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

• Type of Material: Article
• Authors: Bridget Whaley, Emory University; Elizabeth Butrick, University of California San Francisco; Jessica Sales, Emory University; Anthony Wanyoro, Kenyatta University; Peter Waiswa, Makerere University; Dilys Walker, University of California San Francisco; John Cranmer, Emory University
• Language: English
• Date: 2022-04-01
• Publisher: BMJ PUBLISHING GROUP
• Publication Version: Final Published Version
• Copyright Statement: © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1136/bmjopen-2021-057954
• Title of Journal or Parent Work: BMJ OPEN
• Volume: 12
• Issue: 4
• Start Page: e057954
• End Page: e057954
• Grant/Funding Information: This work was supported, in whole or in part, by the Bill & Melinda Gates Foundation (Grant # OPP1107312). Bill & Melinda Gates Foundation funded primary data collection and article processing charges. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission. Emory University Rollins School of Public Health’s Global Field Experience Financial Award funded effort for the literature review.
• Keywords: COUNTRIES; INDICATORS; CARE; Medicine, General & Internal; General & Internal Medicine; Science & Technology; Life Sciences & Biomedicine; AVAILABILITY
• Research Categories: Health Sciences, Obstetrics and Gynecology; Health Sciences, Public Health

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.