Bottlenecks in the implementation of essential screening tests in antenatal care: Syphilis, HIV, and anemia testing in rural Tanzania and Uganda

Diagnostic accuracy of a non-invasive spot-check hemoglobin meter, Masimo Rad-67® pulse CO-Oximeter®, in detection of anemia in antenatal care settings in Kenya

Background

Point of care hemoglobin meters play key roles in increasing access to anemia screening in antenatal care especially in settings with limited access to laboratories. We aimed to determine the diagnostic accuracy of a non-invasive spot-check hemoglobin (SpHb) meter, Masimo Rad-67® Pulse CO-Oximeter®, in the diagnosis of anemia in pregnant women attending antenatal care clinics in Kilifi, Kenya.

Methods

This was a diagnostic accuracy study that retrospectively evaluated SpHb against a validated reference standard of laboratory assessed hemoglobin (Lab Hb) by a SYSMEX XN-330 automated hematology analyzer. The study was nested within a prospective pregnancy cohort study that recruited unselected pregnant women from antenatal care clinics in two public hospitals in Kilifi County, coastal Kenya. Records with both SpHb and Lab Hb were selected from pregnancy visits between May 2021 and December 2022. Linear regression and Bland-Altman analysis were performed to compare the two tests and diagnostic accuracy parameters obtained for the diagnosis of anemia.

Results

A total of 2,975 records (from 2,203 unique participants), with paired SpHb and Lab Hb were analyzed. Linear regression showed a significant but weak positive correlation, a proportional bias of 0.44 (95% CI 0.41-0.47) and a constant of 7.59 (95% CI 7.30-7.87, p < 0.001). The median bias was 1.70 g/dl, with limits of agreement of -0.80 to 4.20. SpHb tended to be higher than Lab Hb on the low hemoglobin range but lower than Lab Hb on the high hemoglobin range. The sensitivity of SpHb in detecting anemia was 18.66%. Prevalence, specificity, positive predictive value, and negative predictive values were 46.37%, 96.77%, 83.33%, and 57.92% respectively.

Conclusion

Overall, SpHb by Masimo Rad-67® Pulse CO-Oximeter® did not accurately identify pregnant women with anemia and many cases would be missed. We would not recommend its use in antenatal care settings.

The cost-effectiveness of syphilis screening in pregnant women: a systematic literature review

Introduction

The cost-effectiveness study of syphilis screening in pregnant women has not been synthesized. This study aimed to synthesize the economic evidence on the cost-effectiveness of syphilis screening in pregnant women that might contribute to making recommendations on the future direction of syphilis screening approaches.

Methods

We systematically searched MEDLINE, PubMed, and Web of Science databases for relevant studies published before 19 January 2023 and identified the cost-effectiveness analyses for syphilis screening in pregnant women. The methodological design quality was appraised by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist.

Results

In total, 17 literature met the eligibility criteria for a full review. Of the 17 studies, four evaluated interventions using different screening methods, seven assessed a combination of syphilis testing and treatment interventions, three focused on repeat screening intervention, and four evaluated the interventions that integrated syphilis and HIV testing. The most cost-effective strategy appeared to be rapid syphilis testing with high treatment rates in pregnant women who were positive.

Discussion

The cost-effectiveness of syphilis screening for pregnancy has been widely demonstrated. It is very essential to improve the compliance with maternal screening and the treatment rates for positive pregnant women while implementing screening.

Toward mandatory health insurance in low-income countries? An analysis of claims data in Tanzania

Many low-income countries are in the process of scaling up health insurance with the goal of achieving universal coverage. However, little is known about the usage and financial sustainability of mandatory health insurance. This study analyzes 26 million claims submitted to the Tanzanian National Health Insurance Fund (NHIF), which covers two million public servants for whom public insurance is mandatory, to understand insurance usage patterns, cost drivers, and financial sustainability. We find that in 2016, half of policyholders used a health service within a single year, with an average annual cost of 33 US$ per policyholder. About 10% of the population was responsible for 80% of the health costs, and women, middle-age and middle-income groups had the highest costs. Out of 7390 health centers, only five health centers are responsible for 30% of total costs. Estimating the expected health expenditures for the entire population based on the NHIF cost structure, we find that for a sustainable national scale-up, policy makers will have to decide between reducing the health benefit package or increasing revenues. We also show that the cost structure of a mandatory insurance scheme in a low-income country differs substantially from high-income settings. Replication studies for other countries are warranted.

Supply-side readiness to deliver HIV testing and treatment services in Indonesia: Going the last mile to eliminate mother-to-child transmission of HIV

INTRODUCTION

Despite national efforts to integrate Prevention of Mother-to-Child Transmission (PMTCT) of HIV services into antenatal care in Indonesia, the rate of mother-to-child transmission of HIV remains the highest in the world. A range of barriers to uptake and long-term engagement in care have been identified, but far less is known about health system preparedness to deliver PMTCT of HIV services. This study explored supply-side barriers to the delivery of PMTCT services in Indonesia and whether these factors are associated with the uptake of antenatal HIV testing.

MATERIALS AND METHODS

An ecological analysis was undertaken, linking data from the World Bank Quality Service and Delivery Survey (2016) with routine data from Indonesia's HIV and AIDS case surveillance system and district health profile reports (2016). Supply-side readiness scores-generated from a readiness index that measures overall structural capacity and is often used as proxy for quality of care-were adapted from the WHO Service Availability and Readiness Assessment and presented by sector and geographic area. Univariate and multivariate regression analysis was used to explore factors associated with the uptake of antenatal HIV testing in public facilities.

RESULTS

In general, public facilities scored more highly in most inputs compared to private facilities. Facilities located in urban areas also scored more highly in the majority of inputs compared to ones in rural areas. Readiness scores were lowest for PMTCT services compared to Antenatal Care and HIV Care and Support services, especially for the availability of medicines such as zidovudine and nevirapine. The national composite readiness score for PMTCT was only 0.13 (based on a maximum score of 1) with a composite score of 0.21 for public facilities and 0.06 for private facilities. The multivariate analysis shows that the proportion of pregnant women tested for HIV was more likely to be greater than or equal to 10% in facilities with a higher readiness score and a higher number of trained counsellors available, and less likely in facilities located outside of Java-Bali and in facilities supporting a higher number of village midwives.

