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

• Type of Material: Article
• Authors: John Cranmer, Emory University; Julia Dettinger, University of Washington; Kimberly Calkins, University of Washington; Minnie Kibore, University of Nairobi; Onesmus Gachuno, University of Nairobi; Dilys Walkers, University of California San Francisco
• Language: English
• Date: 2018-02-23
• Publisher: Public Library of Science
• Publication Version: Final Published Version
• Copyright Statement: © 2018 Cranmer et al
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1371/journal.pone.0184252
• Title of Journal or Parent Work: PLoS ONE
• ISSN: 1932-6203
• Volume: 13
• Issue: 2
• Start Page: e0184252
• End Page: e0184252
• Grant/Funding Information: The MicroNutrient Initiative funded the research activities of the Linda Mama study with a grant from the Canadian International Development Agency (http://www.micronutrient.org).; A portion of the JNC’s research activities were sponsored by Fogarty International Center of NIMH & NIH office of the director (#R25 TW009345) in a grant to the Northern Pacific Global Health Research Fellows Training Consortium (https://www.fic.nih.gov/Pages/Default.aspx and http://fogartyfellows.org).; The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.; MI-Kenya staff participated in the program implementation design and data collection plan.
• Keywords: QUALITY-OF-CARE; CHILD-MORTALITY; NEWBORN HEALTH; NEONATAL DEATHS; SAFE MOTHERHOOD; Multidisciplinary Sciences; MATERNAL MORTALITY; Science & Technology - Other Topics; Science & Technology; INDICATORS; NATIONAL CAUSES; HIV CARE; SYSTEMATIC ANALYSIS
• Research Categories: Health Sciences, Obstetrics and Gynecology; Health Sciences, General; Health Sciences, Public Health

Abstract

BACKGROUND: Globally, 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-METHOD: We 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. FINDINGS: Although 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%. SIGNIFICANCE: Comparing 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.