Maternal mortality remains a significant public health concern (1). The World Health Organization (WHO) reported in 2017, that 810 women died every day from preventable causes related to their pregnancy and or delivery (1). One’s country of residence is a profound determinant of maternal mortality. 94.0% of all global maternal deaths occur in low-middle income countries (LMICs) (2). Further, two-thirds of the global maternal mortality burden is borne by Sub-Saharan Africa (SSA) (1). Ethiopia bears the fourth largest total number of maternal deaths in the world, with 14,000 annually (1, 2).
Furthermore, the region of Amhara consistently reports worse maternal outcomes and obstetric readiness compared to the country average (3, 4). In a recent cross-sectional study, the authors found that 29.4% of mothers from Amhara had facility births, which is lower than the national rate of facility births of 38.9% (5). Additionally, the 2018 Service Availability and Readiness Assessment found that Amhara was less prepared to administer parenteral antibiotics (44.0%), administer oxytocic drugs (47.0%), and performed assisted vaginal delivery (50.0%) when compared to Ethiopia as a whole (49.0%, 50.0%, 52.0% respectively) (6). This is significant, because those clinical skills are crucial for combatting the most common causes of maternal mortality.
Obstetric Emergency Readiness
To have a profound impact on maternal outcomes Ministries of Health (MOH) can use specific and effective tools that are capable of accurately measuring a facility’s clinical readiness to manage an obstetric emergency. This would provide the MOH the ability to track the availability of adequate obstetric care. When the functional capacity of a facility is known, along with its weaknesses, interventions can be deployed to improve them. This will in turn increase the caliber of care being delivered and decrease maternal mortality. Obstetric emergency readiness at the facility level is defined as the “proportion of specified clinical items that are present at a facility on the day a facility inventory is conducted” (7). This readiness can be evaluated as a whole or researchers can look at readiness to manage individual obstetric emergencies. Both the SF tracer items and CC categorize the six most common obstetric emergencies into two different types of emergencies. The two categories are medical readiness and manual readiness. Medical readiness included the ability to manage sepsis/infection, manage hemorrhage, and manage hypertensive emergencies. These conditions are defined as medical because they require some form of medication administration to treat the condition. The second category, manual readiness, includes the ability to manage retained placentas, incomplete abortions, and prolonged labor. These conditions are defined as manual because their treatment requires some form of a manual action to treat the emergency.
Signal Functions (Sf) For Obstetric Emergency Readiness
The Signal Function (SF) tool was created to provide succinct indicators of a facility’s readiness to provide Basic Emergency Obstetric Care (BEmOC). It consists of three medical and three manual procedures that cover the care necessary to handle the six most common causes of maternal mortality (7, 8). The most common global obstetric emergencies are hemorrhage (27.1%), infections or sepsis (10.7%), pre-eclampsia and eclampsia (14.0%), incomplete abortion or ectopic pregnancy (7.9%), delivery complications and retained placenta (9.6%) (9). To objectively measure facility readiness for emergencies, specific items, also known as tracers, are used as proxies for measuring the individual SF in the World Health Organization’s (WHO) Service Readiness Index methodology (SRI) (10). These tracer items are the core resources most essential for managing the emergency. The medical tracer items include three parenteral drugs (uterotonic, antibiotic, and anticonvulsant), three intravenous items (IV solution, and a 2-part IV infusion kit (tubing and needle or cannula), a manual vacuum apparatus (MVA), and two multi-purpose items (gloves and a light source) (7). The SRI application of the SF uses these tracer items to create an overall emergency readiness indicator for facilities, countries or regions based on the overall percent of these items present at a facility on the day of assessment (6). Table 1 maps the SF tracer items to the emergency it is required to treat.
Table 1
Tracer items and their corresponding obstetric emergencies
Tracer Item | Obstetric Emergency |
IV Solution | 1, 2, 3, 4, 5, 6 |
2-Part IV Kit (tubing, needle/cannula) | 1, 2, 3, 4, 5, 6 |
Parenteral Antibiotic | 1, 4, 5, 6 |
Light Source | 4, 5, 6 |
Parenteral Uterotonic | 2, 4 |
Manual Vacuum Aspiration Kit | 5, 6 |
Parenteral Anticonvulsant | 3 |
Gloves | 2 |
Obstetric Emergencies: (1) Sepsis-Infection, (2) Hemorrhage, (3) Hypertensive Emergency, (4) Retained Placenta, (5) Incomplete Abortion, (6) Prolonged Labor |
The SF approach to measuring tracer items has emerged as the dominant approach for measuring basic emergency readiness at facilities around the world. This SF-based method is still the method recommended by WHO (7). However, in recent years, researchers have called for improvements in the SF tracers or alternative methods for assessing BEmOC globally (7, 11-17). First, the SF tracer item indicators have not yet been used to predict labor-related outcomes or a facility’s practical readiness to identify and treat specific obstetric emergencies since the SRI readiness indicator is a pooled percent readiness for all six emergencies (11, 17). Additionally, some studies have measured facility readiness using the SF tracers and other readiness tools and determined that a facility estimate of emergency readiness based only on a tracer items consistently overestimates practical readiness (7, 10, 14). If the SRI-signal function estimates of facility readiness do overestimate a facility’s practical readiness, it may make actual gaps in a facility or region’s emergency readiness seem smaller than they actually are.
Clinical Cascade For Obstetric Emergency Readiness
The Clinical Cascade for obstetric emergencies is an emerging set of readiness indicators designed in response to apparent overestimates of emergency readiness from the commonly used SRI-signal function tracer-based indicators (6). The Clinical Cascade is a “clinically-oriented approach to measuring facility readiness” that measures the “step-wise cascading relationship between emergency resources [loss]” (10). As with the SF tracer item and SRI readiness estimates, the Clinical Cascade uses an obstetric commodity inventory to estimate readiness. All SF tracer items are included in the cascade model. However, the cascades add a few additional durable goods, medications, and supplies that are critical to clinically manage each of the six common basic obstetric emergencies.
A unique feature of the Clinical Cascade is its attempt to measure the potential for providing quality care using commodities related to monitoring the initial treatment’s efficacy and then adjusting-escalating treatment as indicated by the patient’s initial response to therapy. To accomplish this, the Clinical Cascade reports the presence of resources, drugs and emergency protocols required to adjust therapy if the patient does not successfully respond to initial treatment. For example, for a facility to be classified as ready to monitor and modify care for maternal hemorrhage, the facility would need a sphygmomanometer, stethoscope, uterotonic, urinary catheter, oxygen, and a hemorrhage protocol. While the presence of protocols and resources for escalating treatment does not guarantee the level of clinician skill, and the absence of protocols does not guarantee a lack of clinician ability, measuring these resources for monitoring-modifying therapy provides a commodity-based, readily measurable approach to estimating the quality of obstetric emergency care.
Clinical Logic for the Clinical Cascades
The Clinical Cascade categorizes EmOC readiness into three phases, identification of the emergency, treatment of the emergency, and monitoring and modification of treatment as clinically necessary (7). Within this measurement, there is also a scale to determine readiness for each of the six most common obstetric emergencies individually. For a facility to be deemed ready to manage an obstetric emergency it must have all the necessary supplies to identify, treat and monitor the specific obstetric emergency. The purpose of this study is to quantify facility readiness for BEmOC obstetric emergencies in Amhara, Ethiopia as measured by the SF tracer items and Clinical Cascades.