Development and testing of a composite index to monitor the continuum of maternal health service delivery at provincial and district level in South Africa

Abstract

Introduction The continuum of care is a recommended framework for comprehensive health service delivery for maternal health, and it integrates health system and social determinants of health. There is a current lack of knowledge on a measurement approach to monitor performance on the framework. In this study we aim to develop and test a composite index for assessing the maternal health continuum in a province in South Africa with the possibility of nationwide use. Materials and methods The composite index was computed as a geometric mean of four dimensions of adequacy of the continuum of care. Data was sourced from the district health information system, household surveys and the census. The index formula was tested for robustness when alternative inputs for indicators and standardization methods were used. The index was used to assess performance in service delivery in the North West province of South Africa, as well as its four districts over a five-year period (2013–2017). The index was validated by assessing associations with maternal health and other outcomes. And factor analysis was used to assess the statistical dimensions of the index. Results The provincial level index score increased from 62.3 in 2013 to 74 in 2017, showing general improvement in service delivery over time. The district level scores also improved over time, and our analysis identified areas for performance improvement. These include social determinants of health in some districts, and access and linkages to care in others. The provincial index was correlated with institutional maternal mortality rates (rs = -0.90, 90% CI = (-1.00, -0.25)) and the Human Development Index (r = 0.97, 95% CI = (0.63, 0.99). It was robust to alternative approaches including z-score standardization of indicators. Factor analysis showed three groupings of indicators for the health system and social determinants of health. Conclusions This study demonstrated the development and testing of a composite index to monitor and assess service delivery on the continuum of care for maternal health. The index was shown to be robust and valid, and identified potential areas for service improvement. A contextualised version can be tested in other settings within and outside of South Africa.

Persistence of geographic barriers to maternal care services following a health system strengthening initiative in rural Madagascar

“…Moreover, the increasing availability of detailed geographic data is allowing the integration of more realistic measures of travel time to health facilities into assessments of geographic accessibility [28,41,42] Other studies on maternal care access use composite indices that combine into a single measure either multiple types of maternal health care (antenatal, delivery and postnatal care), or multiple factors related to geographic accessibility (e.g. travel time, transportation options, and topographical constraints) [43][44][45]. In contrast, we analyzed each maternal care indicator separately, revealing how geographic accessibility can impact them differently.…”

Maternal Service Coverage and Its Relationship To Health Information System Performance: A Linked Facility and Population-Based Survey in Ethiopia

“…Some wanted to have the composite index including maternal and child health care services and others wanted to have family planning, maternal and child health, and nutrition combined. [27][28][29] We focused on maternal care based on the concept of the continuum of care framework using essential maternal services during pregnancy, intrapartum, and postpartum periods. The calculation used 9 indicators of essential interventions, 5 for antenatal, 2 for intrapartum, and 2 for postnatal care.…”