Poor quality of care limits achieving better outcomes in maternal and newborn health (MNH). To ensure greater accountability for high quality care, effective coverage measures are now recommended. Despite global agreement on the need to apply an effective coverage cascade, operationalising the cascade is problematic and the development of actionable methods have been identified as a research priority. This PhD investigated how effective coverage cascades can be operationalised for childbirth care using data from Gombe state, northeast Nigeria. A systematic review examined how effective coverage measures have previously been defined. The review highlighted a lack of harmonisation and identified only one study which used routine data derived from health management information systems. Subsequently, a cascade was developed for childbirth care by selecting the most frequently cited items from the literature that were also recommended by WHO. The PhD applied this definition to examine the extent to which meaningful effective coverage measures can be constructed from routinely available data sources in Gombe. Linking representative population data to facility data from DHIS2 it was feasible to construct a partial effective coverage measure. Compared to a gold standard measure - constructed using comprehensive health facility data – the analysis resulted in the same conclusion that effective coverage was very low. The analysis identified a vital gap in our ability to accurately measure all steps of the cascade using routinely available data in this setting. This is problematic, given the in-depth analysis of observations of childbirth care undertaken in this PhD revealed few women received the recommended routine processes of care. Extending routine data beyond inputs requires greater advocacy to promote the value of process of care indicators for decision making. Finally, this study identified challenges in assessing inequalities in effective coverage where relying on summarised health facility data, that warrant further consideration by the measurement community as we continue to promote the use of effective coverage measures
