School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa.
Department of Primary and Interdisciplinary Care, Centre for General Practice, University of Antwerp, Antwerp, Belgium.
PLoS One. 2021 May 25;16(5):e0252182. doi: 10.1371/journal.pone.0252182. eCollection 2021.
The continuum of care is a recommended framework for comprehensive health service delivery for maternal health, and it integrates health system and social determinants of health. There is a current lack of knowledge on a measurement approach to monitor performance on the framework. In this study we aim to develop and test a composite index for assessing the maternal health continuum in a province in South Africa with the possibility of nationwide use.
The composite index was computed as a geometric mean of four dimensions of adequacy of the continuum of care. Data was sourced from the district health information system, household surveys and the census. The index formula was tested for robustness when alternative inputs for indicators and standardization methods were used. The index was used to assess performance in service delivery in the North West province of South Africa, as well as its four districts over a five-year period (2013-2017). The index was validated by assessing associations with maternal health and other outcomes. And factor analysis was used to assess the statistical dimensions of the index.
The provincial level index score increased from 62.3 in 2013 to 74 in 2017, showing general improvement in service delivery over time. The district level scores also improved over time, and our analysis identified areas for performance improvement. These include social determinants of health in some districts, and access and linkages to care in others. The provincial index was correlated with institutional maternal mortality rates (rs = -0.90, 90% CI = (-1.00, -0.25)) and the Human Development Index (r = 0.97, 95% CI = (0.63, 0.99). It was robust to alternative approaches including z-score standardization of indicators. Factor analysis showed three groupings of indicators for the health system and social determinants of health.
This study demonstrated the development and testing of a composite index to monitor and assess service delivery on the continuum of care for maternal health. The index was shown to be robust and valid, and identified potential areas for service improvement. A contextualised version can be tested in other settings within and outside of South Africa.
关怀连续体是一个被推荐的框架，用于全面提供妇幼保健健康服务，并整合了卫生系统和健康的社会决定因素。目前，我们对监测该框架绩效的衡量方法知之甚少。在这项研究中，我们旨在开发和测试一种综合指数，以评估南非一个省份的妇幼保健关怀连续体，该指数有可能在全国范围内使用。
综合指数是通过关怀连续体的四个维度的充足性的几何平均值计算得出的。数据来自地区卫生信息系统、家庭调查和人口普查。当使用替代指标输入和标准化方法时，我们测试了指数公式的稳健性。该指数用于评估南非西北省在五年期间（2013-2017 年）的服务提供情况，并评估了其四个地区的表现。该指数通过评估与母婴健康和其他结果的关联进行验证。因子分析用于评估指数的统计维度。
省级指数得分从 2013 年的 62.3 增加到 2017 年的 74，表明服务提供总体上随时间有所改善。地区级分数也随时间而提高，我们的分析确定了需要改进的领域。这些领域包括一些地区的健康的社会决定因素，以及其他地区的获得和连接护理。省级指数与机构孕产妇死亡率（rs = -0.90，90%置信区间（-1.00，-0.25））和人类发展指数（r = 0.97，95%置信区间（0.63，0.99））呈负相关。该指数对替代方法具有稳健性，包括指标的 z 分数标准化。因子分析显示了卫生系统和健康的社会决定因素的三个指标分组。
本研究展示了一种综合指数的开发和测试，用于监测和评估妇幼保健关怀连续体的服务提供情况。该指数被证明是稳健和有效的，并确定了潜在的服务改进领域。可以在南非内外的其他环境中测试一个本地化版本。