DISCUSSION

Despite targeted efforts by the Indonesian government and multinational agencies, significant gaps exist in the delivery of PMTCT that compromise the standard of care delivered in Indonesia. Future strategies should focus on improving the availability of tests and treatment, especially in the private sector and in rural areas.

Facilitators and barriers to point-of-care testing for sexually transmitted infections in low- and middle-income countries: a scoping review

BACKGROUND

Sexually transmitted infections (STIs) in low- and middle-income countries (LMICs) are predominantly managed by syndromic management. However, most STIs are asymptomatic. These untreated STIs cause individual morbidity, and lead to high STI prevalences. There is increasing interest in the use of point-of-care tests (POCTs) for STIs in LMICs, which could facilitate same day testing and treatment. To best utilise these tests, we must understand the facilitators and barriers to their implementation. The aim of this review is to explore how point-of-care testing for STIs has been implemented into healthcare systems in LMIC and the facilitators and barriers to doing so.

METHODS

A scoping review was conducted by searching MEDLINE, Embase, Emcare, CINAHL, Scopus, LILACS, the Cochrane Library, and ProQuest Dissertations and Theses for studies published between 1st January 1998 and 5th June 2020. Abstracts and full articles were screened independently by two reviewers. Studies were considered for inclusion if they assessed the acceptability, feasibility, facilitators, or barriers to implementation of point-of-care testing for chlamydia, gonorrhoea, trichomoniasis or syphilis in LMICs. Thematic analysis was used to analyse and present the facilitators and barriers to point-of-care STI testing.

RESULTS

The literature search revealed 82 articles suitable for inclusion; 44 (53.7%) from sub-Saharan Africa; 21 (25.6%) from Latin American and the Caribbean; 10 (12.2%) from East Asia and the Pacific; 6 (7.3%) from South Asia; and one (1.2%) multi-regional study. Thematic analysis revealed seven overarching themes related to the implementation of POCTs in LMICs, namely (i) Ideal test characteristics, (ii) Client factors, (iii) Healthcare provision factors, (iv) Policy, infrastructure and health system factors, (v) Training, audit, and feedback, (vi) Reaching new testing environments, and (vii) Dual testing.

CONCLUSION

Implementation of POCTs in LMICs is complex, with many of the barriers due to wider health system weakness. In addition to pressing for broader structural change to facilitate basic healthcare delivery, these themes may also be used as a basis on which to develop future interventions. The literature was heavily skewed towards syphilis testing, and so more research needs to be conducted assessing chlamydia, gonorrhoea, and trichomoniasis testing, as well as home or self-testing.

Socioeconomic inequalities in effective service coverage for reproductive, maternal, newborn, and child health: a comparative analysis of 39 low-income and middle-income countries

BACKGROUND

Reducing socioeconomic inequalities in access to good quality health care is key for countries to achieve Universal Health Coverage. This study aims to assess socioeconomic inequalities in effective coverage of reproductive, maternal, newborn and child health (RMNCH) in low- and middle-income countries (LMICs).

METHODS

Using the most recent national health surveys from 39 LMICs (between 2014 and 2018), we calculated coverage indicators using effective coverage care cascade that consists of service contact, crude coverage, quality-adjusted coverage, and user-adherence-adjusted coverage. We quantified wealth-related and education-related inequality using the relative index of inequality, slope index of inequality, and concentration index.

FINDINGS

The quality-adjusted coverage of RMNCH services in 39 countries was substantially lower than service contact, in particular for postnatal care (64 percentage points [pp], p-value<0·0001), family planning (48·7 pp, p<0·0001), and antenatal care (43·6 pp, p<0·0001) outcomes. Upper-middle-income countries had higher effective coverage levels compared with low- and lower-middle-income countries in family planning, antenatal care, delivery care, and postnatal care. Socioeconomic inequalities tend to be wider when using effective coverage measurement compared with crude and service contact measurements. Our findings show that upper-middle-income countries had a lower magnitude of inequality compared with low- and lower-middle-income countries.

INTERPRETATION

Reliance on the average contact coverage tends to underestimate the levels of socioeconomic inequalities for RMNCH service use in LMICs. Hence, the effective coverage measurement using a care cascade approach should be applied. While RMNCH coverages vary considerably across countries, equitable improvement in quality of care is particularly needed for lower-middle-income and low-income countries.

FUNDING

None.

Implementation of the new WHO antenatal care model for a positive pregnancy experience: a monitoring framework

Monitoring the implementation and impact of routine antenatal care (ANC), as described in the new World Health Organization (WHO) ANC model, requires indicators that go beyond the previously used global benchmark indicator of four or more ANC visits. To enable consistent monitoring of ANC content and care processes and to provide guidance to countries and health facilities, WHO developed an ANC monitoring framework. This framework builds on a conceptual framework for quality ANC and a scoping review of ANC indicators that mapped existing indicators related to recommendations in the new WHO ANC model. Based on the scoping review and following an iterative and consultative process, we developed a monitoring framework consisting of core indicators recommended for monitoring ANC recommendations in all settings, as well as a menu of additional measures. Finally, a research agenda highlights areas where ANC recommendations exist, but measures require further development. Nine core indicators can already be monitored globally and/or nationally, depending on the preferred data sources. Two core indicators (experience of care, ultrasound scan before 24 weeks) are included as placeholders requiring priority by the research agenda. Six context-specific indicators are appropriate for national and subnational monitoring in various settings based on specific guidance. Thirty-five additional indicators may be relevant and desirable for monitoring, depending on programme priorities. Monitoring implementation of the new WHO ANC model and the outcomes of routine ANC require greater attention to the measurement of ANC content and care processes as well as women’s experience of ANC.

Evaluating the design and implementation fidelity of an adapted Plan-Do-Study-Act approach to improve health system performance in a Nigerian state

BACKGROUND

The Plan-Do-Study-Act (PDSA) cycle is fundamental to many quality improvement (QI) models. For the approach to be effective in the real-world, variants must align with standard elements of the PDSA. This study evaluates the alignment between theory, design and implementation fidelity of a PDSA variant adapted for Nigeria's health system performance improvement.

METHODS

An iterative consensus building approach was used to develop a scorecard evaluating new conceptual indices of design and implementation fidelity of QI interventions (design and implementation index, defects and gaps) based on Taylor's theoretical framework.

