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

Bridget Whaley; Elizabeth Butrick; Jessica M Sales; Anthony Wanyoro; Peter Waiswa; Dilys Walker; John N Cranmer

doi:10.1136/bmjopen-2021-057954

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

BMJ Open. 2022 Apr 4;12(4):e057954. doi: 10.1136/bmjopen-2021-057954.

Authors

Bridget Whaley¹, Elizabeth Butrick², Jessica M Sales³, Anthony Wanyoro⁴, Peter Waiswa⁵, Dilys Walker^{2

6}, John N Cranmer⁷

Affiliations

¹ Behavioral, Social and Health Education Sciences, Emory University, Atlanta, Georgia, USA whaley.bridget@gmail.com.
² Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA.
³ Behavioral, Social and Health Education Sciences, Emory University, Atlanta, Georgia, USA.
⁴ Department of Obstetrics and Gynecology, Kenyatta University, Nairobi, Kenya.
⁵ School of Public Health, Makerere University, Kampala, Uganda.
⁶ Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, USA.
⁷ Woodruff Health Sciences Center, Emory University, Atlanta, Georgia, USA.

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.

Keywords: international health services; maternal medicine; obstetrics; quality in health care.

Publication types

Clinical Study

MeSH terms

Cross-Sectional Studies
Female
Health Facilities
Humans
Infant, Newborn
Kenya
Pregnancy
Premature Birth*
Uganda

Associated data

ClinicalTrials.gov/NCT03112018