About this item:

58 Views | 35 Downloads

Author Notes:

Bridget Whaley, Email: whaley.bridget@gmail.com

All authors listed are responsible for this study and have participated in the concept and design, analysis, and interpretation of data, and drafting and revising of the manuscript. DW, EB, AW and PW conceptualised, secured funding and oversaw data collection for the parent study. BW and JNC conceptualised the nested analysis. BW analysed the data and wrote the first draft of the submitted manuscript, with assistance from JNC and JMS. All authors provided feedback and commented on the manuscript. BW is responsible for the overall content as the guarantor.

We thank Damien Scogin for his graphic design and Cecilia Roach for her copy-editing contributions. We appreciate all the facility healthcare workers, leadership and administration who made this work possible. We thank all members of the Preterm Birth Initiative Kenya and Uganda Implementation Research Collaborative, particularly the data teams who helped strengthen and collect data from facility maternity registers for the parent PTBi study. We are grateful to the facility clinicians and study participants for their valuable contribution to the parent PTBi study and by extension this nested analysis. Furthermore, we thank the research teams at UCSF, Makerere University, Kenya Medical Research Institute and Emory University for their hard work, collaboration and ongoing commitment to maternal survival.

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.


Research Funding:

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.


  • Science & Technology
  • Life Sciences & Biomedicine
  • Medicine, General & Internal
  • General & Internal Medicine
  • CARE

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

Journal Title:



Volume 12, Number 4


, Pages e057954-e057954

Type of Work:

Article | Final Publisher PDF


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.

Copyright information:

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

This is an Open Access work distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/rdf).
Export to EndNote