RESULTS

Design (adaptation) scores were optimal across all standard features indicating that design was well adapted to the typical PDSA. Conversely, implementation fidelity scores were only optimal with two standard features: prediction-based test of change and the use of data over time. The other features, use of multiple iterative cycles and documentation had implementation gaps of 17 % and 50 % respectively.

CONCLUSION

This study demonstrates how both adaptation and implementation fidelity are important for success of QI interventions. It also presents an approach for evaluating other QI models using Taylor's PDSA assessment framework as a guide, which might serve to strengthen the theory behind future QI models and provide guidance on their appropriate use.

Cost-effectiveness of dual maternal HIV and syphilis testing strategies in high and low HIV prevalence countries: a modelling study

BACKGROUND

Dual HIV and syphilis testing might help to prevent mother-to-child transmission (MTCT) of HIV and syphilis through increased case detection and treatment. We aimed to model and assess the cost-effectiveness of dual testing during antenatal care in four countries with varying HIV and syphilis prevalence.

METHODS

In this modelling study, we developed Markov models of HIV and syphilis in pregnant women to estimate costs and infant health outcomes of maternal testing at the first antenatal care visit with individual HIV and syphilis tests (base case) and at the first antenatal care visit with a dual rapid diagnostic test (scenario one). We additionally evaluated retesting during late antenatal care and at delivery with either individual tests (scenario two) or a dual rapid diagnosis test (scenario three). We modelled four countries: South Africa, Kenya, Colombia, and Ukraine. Strategies with an incremental cost-effectiveness ratio (ICER) less than the country-specific cost-effectiveness threshold (US$500 in Kenya, $750 in South Africa, $3000 in Colombia, and $1000 in Ukraine) per disability-adjusted life-year averted were considered cost-effective.

FINDINGS

Routinely offering testing at the first antenatal care visit with a dual rapid diagnosis test was cost-saving compared with the base case in all four countries (ICER: -$26 in Kenya,-$559 in South Africa, -$844 in Colombia, and -$454 in Ukraine). Retesting during late antenatal care with a dual rapid diagnostic test (scenario three) was cost-effective compared with scenario one in all four countries (ICER: $270 in Kenya, $260 in South Africa, $2207 in Colombia, and $205 in Ukraine).

INTERPRETATION

Incorporating dual rapid diagnostic tests in antenatal care can be cost-saving across countries with varying HIV prevalence. Countries should consider incorporating dual HIV and syphilis rapid diagnostic tests as the first test in antenatal care to support efforts to eliminate MTCT of HIV and syphilis.

FUNDING

WHO, US Agency for International Development, and the Bill & Melinda Gates Foundation.

Mother's Knowledge on HIV, Syphilis, Rubella, and Associated Factors in Northern Tanzania: Implications for MTCT Elimination Strategies

Background

Infections transmitted from mother to child (MTCT) during pregnancy, childbirth, and breastfeeding contribute significantly to the high infant and childhood morbidity and mortality in sub-Saharan African countries. The most significant and preventable of these include HIV, syphilis, and rubella. To achieve elimination, mothers need to be aware of and to understand effective preventive measures against these infections. Lack of comprehensive knowledge on transmission and prevention of MTCT infections is one of the factors hindering achievement of the elimination goals for these infections. The aim of this study was to assess the knowledge of HIV, syphilis, rubella, and associated factors among mothers in the Kilimanjaro region of Tanzania.

Methods

We conducted a community-based cross-sectional study in three districts of the Kilimanjaro region from September to October 2016. The study involved mothers with children up to five years of age. Data collection involved the use of a questionnaire, administered by face-to-face interviews. Logistic regression analysis was used to assess predictors of mothers' knowledge on MTCT infections.

Results

A total of 618 mothers were recruited, with a mean age of 29.6 (SD 7.6) years. The overall knowledge on MTCT infections was low. The highest level of knowledge on MTCT infections was regarding HIV (89.2%). Fewer mothers had knowledge of syphilis (27.8%). Rubella was the least known; only 12% of mothers were aware of rubella infection. District of residence and having knowledge of syphilis were predictors for rubella knowledge, while for syphilis knowledge, significant predictors were age group, occupation, and those having knowledge on HIV and rubella. Predictors for HIV knowledge were residential district, having a mobile phone, and those having knowledge of syphilis and rubella.

Conclusions

This study confirmed that mothers have low overall knowledge on MTCT infections. To achieve the MTCT elimination goals, targeted interventions to improve knowledge among women of childbearing age are recommended.

Prevalence, associated factors and clinical features of congenital syphilis among newborns in Mbarara hospital, Uganda

Background

While congenital syphilis is a significant public health problem that can cause severe disabilities, little is known about the situation in Uganda. We describe prevalence, associated factors and clinical presentation of congenital syphilis in Mbarara, Uganda.

Methods

A cross sectional study was carried out among mother- newborn dyads from the postnatal ward of Mbarara Regional Referral Hospital (MRRH). After obtaining informed consent, a structured questionnaire was used to capture data on risk factors for congenital syphilis. A finger prick was performed on the mothers for Treponema Pallidum Haemagglutination Assay (TPHA). If TPHA was positive, a venous blood sample was collected from the mother to confirm active infection using Rapid Plasma Reagin (RPR). Venous blood was drawn from a newborn if the mother tested positive by TPHA and RPR. A newborn with RPR titres 4 times higher than the mother was considered to have congenital syphilis. We fit logistic regression models to determine factors associated with congenital syphilis.

Results

Between June and September 2015, we enrolled 2500 mothers and 2502 newborns. Prevalence of syphilis was 3.8% (95% CI 3.1–4.6) among newborn infants and 4.1% (95% CI 3.4–5.0) among their mothers. Maternal age <25 years, past history of genital ulcer, a past history of abnormal vaginal discharge, and not receiving treatment of at least one of genital ulcer, genital itching, lower abdominal pain and abnormal vaginal discharge in the current pregnancy were the risk factors associated with congenital syphilis. The most common clinical feature was hepatosplenomegaly.

Conclusions

We found higher-than-expected syphilis sero-prevalence rates in a high risk population of postnatal mothers and their newborns in Uganda. Bridge populations for syphilis may include mothers not tested during pregnancy, who are usually married and not treated. In accordance with our results, the national policy for syphilis control in Uganda should be strengthened to include universal syphilis screening amongst mother-newborn pairs in postnatal clinics with subsequent partner notification.

