Developing policy-ready digital dashboards of geospatial access to emergency obstetric care: a survey of policymakers and researchers in sub-Saharan Africa

Background Dashboards are increasingly being used in sub-Saharan Africa (SSA) to support health policymaking and governance. However, their use has been mostly limited to routine care, not emergency services like emergency obstetric care (EmOC). To ensure a fit-for-purpose dashboard, we conducted an online survey with policymakers and researchers to understand key considerations needed for developing a policy-ready dashboard of geospatial access to EmOC in SSA. Methods Questionnaires targeting both stakeholder groups were pre-tested and disseminated in English, French, and Portuguese across SSA. We collected data on participants’ awareness of concern areas for geographic accessibility of EmOC and existing technological resources used for planning of EmOC services, the dynamic dashboard features preferences, and the dashboard's potential to tackle lack of geographic access to EmOC. Questions were asked as multiple-choice, Likert-scale, or open-ended. Descriptive statistics were used to summarise findings using frequencies or proportions. Free-text responses were recoded into themes where applicable. Results Among the 206 participants (88 policymakers and 118 researchers), 90% reported that rural areas and 23% that urban areas in their countries were affected by issues of geographic accessibility to EmOC. Five percent of policymakers and 38% of researchers were aware of the use of maps of EmOC facilities to guide planning of EmOC facility location. Regarding dashboard design, most visual components such as location of EmOC facilities had almost universal desirability; however, there were some exceptions. Nearly 70% of policymakers considered the socio-economic status of the population and households relevant to the dashboard. The desirability for a heatmap showing travel time to care was lower among policymakers (53%) than researchers (72%). Nearly 90% of participants considered three to four data updates per year or less frequent updates adequate for the dashboard. The potential usability of a dynamic dashboard was high amongst both policymakers (60%) and researchers (82%). Conclusion This study provides key considerations for developing a policy-ready dashboard for EmOC geographical accessibility in SSA. Efforts should now be targeted at establishing robust estimation of geographical accessibility metrics, integrated with existing health system data, and developing and maintaining the dashboard with up-to-date data to maximise impact in these settings

Bohm and Einstein-Sasaki Metrics, Black Holes and Cosmological Event Horizons

We study physical applications of the Bohm metrics, which are infinite sequences of inhomogeneous Einstein metrics on spheres and products of spheres of dimension 5 <= d <= 9. We prove that all the Bohm metrics on S^3 x S^2 and S^3 x S^3 have negative eigenvalue modes of the Lichnerowicz operator and by numerical methods we establish that Bohm metrics on S^5 have negative eigenvalues too. We argue that all the Bohm metrics will have negative modes. These results imply that higher-dimensional black-hole spacetimes where the Bohm metric replaces the usual round sphere metric are classically unstable. We also show that the stability criterion for Freund-Rubin solutions is the same as for black-hole stability, and hence such solutions using Bohm metrics will also be unstable. We consider possible endpoints of the instabilities, and show that all Einstein-Sasaki manifolds give stable solutions. We show how Wick rotation of Bohm metrics gives spacetimes that provide counterexamples to a strict form of the Cosmic Baldness conjecture, but they are still consistent with the intuition behind the cosmic No-Hair conjectures. We show how the Lorentzian metrics may be created ``from nothing'' in a no-boundary setting. We argue that Lorentzian Bohm metrics are unstable to decay to de Sitter spacetime. We also argue that noncompact versions of the Bohm metrics have infinitely many negative Lichernowicz modes, and we conjecture a general relation between Lichnerowicz eigenvalues and non-uniqueness of the Dirichlet problem for Einstein's equations.Comment: 53 pages, 11 figure

On the Importance of Countergradients for the Development of Retinotopy: Insights from a Generalised Gierer Model

During the development of the topographic map from vertebrate retina to superior colliculus (SC), EphA receptors are expressed in a gradient along the nasotemporal retinal axis. Their ligands, ephrin-As, are expressed in a gradient along the rostrocaudal axis of the SC. Countergradients of ephrin-As in the retina and EphAs in the SC are also expressed. Disruption of any of these gradients leads to mapping errors. Gierer's (1981) model, which uses well-matched pairs of gradients and countergradients to establish the mapping, can account for the formation of wild type maps, but not the double maps found in EphA knock-in experiments. I show that these maps can be explained by models, such as Gierer's (1983), which have gradients and no countergradients, together with a powerful compensatory mechanism that helps to distribute connections evenly over the target region. However, this type of model cannot explain mapping errors found when the countergradients are knocked out partially. I examine the relative importance of countergradients as against compensatory mechanisms by generalising Gierer's (1983) model so that the strength of compensation is adjustable. Either matching gradients and countergradients alone or poorly matching gradients and countergradients together with a strong compensatory mechanism are sufficient to establish an ordered mapping. With a weaker compensatory mechanism, gradients without countergradients lead to a poorer map, but the addition of countergradients improves the mapping. This model produces the double maps in simulated EphA knock-in experiments and a map consistent with the Math5 knock-out phenotype. Simulations of a set of phenotypes from the literature substantiate the finding that countergradients and compensation can be traded off against each other to give similar maps. I conclude that a successful model of retinotopy should contain countergradients and some form of compensation mechanism, but not in the strong form put forward by Gierer

