Using Clinical Cascades to Measure Facilities’ Obstetric Emergency Readiness: An Analysis of Facility Assessments in Migori County, Kenya and Busoga Region, Uganda Open Access

Abstract

Background: Globally, hundreds of women die each day from preventable causes related to pregnancy and childbirth. Nearly 75% of all maternal deaths are attributable to severe bleeding, infections, high blood pressure, delivery complications, and unsafe abortions. Most deaths can be avoided if deliveries are attended to by skilled professionals who have emergency management skills and strategic emergency supplies. High rates of avoidable deaths persist, especially in Sub-Saharan Africa, despite existing facility readiness estimation and intervention strategies. Therefore, facilities and health systems may benefit from more detailed analysis of emergency readiness than is currently available. This study was designed to: (1) compare estimates of facility readiness to manage common obstetric emergencies using clinical cascades and signal functions, (2) compare the estimates between countries and levels of care in Kenya and Uganda, and (3) test the cascading loss of emergency obstetric resources within the two countries.

 

Methods: Data from all 23 facility in the Preterm Birth Initiative (PTBi) study were used to create signal function and clinical cascade emergency readiness estimates. Facility data were collected in 2016 from Migori County, Kenya and Busoga Region, Uganda. The cascades measure the proportion of facilities with the resources to identify the emergency (stage 1), treat it (stage 2), and monitor-modify therapy based on clinical response (stage 3). Emergency readiness at the treatment stage was used to evaluate the performance against the signal functions.

 

Results: Four critical findings emerged from readiness estimates with the cascades. First, the signal functions overestimated practical emergency readiness by 22.61% across the five emergencies. Second, based on both clinical cascade and signal function estimates, not all comprehensive emergency obstetric care facilities were ready to perform basic emergency obstetric care, with an estimated readiness of 58.00% and 80.00%, respectively, across the five emergencies. Third, across all five clinical cascade emergencies, there was a consistent pattern of readiness loss. Less than half (46.96%) of facilities had all the resources necessary to identify and treat the leading causes of maternal death. Fourth, across the three stages of care, there was a consistent pattern of 28.41% readiness loss for all emergencies. Most readiness was lost in the treatment stage (mean of 33.91%); however, this varied by emergency.

 

Conclusions: These findings support growing consensus on the need to revise standard measures of obstetric emergency readiness. In contrast to the signal functions, the clinical cascades presents a step-wise, emergency-specific estimate of readiness. This novel approach offers a more nuanced picture of facility readiness that can inform facility or health system-level policy or programs. Since accurate measurement of emergency readiness is a prerequisite for strengthening a facility’s capacity to manage emergencies, the cascades may provide a more quantifiable, relevant, and actionable assessment that is specific to each emergency. Future testing in varied geographic and health facility level settings is warranted.

Table of Contents

TABLE OF CONTENTS

CHAPTER 1: INTRODUCTION

Introduction and Rationale

Problem Statement

Theoretical Frameworks

Purpose Statement

Research Questions

Significance Statement

Definition of Terms

CHAPTER 2: LITERATURE REVIEW

Maternal Mortality in Kenya and Uganda

Emergency Obstetric Care

Measuring Emergency Obstetric Care

Emergency Obstetric Care in Kenya and Uganda

Summary

CHAPTER 3: STUDENT CONTRIBUTION

Research Question Development

Primary Data Collection

Data Acquisition

Data Analysis

Write-Up

CHAPTER 4: MANUSCRIPT

TITLE PAGE

ABSTRACT

BACKGROUND

METHODS

RESULTS

DISCUSSION

CONCLUSIONS

ONLINE SUPPLEMENTARY DOCUMENT

CHAPTER 5: PUBLIC HEALTH IMPLICATIONS

REFERENCES

 

Figure 1. Signal Function versus Clinical Cascade Estimates of Emergency Readiness

Figure 2. Mean Readiness Loss along the Clinical Cascade of Care

Figure 3. Hemorrhage Clinical Cascade

Figure 4. Retained Placenta Clinical Cascade

Figure 5. Emergency Readiness Estimates by Emergency Cascade and Stage

 

Table 1. Cascade Emergency Readiness Stratified by Medical Signal Function

Table 2. Cascade Emergency Readiness Stratified by Manual Signal Function

Table 3. Comparison of Emergency Readiness Using Clinical Cascades and Signal Functions, Full Sample ⁽¹⁾

Table 4. Comparison of Emergency Readiness Using Clinical Cascades and Signal Functions, Facilities with Reported C-Section Capability ⁽¹⁾

Table 5. Comparison of Emergency Readiness Using Clinical Cascades and Signal Functions, Facilities with No Reported C-Section Capability ⁽¹⁾

Table 6. Mean Readiness Loss by Cascade and Stage among All Facilities (1)

Figure S 1. Sepsis Clinical Cascade

Figure S 2. Hypertensive Emergency Clinical Cascade

Figure S 3. Incomplete Abortion Clinical Cascade

Table S 1. Facility Demographics

Table S 2. Annual Delivery Volume

Table S 3. Consumable Supplies at Facilities

Table S 4. Durable Goods at Facilities

Table S 5.Drugs at Facilities

Table S 6. Guidelines and Protocols at Facilities

Table S 7. Comparison of Emergency Readiness Using Clinical Cascades and Signal Functions, Kenyan Facilities ⁽¹⁾

Table S 8. Comparison of Emergency Readiness Using Clinical Cascades and Signal Functions, Ugandan Facilities ⁽¹⁾

Table S 9. Mean Readiness Loss by Cascade and Stage among Government Facilities ⁽¹⁾

Table S 10. Mean Readiness Loss by Cascade and Stage among Mission Facilities ⁽¹⁾

Table S 11. Mean Readiness Loss by Cascade and Stage among Referral Facilities ^{(1, 2)}

Table S 12. Mean Readiness Loss by Cascade and Stage among Kenyan Government Facilities (1)

Table S 13. Mean Readiness Loss by Cascade and Stage among Ugandan Government Facilities ⁽¹⁾

Table S 14. Mean Readiness Loss by Cascade and Stage among Facilities with Reported C-Section Capability ⁽¹⁾

Table S 15. Mean Readiness Loss by Cascade and Stage among Facilities without Reported C-Section Capability ⁽¹⁾

Table S 16. Clinical Cascade Readiness Estimates Tests of Significance

About this Master's Thesis

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School	Rollins School of Public Health
Department	Behavioral Sciences and Health Education
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Obstetrics and Gynecology
Keyword	Uganda Signal Functions Emergency Obstetric Care Clinical Cascades Maternal Mortality Kenya
Committee Chair / Thesis Advisor	Sales, Jessica, Emory University
Committee Members	Cranmer, John, Emory University

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