Variance estimation for effective coverage measures: A simulation study

Background

Effective coverage research is increasing rapidly in global health and development, as researchers use a range of measures and combine data sources to adjust coverage for the quality of services received. However, most estimates of effective coverage that combine data sources are reported only as point estimates, which may be due to the challenge of calculating the variance for a composite measure. In this paper, we evaluate three methods to quantify the uncertainty in the estimation of effective coverage.

Methods

We conducted a simulation study to evaluate the performance of the exact, delta, and parametric bootstrap methods for constructing confidence intervals around point estimates that are calculated from combined data on coverage and quality. We assessed performance by computing the number of nominally 95% confidence intervals that contain the truth for a range of coverage and quality values and data source sample sizes. To illustrate these approaches, we applied the delta and exact methods to estimates of adjusted coverage of antenatal care (ANC) in Senegal. We used household survey data for coverage and health facility assessments for readiness to provide services.

Results

With small sample sizes, when the true effective coverage value was close to the boundaries 0 or 1, the exact and parametric bootstrap methods resulted in substantial over or undercoverage and, for the exact method, a high proportion of invalid confidence intervals, while the delta method yielded modest overcoverage. The proportion of confidence intervals containing the truth in all three methods approached the intended 95% with larger sample sizes and as the true effective coverage value moved away from the 0 or 1 boundary. Confidence intervals for adjusted ANC in Senegal were largely overlapping across the delta and exact methods, although at the sub-national level, the exact method produced invalid confidence intervals for estimates near 0 or 1. We provide the code to implement these methods.

Conclusions

The uncertainty around an effective coverage estimate can be characterized; this should become standard practice if effective coverage estimates are to become part of national and global health monitoring. The delta method approach outperformed the other methods in this study; we recommend its use for appropriate inference from effective coverage estimates that combine data sources, particularly when either sample size is small. When used for estimates created from facility type or regional strata, these methods require assumptions of independence that must be considered in each example.

Evaluating coverage of maternal syphilis screening and treatment within antenatal care to guide service improvements for prevention of congenital syphilis in Countdown 2030 Countries

Background

Countdown to 2030 (CD2030) tracks progress in the 81 countries that account for more than 90% of under-five child deaths and 95% of maternal deaths in the world. In 2017, CD2030 identified syphilis screening and treatment during antenatal care (ANC) as priority indicators for monitoring.

Methods

Country-reported data in the UNAIDS Global AIDS Monitoring System (GAM) system were used to evaluate four key syphilis indicators from CD2030 countries: (1) maternal syphilis screening and (2) treatment coverage during ANC, (3) syphilis seroprevalence among ANC attendees, and (4) national congenital syphilis (CS) case rates. A cascade analysis for CD2030 countries with coverage data for the number of women attending at least 4 antenatal care visits (ANC4), syphilis testing, seroprevalence and treatment was performed to estimate the number of CS cases that were attributable to missed opportunities for syphilis screening and treatment during antenatal care.

Results

Of 81 countries, 52 (64%) reported one or more values for CS indicators into the GAM system during 2016-2017; only 53 (65%) had maternal syphilis testing coverage, 41 (51%) had screening positivity, and 40 (49%) had treatment coverage. CS case rates were reported by 13 (16%) countries. During 2016-2017, four countries reported syphilis screening and treatment coverage of ≥95% consistent with World Health Organization (WHO) targets. Sufficient data were available for 40 (49%) of countries to construct a cascade for data years 2016 and 2017. Syphilis screening and treatment service gaps within ANC4 resulted in an estimated total of 103 648 adverse birth outcomes with 41 858 of these occurring as stillbirths among women attending ANC4 (n = 31 914 408). Women not in ANC4 (n = 25 619 784) contributed an additional 67 348 estimated adverse birth outcomes with 27 198 of these occurring as stillbirths for a total of 69 056 preventable stillbirths attributable to syphilis in these 40 countries.

Conclusion

These data and findings can serve as an initial baseline evaluation of antenatal syphilis surveillance and service coverage and can be used to guide improvement of delivery and monitoring of syphilis screening and treatment in ANC for these priority countries.

Examining coverage, content, and impact of maternal nutrition interventions: the case for quality-adjusted coverage measurement

Background

Reductions in neonatal mortality remain stagnant, despite gains in health care access and utilization. Nutrition interventions during antenatal care (ANC) and in the immediate postpartum period are associated with improved neonatal outcomes. Adjusting coverage estimates for the quality of care provided yields greater insight into health system performance and potential population health benefits of accessing care. In this cross-sectional study, we adjust maternity care coverage measures for quality of nutrition interventions to determine the impact on infant birth weight and breastfeeding.

Methods

We used household data from the Malawi 2013-2014 Multiple Indicator Cluster Survey to assess use of maternal health services and direct observations of ANC and delivery from the 2013 Service Provision Assessment to measure nutrition interventions provided. We adjusted coverage measures combining self-reported utilization of care with the likelihood of receipt of nutrition interventions. Using adjusted log-linear regression, we estimated the associations of these nutrition quality-adjusted metrics with infant birthweight and immediate breastfeeding.

Results

Health facility data provided over 2500 directly observed clinical encounters and household data provided 7385 individual reports of health care utilization and outcomes. Utilization of ANC and facility-delivery was high. Women received nutrition-related interventions considerably less often than they sought care: over the course of ANC women received a median of 1.6 interventions on iron, 1 instance of nutrition counseling, and 0.06 instances of breastfeeding counseling. Nutrition quality-adjusted ANC coverage was associated with a reduced risk of low birthweight (adjusted relative risk [ARR] 0.87, 95% confidence interval (CI) = 0.79, 0.96) and increased likelihood of immediate breastfeeding (ARR = 1.04, 95% CI = 1.02, 1.07); nutrition quality-adjusted post-delivery care was also associated with greater uptake of immediate breastfeeding (ARR = 1.08, 95% CI = 1.02, 1.14). Based on these models, delivering nutrition interventions consistently within the existing level of coverage would decrease population prevalence of low birthweight from 13.7% to 10.8% and increase population prevalence of immediate breastfeeding from 75.9% to 86.0%.

Conclusions

Linking household survey data to health service provision assessments demonstrates that despite high utilization of maternal health services in Malawi, low provision of nutrition interventions is undermining infant health. Substantial gains in newborn health are possible in Malawi if quality of existing services is strengthened.