A geospatial database of close-to-reality travel times to obstetric emergency care in 15 Nigerian conurbations

Travel time estimation accounting for on-the-ground realities between the location where a need for emergency obstetric care (EmOC) arises and the health facility capable of providing EmOC is essential for improving pregnancy outcomes. Current understanding of travel time to care is inadequate in many urban areas of Africa, where short distances obscure long travel times and travel times can vary by time of day and road conditions. Here, we describe a database of travel times to comprehensive EmOC facilities in the 15 most populated extended urban areas of Nigeria. The travel times from cells of approximately 0.6 × 0.6 km to facilities were derived from Google Maps Platform’s internal Directions Application Programming Interface, which incorporates traffic considerations to provide closer-to-reality travel time estimates. Computations were done to the first, second and third nearest public or private facilities. Travel time for eight traffic scenarios (including peak and non-peak periods) and number of facilities within specific time thresholds were estimated. The database offers a plethora of opportunities for research and planning towards improving EmOC accessibility

Developing policy-ready digital dashboards of geospatial access to emergency obstetric care: a survey of policymakers and researchers in sub-Saharan Africa

Background Dashboards are increasingly being used in sub-Saharan Africa (SSA) to support health policymaking and governance. However, their use has been mostly limited to routine care, not emergency services like emergency obstetric care (EmOC). To ensure a fit-for-purpose dashboard, we conducted an online survey with policymakers and researchers to understand key considerations needed for developing a policy-ready dashboard of geospatial access to EmOC in SSA. Methods Questionnaires targeting both stakeholder groups were pre-tested and disseminated in English, French, and Portuguese across SSA. We collected data on participants’ awareness of concern areas for geographic accessibility of EmOC and existing technological resources used for planning of EmOC services, the dynamic dashboard features preferences, and the dashboard's potential to tackle lack of geographic access to EmOC. Questions were asked as multiple-choice, Likert-scale, or open-ended. Descriptive statistics were used to summarise findings using frequencies or proportions. Free-text responses were recoded into themes where applicable. Results Among the 206 participants (88 policymakers and 118 researchers), 90% reported that rural areas and 23% that urban areas in their countries were affected by issues of geographic accessibility to EmOC. Five percent of policymakers and 38% of researchers were aware of the use of maps of EmOC facilities to guide planning of EmOC facility location. Regarding dashboard design, most visual components such as location of EmOC facilities had almost universal desirability; however, there were some exceptions. Nearly 70% of policymakers considered the socio-economic status of the population and households relevant to the dashboard. The desirability for a heatmap showing travel time to care was lower among policymakers (53%) than researchers (72%). Nearly 90% of participants considered three to four data updates per year or less frequent updates adequate for the dashboard. The potential usability of a dynamic dashboard was high amongst both policymakers (60%) and researchers (82%). Conclusion This study provides key considerations for developing a policy-ready dashboard for EmOC geographical accessibility in SSA. Efforts should now be targeted at establishing robust estimation of geographical accessibility metrics, integrated with existing health system data, and developing and maintaining the dashboard with up-to-date data to maximise impact in these settings

Application of GIS in public health practice: a consortium’s approach to tackling travel delays in obstetric emergencies in urban areas

Geographic Information System (GIS) has become an effective and reliable tool for researchers, policymakers, and decision-makers to map health outcomes and inform targeted planning, evaluation, and monitoring. With the advent of big data-enabled GIS, researchers can now identify disparities and spatial inequalities in health at more granular levels, enabling them to provide more accurate and robust services and products for healthcare. This paper aims to showcase the progress of the On Tackling In-transit Delays for Mothers in Emergency (OnTIME) project, which is a unique collaborative effort between academia, policymakers, and industrial partners. The paper demonstrates how the limitations of traditional spatial accessibility models and data gaps have been overcome by combining GIS and big data to map the geographic accessibility and coverage of health facilities capable of providing emergency obstetric care (EmOC) in conurbations in Africa. The OnTIME project employs various GIS technologies and concepts, such as big spatial data, spatial databases, and public participation geographic information systems (PPGIS). We provide an overview of these concepts in relation to the OnTIME project to demonstrate the application of GIS in public health practice

Leveraging big data for improving the estimation of close to reality travel time to obstetric emergency services in urban low- and middle-income settings.

