Facility characteristics.

Measuring facility readiness to manage basic obstetric emergencies is a critical step toward reducing persistently elevated maternal mortality ratios (MMR). Currently, the Signal Functions (SF) is the gold standard for measuring facility readiness globally and endorsed by the World Health Organization. The presence of tracer items classifies facilities’ readiness to manage basic emergencies. However, research suggests the SF may be an incomplete indicator. The Clinical Cascades (CC) have emerged as a clinically-oriented alternative to measuring readiness. The purpose of this study is to determine Amhara’s clinical readiness and quantify the relationship between SF and CC estimates of readiness. Data were collected in May 2021via Open Data Kit (ODK) and KoBo Toolbox. We surveyed 20 hospitals across three levels of the health system. Commodities were used to create measures of SF-readiness (e.g., % tracers) and CC-readiness. We calculated differences in SF and CC estimates and calculated readiness loss across six emergencies and 3 stages of care in the cascades. The overall SF estimate for all six obstetric emergencies was 29.6% greater than the estimates using the CC. Consistent with global patterns, hospitals were more prepared to provide medical management (70.0% ready) compared to manual procedures (56.7% ready). The SF overestimate was greater for manual procedures 33.8% overall for retained placenta and incomplete abortion) and less for medical treatments (25.3%). Hospitals were least prepared to manage retained placentas (30.0% of facilities were ready at treatment and 0.0% were ready at monitor and modify) and most prepared to manage hypertensive emergencies (85.0% of facilities were ready at the treatment stage). When including protocols in the analysis, no facilities were ready to monitor and modify the initial therapy when clinically indicated for 3 common emergencies—sepsis, post-partum hemorrhage and retained placentas. We identified a significant discrepancy between SF and CC readiness classifications. Those facilities that fall within this discrepancy are unprepared to manage common obstetric emergencies, and employees in supply management may have difficulty identify the need. Future research should explore the possibility of modifying the SF or replacing it with a new readiness measurement.

评估医疗机构应对基本产科急症的能力，是持续降低居高不下的孕产妇死亡率（Maternal Mortality Ratio，MMR）的关键举措。目前，信号功能（Signal Functions，SF）是全球范围内评估医疗机构服务准备情况的金标准，且得到了世界卫生组织的认可。通过核查标识性物品的配备情况，可对医疗机构应对基本急症的能力进行分级评定。然而，相关研究表明，SF或许并非完善的评估指标。临床级联（Clinical Cascades，CC）作为一种以临床为导向的替代评估方案，逐渐被应用于服务准备情况的测评。本研究旨在评估阿姆哈拉地区的临床服务准备情况，并量化SF与CC两种评估方式下的服务准备情况评估结果之间的相关性。研究数据于2021年5月通过开放数据工具包（Open Data Kit，ODK）与KoBo工具箱采集完成。我们对卫生系统三个层级的20家医院开展了调研。基于医疗物资配备情况，我们构建了SF服务准备情况（如标识性物品占比）与CC服务准备情况的评估指标。我们计算了SF与CC评估结果的差值，并针对6种产科急症及临床级联中的3个照护阶段，测算出了服务准备度的缺失程度。针对全部6种产科急症，SF的整体评估得分较CC评估结果高出29.6%。与全球整体趋势一致，相较于徒手操作（准备度为56.7%），医疗机构对药物治疗的准备度更高（准备度为70.0%）。针对徒手操作，SF的高估情况更为显著（如针对胎盘滞留与不全流产的高估幅度达33.8%），而针对药物治疗的高估幅度则相对较低（25.3%）。医疗机构对胎盘滞留的应对准备度最低（仅30.0%的机构可开展治疗环节的准备，0.0%的机构可完成监测与调整环节的准备），而对高血压急症的应对准备度最高（85.0%的机构可完成治疗环节的准备）。若将诊疗方案纳入分析范畴，则针对3种常见产科急症——脓毒症、产后出血与胎盘滞留，没有任何一家医疗机构能够在临床指征明确时完成初始治疗的监测与调整工作。本研究发现SF与CC两种评估方式的服务准备度分级结果存在显著差异。存在此类评估差异的医疗机构，均无法有效应对常见产科急症，且物资管理部门的工作人员可能难以识别相关需求。未来的研究可探索优化SF评估方案，或是采用全新的服务准备情况评估工具替代SF的可行性。