Using Clinical Cascades to Measure Hospitals’ Neonatal Emergency Readiness Across the Continuum of Care: Cross-Sectional Data from Amhara, Ethiopia Restricted; Files Only

Abstract

Background: Globally, 2.4 million children died in the first month of life in 2019. Essential evidence-based interventions to assess facility-level’s capacity and readiness to provide care are limited in low-to-middle-income countries (LMIC). This study is designed to measure the physical readiness of hospitals to identify, treat, and monitor-modify the treatment for neonatal emergencies that drive the majority of newborn deaths.

Methods: We utilized the clinical cascade model to estimate emergency readiness for 6 common neonatal conditions of 20 government hospitals in Amhara, Ethiopia. Data collectors recorded resource availability and facility characteristics from June-July 2021 using mobile tablets through Kobo Toolbox. Using the cascades model, we reported the percent of facilities with the physical resources to identify, treat and monitor-modify therapy. In addition, we measured the pooled mean readiness across all six emergencies and three stages of clinical care. Furthermore, we measured the percent of readiness loss by individual emergency and across all emergencies.

Results: Across all three stages of care and the six neonatal cascades, there was a consistent overall mean readiness loss of 31% which varied little (SD: 2.0). Facilities were most ready to manage essential newborn care and neonatal resuscitation with 15% readiness, respectively, and least ready to manage infections-convulsions with 0% readiness. Among the 6 neonatal conditions, the largest mean readiness loss was in the monitor-modify treatment stage. There is variability in how loss occurred across the three stages (SD= 25).

Conclusions: The cascade approach provides a stepwise and emergency-specific readiness estimate that identifies where facility readiness to manage neonatal emergencies. We found a consistent overall pattern of 31% pooled mean readiness loss across 6 cascades and three stages of care. The loss pattern identified by the cascade model may inform future strategies related system-level strategies for closing the gap for emergency resources at hospitals.

Table of Contents

CHAPTER I : INTRODUCTION ................................................................................................................. 1

Background/Introduction .......................................................................................................................... 1

Research Question .................................................................................................................................... 6

Significance Statement .............................................................................................................................. 6

CHAPTER II : LITERATURE REVIEW .................................................................................................... 7

Maternal and Neonatal Mortality .............................................................................................................. 7

Ethiopia’s Maternal and Neonatal Mortality ............................................................................................ 8

Signal Functions........................................................................................................................................ 9

Facility Readiness and Signal Functions, SARA, and SRI to Manage Emergencies for Mothers and Neonates .................................................................................................................................................. 10

Clinical cascade development ................................................................................................................. 11

Clinical Cascades model for health facilities .......................................................................................... 12

Clinical cascades model for maternal and neonates ................................................................................ 13

Relationship between Emergency Readiness for Mothers & Neonates .................................................. 13

Summary ................................................................................................................................................. 14

CHAPTER III : MANUSCRIPT ................................................................................................................ 16

TITLE PAGE .......................................................................................................................................... 17

ABSTRACT ............................................................................................................................................ 18

INTRODUCTION .................................................................................................................................. 19

METHODS ............................................................................................................................................. 23

Study Design ....................................................................................................................................... 23

Study Population ................................................................................................................................. 23

Variable definition .............................................................................................................................. 25

Data Analysis ...................................................................................................................................... 25

Ethics................................................................................................................................................... 27

RESULTS ................................................................................................................................................... 28

Facility Characteristics ............................................................................................................................ 28

Neonatal care resource availability at hospitals ...................................................................................... 29

Indicator measures and clinical cascade readiness estimates .................................................................. 30

Overall readiness (pooled mean readiness) ........................................................................................ 30

Readiness by overall identification capacity (stage one) .................................................................... 31

Readiness by emergency for stage two (treatment) ............................................................................. 31

Readiness by emergency for stage three (monitor-modify) ................................................................. 31

Readiness Loss Estimates by Emergency Cascade ................................................................................. 32

Readiness Loss Estimates by Stage ........................................................................................................ 32

DISCUSSION ......................................................................................................................................... 34

SUPPLEMENTARY DOCUMENTS..................................................................................................... 41

CHAPTER IV : PUBLIC HEALTH IMPLICATIONS .............................................................................. 67

REFERENCES ........................................................................................................................................... 70

Table 1: Facility Characteristics and Delivery Volume of Hospitals ........................................... 41

Table 2: Human Resources by Health Facility Level ................................................................... 43

Table 3: Infrastructure by Hospital Level ..................................................................................... 45

Table 4: Annual Neonatal and Obstetric Care Outcomes per 1000 live births by Hospital Level 47

Table 5: Consumable Supplies by Hospital Level ....................................................................... 49

Table 6: Frequency and proportion of facilities with durable supplies for neonatal care ............ 51

Table 7 : Neonatal Medication/Drugs by Hospital Level ............................................................. 55

Table 8: Protocols and Guidelines by Hospital Level .................................................................. 57

Table 9. Neonatal care readiness for essential newborn care N=20 ............................................. 58

Table 10. Neonatal care readiness for neonatal resuscitation (N = 20 facilities) ......................... 59

Table 11. Neonatal care readiness for the respiratory distress-apnea (N = 20 facilities). ............ 60

Table 12. Neonatal care readiness for poor feeding-hypothermia clinical cascades. N=20 ......... 61

Table 13. Neonatal care readiness for infection-convulsions (N = 20 facilities).......................... 62

Table 14. Neonatal care readiness for jaundice. (N = 20 facilities) .............................................. 63

Table 15. Readiness loss (%) by clinical cascades and stage of care of all health facilities ........ 64

Table 16. Neonatal care readiness of all hospitals by clinical cascade and stage ......................... 65

Figure 1. Percent of neonatal emergency preparedness readiness loss by stage and cascade ...... 66

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Epidemiology Health Sciences, Public Health
Palavra-chave	Clinical Cascade Ethiopia Neonatal Emergency Care Readiness
Committee Chair / Thesis Advisor	Amy Webb Girard, Emory University
Committee Members	John Cranmer, Emory University

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