Introduction

Questions of how to scale up programmes known to be effective are currently high on the global health agenda . The focus is on translating evidence into policy and practice on a much larger scale in order to reach a larger number of people or a broader geographical area and to improve care . Emergency obstetric and neonatal care (EmONC) should be considered a basic quality-of-care intervention for which universal access and coverage is needed .

Yamey contends that ‘large-scale implementation is more likely if the intervention being scaled up is simple and technically sound and there is wide consensus about its value’ (p. 3) . Although EmONC programmes vary in complexity, in our experience, there are three basic building blocks that have to be attended to simultaneously: developing knowledgeable and skilled clinicians (training), allocating appropriate resources (including staff) to improve emergency services and building up a reliable referral transport system. For scaling up an EmONC programme, multiple strategies are needed. There should be an increase in the number of women and babies accessing more appropriate and better-quality emergency care as a result of: an increase in health worker skills; the reallocation of human, financial, capital and material resources ; improved health facility functionality in terms of signal functions; and improved service delivery mechanisms (e.g., emergency transport).

Interventions or innovations that are converted into a programme mostly start with a research phase where the intervention is tested in a research setting before being implemented in practice on a large scale . After the pilot, it is expected that the key features of the intervention or innovation would be replicated in the further expansion, as it is important not to lose the essential characteristics of the tested new practices . Implementation could entail the phased expansion of the intervention. The lessons learned on the way provide input for the refinement of further expansion . In the case of EmONC, a number of interventions known to be effective for different emergency conditions are combined in a programme to be rolled out as part of health systems strengthening .

This paper reflects on the current evidence and experience, and it puts forward proposals with regard to what would be needed to (a) implement an EmONC programme, (b) scale up such a programme and (c) sustain the programme. The focus is on providing clinician practitioners and service managers with a better understanding of the conditions and challenges relating to the scale-up of EmONC, of how they should act within different country- and health-facility contexts and of how they should position themselves with regard to the implementation of an EmONC programme within the broader health system’s policy of scaling up the programme.

Overview of the development and scale-up of EmONC programmes

EmONC is intricately linked to mortality and the health outcomes of women and babies . This has led to the development of structured programmes to institute and scale up care. A number of well-known EmONC and related obstetric and neonatal programmes exist that demonstrate some elements of the scale-up processes. Most of these programmes use health-care worker training as the point of departure. They are often embedded in safe-motherhood-type programmes or sector-wide approach (SWAp) initiatives . Some of the more well-known programmes are Advance in Labour and Risk Management (ALARM) , Making It Happen , Practical Obstetric Multi-Professional Training (PROMPT) and ALSO (Advanced Life Support in Obstetrics) . There are also country-specific programmes such as Nepal’s Safe Delivery Incentive Programme (SDIP) , Tanzania’s comprehensive emergency obstetric and newborn care (CmONC) scale-up programme and South Africa’s Essential Steps in the Management of Obstetric Emergencies (ESMOE) .

The ALARM programme has been delivered in more than 16 low- and middle-income countries (LMICs), and internal assessment suggests that the programme not only improves clinical care but also acts as an enabler for countries involved to engage with other key stakeholders in their region . ALARM has been tested in conjunction with audit and review and proven as a mechanism for improving maternal mortality in the QUARITE (quality of care, risk management and technology in obstetrics) trial in Senegal and Mali . The Making It Happen programme from the Liverpool School of Tropical Medicine is based on the Royal College of Obstetricians and Gynaecologists’ Life Saving Skills Programme and it is currently rolled out in 11 LMICs in Africa and Asia . ESMOE is based on this programme and it trains participants in the following 12 modules: maternal resuscitation, care of the newborn, shock and the unconscious patient, pre-eclampsia and eclampsia, obstetric haemorrhage, sepsis, assisted delivery, obstructed labour, obstetric complications, surgical skills, complications of abortion and HIV in pregnancy . ESMOE will be used as an example to demonstrate the process of scale-up.

Programmes based in high-income countries are also being implemented. Examples of these include the ALSO course, developed in the United States, which aims to improve emergency obstetric care through a standardised approach in responding to emergencies . This is similar to PROMPT, developed in the United Kingdom, where on-site training standardises responses to obstetric emergencies, with demonstrable improvement in clinical outcomes . The In Time course based at the King Edward Memorial Hospital in Perth, Western Australia, is a locally developed programme based on the PROMPT course and it is a small-scale example of scale-up in emergency obstetric training . Finally, there is the MOET course , which is aimed at training specialist obstetricians in high-, middle- and low-income countries.

From a research point of view, there is therefore sufficient evidence for the effectiveness of EmONC programmes introduced on a small scale in terms of health-care provider behaviour, service delivery and policy. The question is, however, what conditions need to be met in order to take these programmes to a large scale.

Overview of the development and scale-up of EmONC programmes

EmONC is intricately linked to mortality and the health outcomes of women and babies . This has led to the development of structured programmes to institute and scale up care. A number of well-known EmONC and related obstetric and neonatal programmes exist that demonstrate some elements of the scale-up processes. Most of these programmes use health-care worker training as the point of departure. They are often embedded in safe-motherhood-type programmes or sector-wide approach (SWAp) initiatives . Some of the more well-known programmes are Advance in Labour and Risk Management (ALARM) , Making It Happen , Practical Obstetric Multi-Professional Training (PROMPT) and ALSO (Advanced Life Support in Obstetrics) . There are also country-specific programmes such as Nepal’s Safe Delivery Incentive Programme (SDIP) , Tanzania’s comprehensive emergency obstetric and newborn care (CmONC) scale-up programme and South Africa’s Essential Steps in the Management of Obstetric Emergencies (ESMOE) .