Prevalence and factors associated with HIV and syphilis infection among children aged 0-36 months in Kilimanjaro, Tanzania: a community-based cross-sectional study

Background

Childhood mortality is high in sub-Saharan Africa. Mother-to-child transmission (MTCT) of HIV and congenital syphilis are among significant causes. Dual elimination of these two infections is one of the international goals. Community-based studies on the burden of HIV and syphilis among children will contribute to fine-tuning the interventions to achieve the elimination goal. This study aims to describe the prevalence of HIV and syphilis among children aged 0–36 months and associated factors in northern Tanzania.

Methods

This was a community-based cross-sectional study, which was conducted in all the seven districts of Kilimanjaro region. Multistage sampling was used, and a total of 2452 children aged 0 to 36 months and their primary caretakers were enrolled. Interviews were conducted with the mother/caretaker, and dried blood samples were collected from the children and processed for laboratory diagnosis of HIV and syphilis. HIV ELISA was first performed on all the samples. Positive samples of children < 18 months were confirmed using PCR.

Results

The prevalence of HIV among 2452 children aged 0–36 months was 1.7% (n = 42). There was a significant difference in the distribution of HIV by age of the child, maternal antenatal attendance, and breastfeeding history.

The prevalence of syphilis was 0.4% (n = 10). Five of the children were more than 1 year old. All children with a positive test for syphilis were from Moshi rural district, and their mothers consumed alcohol. No child was co-infected with HIV and syphilis.

Conclusions

Though the prevalence of the two infections was low, detecting syphilis in children suggests a missed opportunity in screening women during pregnancy. The region may be on track with the goal to achieve dual elimination of mother-to-child transmitted HIV and syphilis. However, efforts are needed to reduce missed opportunities for screening women for syphilis and HIV early in pregnancy and retesting at 3rd trimester/delivery. Strategies to improve testing for HIV-exposed children are needed.

Integrating HIV, syphilis, malaria and anaemia point-of-care testing (POCT) for antenatal care at dispensaries in western Kenya: discrete-event simulation modelling of operational impact

BACKGROUND

Despite WHO advocating for an integrated approach to antenatal care (ANC), testing coverage for conditions other than HIV remains low and women are referred to distant laboratories for testing. Using point-of-care tests (POCTs) at peripheral dispensaries could improve access to testing and timely treatment. However, the effect of providing additional services on nurse workload and client wait times are unknown. We use discrete-event simulation (DES) modelling to understand the effect of providing four point-of-care tests for ANC on nurse utilization and wait times for women seeking maternal and child health (MCH) services.

METHODS

We collected detailed time-motion data over 20 days from one high volume dispensary in western Kenya during the 8-month implementation period (2014-2015) of the intervention. We constructed a simulation model using empirical arrival distributions, activity durations and client pathways of women seeking MCH services. We removed the intervention from the model to obtain wait times, length-of-stay and nurse utilization rates for the baseline scenario where only HIV testing was offered for ANC. Additionally, we modelled a scenario where nurse consultations were set to have minimum durations for sufficient delivery of all WHO-recommended services.

RESULTS

A total of 183 women visited the dispensary for MCH services and 14 of these women received point-of-care testing (POCT). The mean difference in total waiting time was 2 min (95%CI: < 1-4 min, p = 0.026) for MCH women when integrated POCT was given, and 9 min (95%CI: 4-14 min, p < 0.001) when integrated POCT with adequate ANC consult times was given compared to the baseline scenario. Mean length-of-stay increased by 2 min (95%CI: < 1-4 min, p = 0.015) with integrated POCT and by 16 min (95%CI: 10-21 min, p < 0.001) with integrated POCT and adequate consult times compared to the baseline scenario. The two nurses' overall daily utilization in the scenario with sufficient minimum consult durations were 72 and 75%.

CONCLUSION

The intervention had a modest overall impact on wait times and length-of-stay for women seeking MCH services while ensuring pregnant women received essential diagnostic testing. Nurse utilization rates fluctuated among days: nurses experienced spikes in workload on some days but were under-utilized on the majority of days. Overall, our model suggests there was sufficient time to deliver all WHO's required ANC activities and offer integrated testing for ANC first and re-visits with the current number of healthcare staff. Further investigations on improving healthcare worker, availability, performance and quality of care are needed. Delivering four point-of-care tests together for ANC at dispensary level would be a low burden strategy to improve ANC.

Quality of care in six sub-Saharan Africa countries: a provider-based study on adherence to WHO's antenatal care guideline

OBJECTIVE

Quality of care may help explain the high burden of disease in maternal, newborn and child health in low- and middle-income countries even as access to care is improved. We explored the determinants of quality of antenatal care (ANC) in sub-Saharan Africa (SSA).

DESIGN

Cross-sectional study. Multilevel Generalized Linear Latent Mixed-Effect models with logit link function were employed to obtain the adjusted odds ratios (AORs) and 95% confidence interval (CI).

SETTING

We used Service Provision Assessment data from six countries in SSA, including Kenya, Malawi, Namibia, Rwanda, Tanzania and Uganda.

PARTICIPANTS

Seven thousand, five hundred and seventy seven observed antenatal clients across the six countries.

MAIN OUTCOME MEASURES

Quality of ANC services, measured using indexes of quality of clinical care and quality of information provided.

RESULTS

Providers in facilities that had ANC guideline (AOR = 1.26; 95% CI, 1.08-1.48), were well-equipped (AOR = 1.65; 95% CI, 1.41-1.92), were classified as upper level facility (AOR = 1.32; 95% CI, 1.05-1.66), had central electricity supply (AOR = 2.19; 95% CI, 1.81-2.65), and piped water (AOR = 1.30; 95% CI, 1.09-1.55) were more likely to provide optimal quality of clinical care. Moreover, those having ANC guideline (AOR = 1.81; 95% CI, 1.43-2.28) and central electricity supply (AOR = 2.67; 95% CI, 2.01-3.44) were more likely to provide optimal information as well. Provider's qualification and experience were also important in information provision and clinical care independently.

CONCLUSION

The lack of some very basic facility equipment and amenities compromised quality of care in sub-Saharan countries. Policy actions and investment on facility and providers will enable provision of quality services necessary to improve maternal, newborn and child health in SSA.

