common maternal emergencies [ 33 ].…”

“…Informed by Potter and Brough’s capacity pyramid and based on the obstetric emergency cascade [ 24 , 33 ], we aimed i) to develop clinical cascades to evaluate facility readiness to care for small, sick neonates and ii) to utilize these to assess 23 health facilities in Kenya and Uganda.…”

What the percentage of births in facilities does not measure: readiness for emergency obstetric care and referral in Senegal

“…Previous studies have highlighted low readiness to provide childbirth care in health facilities in sub-Saharan Africa, due to low provider skill and suboptimal equipment and supplies 13–21. Evidence on referral systems for transferring patients with complications between facilities in low-income countries is limited22 but indicates that these are often not functional or non-existent, with lack of communication and transport means, and poor road infrastructure 23–25.…”