The ALARM programme has been delivered in more than 16 low- and middle-income countries (LMICs), and internal assessment suggests that the programme not only improves clinical care but also acts as an enabler for countries involved to engage with other key stakeholders in their region . ALARM has been tested in conjunction with audit and review and proven as a mechanism for improving maternal mortality in the QUARITE (quality of care, risk management and technology in obstetrics) trial in Senegal and Mali . The Making It Happen programme from the Liverpool School of Tropical Medicine is based on the Royal College of Obstetricians and Gynaecologists’ Life Saving Skills Programme and it is currently rolled out in 11 LMICs in Africa and Asia . ESMOE is based on this programme and it trains participants in the following 12 modules: maternal resuscitation, care of the newborn, shock and the unconscious patient, pre-eclampsia and eclampsia, obstetric haemorrhage, sepsis, assisted delivery, obstructed labour, obstetric complications, surgical skills, complications of abortion and HIV in pregnancy . ESMOE will be used as an example to demonstrate the process of scale-up.

Programmes based in high-income countries are also being implemented. Examples of these include the ALSO course, developed in the United States, which aims to improve emergency obstetric care through a standardised approach in responding to emergencies . This is similar to PROMPT, developed in the United Kingdom, where on-site training standardises responses to obstetric emergencies, with demonstrable improvement in clinical outcomes . The In Time course based at the King Edward Memorial Hospital in Perth, Western Australia, is a locally developed programme based on the PROMPT course and it is a small-scale example of scale-up in emergency obstetric training . Finally, there is the MOET course , which is aimed at training specialist obstetricians in high-, middle- and low-income countries.

From a research point of view, there is therefore sufficient evidence for the effectiveness of EmONC programmes introduced on a small scale in terms of health-care provider behaviour, service delivery and policy. The question is, however, what conditions need to be met in order to take these programmes to a large scale.

Setting the implementation and scale-up agenda

The various facets of an EmONC programme cannot all be addressed at the same time, and it takes time to institutionalise a programme, especially at the grass-roots level. We use a stages-of-change framework to organise practical pointers on issues to consider at various levels of a health system when implementing EmONC as part of a scale-up drive ( Fig. 1 ; Table 1 ). The framework consists of three phases. In the pre-implementation phase, two stages are distinguished: creating awareness (after getting acquainted with a programme/intervention/innovation) and committing to implement (adopting the concept). The two stages in the implementation phase are preparation for implementation (taking ownership and mobilising resources) and initial implementation. The stages in the institutionalisation phase consist of integrating the programme/intervention/innovation into routine practice and sustaining the new practice.

A stages-of-change framework.

Table 1

Conditions in a scale-up agenda using a stages-of-change framework.

Stage	Conditions for change
Stage 1: Create awareness • of problem (e.g., high MMR) • that something must be done • of EmONC programmes that could be used	• Baseline assessment or health management information system (HMIS) leads to awareness of the problem (e.g., national, provincial/regional, district and facility) • Identify advocacy needs (e.g., addressing inequity of EmONC access ) and activist leaders • Readiness and willingness of stakeholders and health workers to change (including political will ) • Existing EmONC programmes to inform awareness and provide guidance on the way forward
Stage 2: Commit to implement and scale up an EmONC programme • National level • Provincial/regional level • District level • Facility level • Non-state sector • Community and society	• Agreement among decision makers, opinion leaders, funders and health professions to scale up EmONC • Policy support and strategic planning for scaling up EmONC from state and non-state sectors • Types of commitment and support required (e.g., human resources , financial and capital/material) • Capacity to support sustainable EmONC services at all levels • Dialogue and flow of information between health-care users, providers, and policymakers
Stage 3: Prepare to implement an EmONC programme • Practical aspects to get the services up and running	• Decision on an EmONC scale-up model (including training) • Business plans for the scale-up process and for the maintenance of quality EmONC services at all levels (including resource allocations) • Roles and responsibilities of different partners and role players • Committed leadership across levels • Assessment of preparedness of individual health-care facilities and health networks to implement EmONC and sustain practice • Accountability measures for scale-up and maintenance • Preparation and motivation of health workers at facility level for compulsory activities, including job descriptions and performance agreements
Stage 4: Implement the EmONC programme • On-site training • Provision of additional services • Further improvement of the service	• Support for appointed leaders • Training (initial and continuous refresher training) • Strengthening and expanding clinical services • Resources for continuous training • Documenting the process of EmONC implementation and scale-up at all levels • Recording of improvements as a result of EmONC implementation (e.g., commodities, service, referral, transport and morbidity and mortality improvements)
Stage 5: Integrate EmONC into routine practice • Analysis of the results • Dissemination of results • Use of findings to improve practice • Routine practice	• Regular feedback and response to the changes, outcomes and impact resulting from EmONC across all levels • Regular assessment of and accountability for the quality of EmONC-related data at all levels • Continued commitment and ownership by all role players and support for EmONC leaders • Continued refresher training and regular emergency drills • Support for essential resources integrated into the health system functioning
Stage 6: Sustain EmONC • Data collection • Analysis of the results • Dissemination of results • Use of findings • Sustained over a longer period of time	• Long-term and sustained monitoring, evaluation and feedback on scale-up and provision of EmONC services at all levels • Institutional culture promoting facility- and health-worker ownership of EmONC • Continued support for induction of new staff members into EmONC • Sustained reduction of adverse events and improvement of maternal and perinatal morbidity and mortality, signal functions and service provision at all levels

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