Advances in the measurement of coverage for RMNCH and nutrition: from contact to effective coverage

Current methods for measuring intervention coverage for reproductive, maternal, newborn, and child health and nutrition (RMNCH+N) do not adequately capture the quality of services delivered. Without information on the quality of care, it is difficult to assess whether services provided will result in expected health improvements. We propose a six-step coverage framework, starting from a target population to (1) service contact, (2) likelihood of services, (3) crude coverage, (4) quality-adjusted coverage, (5) user-adherence-adjusted coverage and (6) outcome-adjusted coverage. We support our framework with a comprehensive review of published literature on effective coverage for RMNCH+N interventions since 2000. We screened 8103 articles and selected 36 from which we summarised current methods for measuring effective coverage and computed the gaps between ‘crude’ coverage measures and quality-adjusted measures. Our review showed considerable variability in data sources, indicator definitions and analytical approaches for effective coverage measurement. Large gaps between crude coverage and quality-adjusted coverage levels were evident, ranging from an average of 10 to 38 percentage points across the RMNCH+N interventions assessed. We define effective coverage as the proportion of individuals experiencing health gains from a service among those who need the service, and distinguish this from other indicators along a coverage cascade that make quality adjustments. We propose a systematic approach for analysis along six steps in the cascade. Research to date shows substantial drops in effective delivery of care across these steps, but variation in methods limits comparability of the results. Advancement in coverage measurement will require standardisation of effective coverage terminology and improvements in data collection and methodological approaches.

Developing measures for WHO recommendations on antenatal care for a positive pregnancy experience: a conceptual framework and scoping review

OBJECTIVES

In response to the newest WHO recommendations on routine antenatal care (ANC) for pregnant women and adolescent girls, this paper identifies the literature on existing ANC measures, presents a conceptual framework for quality ANC, maps existing measures to specific WHO recommendations, identifies gaps where new measures are needed to monitor the implementation and impact of routine ANC and prioritises measures for capture.

METHODS

We conducted searches in four databases and five websites. Searches and application of inclusion/exclusion criteria followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow approach for scoping reviews. Data were extracted on measure information, methodology, methodological work and implementation. We adapted and refined a conceptual framework for routine ANC based on these measures.

RESULTS

This scoping review uncovered 58 resources describing 46 existing measures that align with WHO recommendations and good clinical practices for ANC. Of the 42 WHO-recommended ANC interventions and four good clinical practices included in this scoping review, only 14 WHO-recommended interventions and three established good clinical practices could potentially be measured immediately using existing measures. Recommendations addressing the integration of ANC with allied fields are likelier to have existing measures than recommendations that focus on maternal health. When mapped to our conceptual framework, existing measures prioritise content of care and health systems; measures for girls' and women's experiences of care are notably lacking. Available data sources for non-existent measures are currently limited.

CONCLUSION

Our research updates prior efforts to develop comprehensive measures of quality ANC and raises awareness of the need to better assess experiences of ANC. Given the inadequate number and distribution of existing ANC measures across the quality of care conceptual framework domains, new standardised measures are required to assess quality of routine ANC. Girls' and women's voices deserve greater acknowledgement when measuring the quality and delivery of ANC.

Toward Improving Accessibility of Point-of-Care Diagnostic Services for Maternal and Child Health in Low- and Middle-Income Countries

Point-of-care (POC) testing can improve health care provision in settings with limited access to health care services. Access to POC diagnostic services has shown potential to alleviate some diagnostic challenges and delays associated with laboratory-based methods in low- and middle-income countries. Improving accessibility to POC testing (POCT) services during antenatal and perinatal care is among the global health priorities to improve maternal and child health. This review provides insights on the availability of POC testing designed for diagnosing HIV, syphilis, and malaria in pregnancy to improve maternal and child health. In addition, factors such as accessibility of POC testing, training of health work force, and the efficiency of POC testing services delivery in low- and middle-income countries are discussed. A framework to help increase access to POC diagnostic services and improve maternal and child health outcomes in low- and middle-income countries is proposed.

National policies and care provision in pregnancy and childbirth for twins in Eastern and Southern Africa: A mixed-methods multi-country study

BACKGROUND

High-risk pregnancies, such as twin pregnancies, deserve particular attention as mortality is very high in this group. With a view to inform policy and national guidelines development for the Sustainable Development Goals, we reviewed national training materials, guidelines, and policies underpinning the provision of care in relation to twin pregnancies and assessed care provided to twins in 8 Eastern and Southern African countries: Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe.

METHODS AND FINDINGS

We located policies and guidelines by reviewing national repositories and by contacting experts to systematically map country-level maternal and newborn training materials, guidelines, and policies. We extracted recommendations for care for twins spanning ante-, intra-, and postpartum care that typically should be offered during twin pregnancies and childbirth. We compared care provided for mothers of twins to that provided for mothers of singletons during the ante-, intra-, and postpartum period and computed neonatal mortality rates using the most recent Demographic and Health Surveys (DHS) data for each country. There was a paucity of guidance on care specifically for twin or multiple pregnancies: None of the countries provided clear guidance on additional number of antenatal care visits or specific antenatal content, while 7 of the 8 countries recommended twins to be delivered in a comprehensive emergency obstetric and neonatal care facility. These results were mirrored by DHS results of 73,462 live births (of which 1,360 were twin) indicating that twin pregnancies did not receive more frequent or intensified antenatal care. The percentage of twin deliveries in hospitals varied from 25.3% in Mozambique to 63.0% in Kenya, and women with twin deliveries were between 5 and 27 percentage points more likely to deliver in hospitals compared to women with singleton live births; this difference was significant in 5 of the 8 countries (t test p < 0.05). The percentage of twin deliveries by cesarean section varied from 9% in Mozambique to 36% in Rwanda. The newborn mortality rate among twins, adjusted for maternal age and parity, was 4.6 to 7.2 times higher for twins compared to singletons in all 8 countries.

CONCLUSIONS

Despite the limited sample size and the limited number of clinically relevant services evaluated, our study provided evidence that mothers of twins receive insufficient care and that mortality in twin newborns is very high in Eastern and Southern Africa. Most countries have insufficient guidelines for the care of twins. While our data do not allow us to make a causal link between insufficient guidelines and insufficient care, they call for an assessment and reconceptualisation of policies to reduce the unacceptably high mortality in twins in Eastern and Southern Africa.