Maternal and perinatal mortality remain huge challenges globally, particularly in low- and middle-income countries (LMICs) where >98% of these deaths occur. Emergency obstetric care (EmOC) provided by skilled health personnel is an evidence-based package of interventions effective in reducing these deaths associated with pregnancy and childbirth. Until recently, pregnant women residing in urban areas have been considered to have good access to care, including EmOC. However, emerging evidence shows that due to rapid urbanization, this so called "urban advantage" is shrinking and in some LMIC settings, it is almost non-existent. This poses a complex challenge for structuring an effective health service delivery system, which tend to have poor spatial planning especially in LMIC settings. To optimize access to EmOC and ultimately reduce preventable maternal deaths within the context of urbanization, it is imperative to accurately locate areas and population groups that are geographically marginalized. Underpinning such assessments is accurately estimating travel time to health facilities that provide EmOC. In this perspective, we discuss strengths and weaknesses of approaches commonly used to estimate travel times to EmOC in LMICs, broadly grouped as reported and modeled approaches, while contextualizing our discussion in urban areas. We then introduce the novel OnTIME project, which seeks to address some of the key limitations in these commonly used approaches by leveraging big data. The perspective concludes with a discussion on anticipated outcomes and potential policy applications of the OnTIME project

A geospatial database of close-to-reality travel times to obstetric emergency care in 15 Nigerian conurbations

Travel time estimation accounting for on-the-ground realities between the location where a need for emergency obstetric care (EmOC) arises and the health facility capable of providing EmOC is essential for improving pregnancy outcomes. Current understanding of travel time to care is inadequate in many urban areas of Africa, where short distances obscure long travel times and travel times can vary by time of day and road conditions. Here, we describe a database of travel times to comprehensive EmOC facilities in the 15 most populated extended urban areas of Nigeria. The travel times from cells of approximately 0.6 × 0.6 km to facilities were derived from Google Maps Platform’s internal Directions Application Programming Interface, which incorporates traffic considerations to provide closer-to-reality travel time estimates. Computations were done to the first, second and third nearest public or private facilities. Travel time for eight traffic scenarios (including peak and non-peak periods) and number of facilities within specific time thresholds were estimated. The database offers a plethora of opportunities for research and planning towards improving EmOC accessibility

Socio-spatial equity analysis of relative wealth index and emergency obstetric care accessibility in urban Nigeria

Background. Better geographical accessibility to comprehensive emergency obstetric care (CEmOC) facilities can significantly improve pregnancy outcomes. However, with other factors, such as affordability critical for care access, it is important to explore accessibility across groups. We assessed CEmOC geographical accessibility by wealth status in the 15 most-populated Nigerian cities. Methods. We mapped city boundaries, verified and geocoded functional CEmOC facilities, and assembled population distribution for women of childbearing age and Meta’s Relative Wealth Index (RWI). We used the Google Maps Platform’s internal Directions Application Programming Interface to obtain driving times to public and private facilities. City-level median travel time (MTT) and number of CEmOC facilities reachable within 60min were summarised for peak and non-peak hours per wealth quintile. The correlation between RWI and MTT to the nearest public CEmOC was calculated. Results We show that MTT to the nearest public CEmOC facility is lowest in the wealthiest 20%in all cities, with the largest difference in MTT between the wealthiest 20% and least wealthy 20% seen in Onitsha (26 vs 81min) and the smallest in Warri(20vs30min). Similarly, the average number of public CEmOC facilities reachable within 60min varies (11 among the wealthiest 20% and six among the least wealthy in Kano). In five cities, zero facilities are reachable under 60min for the least wealthy 20%. Those who live in the suburbs particularly have poor accessibility to CEmOC facilities. Conclusions. Our findings show that the least wealthy mostly have poor accessibility to care. Interventions addressing CEmOC geographical accessibility targeting poor people are needed to address inequities in urban settings

A Novel Function of DELTA-NOTCH Signalling Mediates the Transition from Proliferation to Neurogenesis in Neural Progenitor Cells

A complete account of the whole developmental process of neurogenesis involves understanding a number of complex underlying molecular processes. Among them, those that govern the crucial transition from proliferative (self-replicating) to neurogenic neural progenitor (NP) cells remain largely unknown. Due to its sequential rostro-caudal gradients of proliferation and neurogenesis, the prospective spinal cord of the chick embryo is a good experimental system to study this issue. We report that the NOTCH ligand DELTA-1 is expressed in scattered cycling NP cells in the prospective chick spinal cord preceding the onset of neurogenesis. These Delta-1-expressing progenitors are placed in between the proliferating caudal neural plate (stem zone) and the rostral neurogenic zone (NZ) where neurons are born. Thus, these Delta-1-expressing progenitors define a proliferation to neurogenesis transition zone (PNTZ). Gain and loss of function experiments carried by electroporation demonstrate that the expression of Delta-1 in individual progenitors of the PNTZ is necessary and sufficient to induce neuronal generation. The activation of NOTCH signalling by DELTA-1 in the adjacent progenitors inhibits neurogenesis and is required to maintain proliferation. However, rather than inducing cell cycle exit and neuronal differentiation by a typical lateral inhibition mechanism as in the NZ, DELTA-1/NOTCH signalling functions in a distinct manner in the PNTZ. Thus, the inhibition of NOTCH signalling arrests proliferation but it is not sufficient to elicit neuronal differentiation. Moreover, after the expression of Delta-1 PNTZ NP continue cycling and induce the expression of Tis21, a gene that is upregulated in neurogenic progenitors, before generating neurons. Together, these experiments unravel a novel function of DELTA–NOTCH signalling that regulates the transition from proliferation to neurogenesis in NP cells. We hypothesize that this novel function is evolutionary conserved