Integrated point-of-care testing (POCT) for HIV, syphilis, malaria and anaemia at antenatal facilities in western Kenya: a qualitative study exploring end-users' perspectives of appropriateness, acceptability and feasibility

Background

HIV, syphilis, malaria and anaemia are leading preventable causes of adverse pregnancy outcomes in sub-Saharan Africa yet testing coverage for conditions other than HIV is low. Availing point-of-care tests (POCTs) at rural antenatal health facilities (dispensaries) has the potential to improve access and timely treatment. Fundamental to the adoption of and adherence to new diagnostic approaches are healthcare workers’ and pregnant women’s (end-users) buy-in. A qualitative approach was used to capture end-users’ experiences of using POCTs for HIV, syphilis, malaria and anaemia to assess the appropriateness, acceptability and feasibility of integrated testing for ANC.

Methods

Seven dispensaries were purposively selected to implement integrated point-of-care testing for eight months in western Kenya. Semi-structured interviews were conducted with 18 healthcare workers (14 nurses, one clinical officer, two HIV testing counsellors, and one laboratory technician) who were trained, had experience doing integrated point-of-care testing, and were still working at the facilities 8–12 months after the intervention began. The interviews explored acceptability and relevance of POCTs to ANC, challenges with testing, training and supervision, and healthcare workers’ perspectives of client experiences. Twelve focus group discussions with 118 pregnant women who had attended a first ANC visit at the study facilities during the intervention were conducted to explore their knowledge of HIV, syphilis, malaria, and anaemia, experience of ANC point-of-care testing services, treatments received, relationships with healthcare workers, and experience of talking to partners about HIV and syphilis results.

Results

Healthcare workers reported that they enjoyed gaining new skills, were enthusiastic about using POCTs, and found them easy to use and appropriate to their practice. Initial concerns that performing additional testing would increase their workload in an already strained environment were resolved with experience and proficiency with the testing procedures. However, despite having the diagnostic tools, general health system challenges such as high client to healthcare worker volume ratio, stock-outs and poor working conditions challenged the delivery of adequate counselling and management of the four conditions. Pregnant women appreciated POCTs, but reported poor healthcare worker attitudes, drug stock-outs, and fear of HIV disclosure to their partners as shortcomings to their ANC experience in general.

Conclusion

This study provides insights on the acceptability, appropriateness, and feasibility of integrating POCTs into ANC services among end-users. While the innovation was desired and perceived as beneficial, future scale-up efforts would need to address health system weaknesses if integrated testing and subsequent effective management of the four conditions are to be achieved.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3844-9) contains supplementary material, which is available to authorized users.

Missed opportunities in antenatal care for improving the health of pregnant women and newborns in Geita district, Northwest Tanzania

Background

Despite the significant benefits of early detection and management of pregnancy related complications during antenatal care (ANC) visits, not all pregnant women in Tanzania initiate ANC in a timely manner. The primary objectives of this research study in rural communities of Geita district, Northwest Tanzania were: 1) to conduct a population-based study that examined the utilization and availability of ANC services; and 2) to explore the challenges faced by women who visited ANC clinics and barriers to utilization of ANC among pregnant women.

Methods

A sequential explanatory mixed method design was utilized. Household surveys that examined antenatal service utilization and availability were conducted in 11 randomly selected wards in Geita district. One thousand, seven hundred and nineteen pregnant women in their 3rd trimester participated in household surveys. It was followed by focus group discussions with community health workers and pregnant women that examined challenges and barriers to ANC.

Results

Of the pregnant women who participated, 86.74% attended an ANC clinic at least once; 3.62% initiated ANC in the first trimester; 13.26% had not initiated ANC when they were interviewed in their 3rd trimester. Of the women who had attended ANC at least once, the majority (82.96%) had been checked for HIV status, less than a half (48.36%) were checked for hemoglobin level, and only a minority had been screened for syphilis (6.51%). Among women offered laboratory testing, the prevalence of HIV was 3.88%, syphilis, 18.57%, and anemia, 54.09%. In terms of other preventive measures, 91.01% received a tetanus toxoid vaccination, 76.32%, antimalarial drugs, 65.13%, antihelminthic drugs, and 76.12%, iron supplements at least once. Significant challenges identified by women who visited ANC clinics included lack of male partner involvement, informal regulations imposed by health care providers, perceived poor quality of care, and health care system related factors. Socio-cultural beliefs, fear of HIV testing, poverty and distance from health clinics were reported as barriers to early ANC utilization.

Conclusion

Access to effective ANC remains a challenge among women in Geita district. Notably, most women initiated ANC late and early initiation did not guarantee care that could contribute to better pregnancy outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-2014-8) contains supplementary material, which is available to authorized users.

Integrated point-of-care testing (POCT) of HIV, syphilis, malaria and anaemia in antenatal clinics in western Kenya: A longitudinal implementation study

Background

In sub-Saharan Africa, HIV, syphilis, malaria and anaemia are leading preventable causes of adverse pregnancy outcomes. In Kenya, policy states women should be tested for all four conditions (malaria only if febrile) at first antenatal care (ANC) visit. In practice, while HIV screening is conducted, coverage of screening for the others is suboptimal and early pregnancy management of illnesses is compromised. This is particularly evident at rural dispensaries that lack laboratories and have parallel programmes for HIV, reproductive health and malaria, resulting in fractured and inadequate care for women.

Methods

A longitudinal eight-month implementation study integrating point-of-care diagnostic tests for the four conditions into routine ANC was conducted in seven purposively selected dispensaries in western Kenya. Testing proficiency of healthcare workers was observed at initial training and at three monthly intervals thereafter. Adoption of testing was compared using ANC register data 8.5 months before and eight months during the intervention. Fidelity to clinical management guidelines was determined by client exit interviews with success defined as ≥90% adherence.

Findings

For first ANC visits at baseline (n = 529), testing rates were unavailable for malaria, low for syphilis (4.3%) and anaemia (27.8%), and near universal for HIV (99%). During intervention, over 95% of first attendees (n = 586) completed four tests and of those tested positive, 70.6% received penicillin or erythromycin for syphilis, 65.5% and 48.3% received cotrimoxazole and antiretrovirals respectively for HIV, and 76.4% received artemether/lumefantrine, quinine or dihydroartemisinin–piperaquine correctly for malaria. Iron and folic supplements were given to nearly 90% of women but often at incorrect doses.

Conclusions

Integrating point-of-care testing into ANC at dispensaries with established HIV testing programmes resulted in a significant increase in testing rates, without disturbing HIV testing rates. While more cases were detected and treated, treatment fidelity still requires strengthening and an integrated monitoring and evaluation system needs to be established.

Gaps in the implementation of antenatal syphilis detection and treatment in health facilities across sub-Saharan Africa

BACKGROUND

Syphilis in pregnancy is an under-recognized public health problem, especially in sub-Saharan Africa which accounts for over 60% of the global burden of syphilis. If left untreated, more than half of maternal syphilis cases will result in adverse pregnancy outcomes including stillbirth and fetal loss, neonatal death, prematurity or low birth weight, and neonatal infections. Achieving universal coverage of antenatal syphilis screening and treatment has been the focus of the global campaign for the elimination of mother-to-child transmission of syphilis. However, little is known about the availability of antenatal syphilis screening and treatment across sub-Saharan Africa. The objective of this study was to estimate the 'likelihood of appropriate care' for antenatal syphilis screening and treatment by analyzing health facility surveys and household surveys conducted from 2010 to 2015 in 12 sub-Saharan African countries.

METHODS

In this secondary data analysis, we linked indicators of health facility readiness to provide antenatal syphilis detection and treatment from Service Provision Assessments (SPAs) and Service Availability and Readiness Assessments (SARAs) to indicators of ANC use from the Demographic and Health Surveys (DHS) to compute estimates of the 'likelihood of appropriate care'.

RESULTS

Based on data from 5,593 health facilities that reported offering antenatal care (ANC) services, the availability of syphilis detection and treatment in ANC facilities ranged from 2% to 83%. The availability of syphilis detection and treatment was substantially lower in ANC facilities in West Africa compared to the other sub-regions. Levels of ANC attendance were high (median 94.9%), but only 27% of ANC attendees initiated care at less than 4 months gestation. We estimated that about one in twelve pregnant women received ANC early (<4 months) at a facility ready to provide syphilis detection and treatment (median 8%, range 7-32%). The largest implementation bottleneck identified was low health facility readiness, followed by timeliness of the first ANC visit.

CONCLUSIONS

While access was fairly high, the low levels of likelihood of antenatal syphilis detection and treatment identified reinforce the need to improve the availability of syphilis rapid diagnostic tests and treatment and the timeliness of antenatal care-seeking across sub-Saharan Africa.

[Effective coverage of treatment of hypertension in Mexican adults by states]

Objective:

To estimate the effective coverage (EC) of treatment of hypertension (HT) in Mexican adults in 2012 and compared with those reported in 2006.

Materials and methods:

The National Health and Nutrition Survey 2012 was analyzed. The EC has three dimensions: health need as prevalence of HT, utilization of health services when the need is real and quality as recovering health after the treatment. The EC of treatment of HT was estimated using instrumental variables.

Results:

In 2012, the EC national of treatment of HT was 28.3% (95%CI 26.5-30.1), ranging from Michoacan with 19.3% (15.3-23.4) to State of Mexico with 39.7% in (25.3-54.0). From 2006 to 2012 the national EC increased 22.5%.

Conclusion:

The EC treatment of hypertension is low and heterogeneous. The use of synthetic indicators should be a daily exercise of measurement, because report summarizes the performance of state health systems.

Association between infrastructure and observed quality of care in 4 healthcare services: A cross-sectional study of 4,300 facilities in 8 countries

BACKGROUND

It is increasingly apparent that access to healthcare without adequate quality of care is insufficient to improve population health outcomes. We assess whether the most commonly measured attribute of health facilities in low- and middle-income countries (LMICs)-the structural inputs to care-predicts the clinical quality of care provided to patients.

METHODS AND FINDINGS

Service Provision Assessments are nationally representative health facility surveys conducted by the Demographic and Health Survey Program with support from the US Agency for International Development. These surveys assess health system capacity in LMICs. We drew data from assessments conducted in 8 countries between 2007 and 2015: Haiti, Kenya, Malawi, Namibia, Rwanda, Senegal, Tanzania, and Uganda. The surveys included an audit of facility infrastructure and direct observation of family planning, antenatal care (ANC), sick-child care, and (in 2 countries) labor and delivery. To measure structural inputs, we constructed indices that measured World Health Organization-recommended amenities, equipment, and medications in each service. For clinical quality, we used data from direct observations of care to calculate providers' adherence to evidence-based care guidelines. We assessed the correlation between these metrics and used spline models to test for the presence of a minimum input threshold associated with good clinical quality. Inclusion criteria were met by 32,531 observations of care in 4,354 facilities. Facilities demonstrated moderate levels of infrastructure, ranging from 0.63 of 1 in sick-child care to 0.75 of 1 for family planning on average. Adherence to evidence-based guidelines was low, with an average of 37% adherence in sick-child care, 46% in family planning, 60% in labor and delivery, and 61% in ANC. Correlation between infrastructure and evidence-based care was low (median 0.20, range from -0.03 for family planning in Senegal to 0.40 for ANC in Tanzania). Facilities with similar infrastructure scores delivered care of widely varying quality in each service. We did not detect a minimum level of infrastructure that was reliably associated with higher quality of care delivered in any service. These findings rely on cross-sectional data, preventing assessment of relationships between structural inputs and clinical quality over time; measurement error may attenuate the estimated associations.

CONCLUSION

Inputs to care are poorly correlated with provision of evidence-based care in these 4 clinical services. Healthcare workers in well-equipped facilities often provided poor care and vice versa. While it is important to have strong infrastructure, it should not be used as a measure of quality. Insight into health system quality requires measurement of processes and outcomes of care.

Linking household surveys and health facility assessments to estimate intervention coverage for the Lives Saved Tool (LiST)

Background

Calls have been made for improved measurement of coverage for maternal, newborn and child health interventions. Recently, methods linking household and health facility surveys have been used to improve estimation of intervention coverage. However, linking methods rely the availability of household and health facility surveys which are temporally matched. Because nationally representative health facility assessments are not yet routinely conducted in many low and middle income countries, estimates of intervention coverage based on linking methods can be produced for only a subset of countries. Estimates of intervention coverage are a critical input for modelling the health impact of intervention scale-up in the Lives Saved Tool (LiST). The purpose of this study was to develop a data-driven approach to estimate coverage for a subset of antenatal care interventions modeled in LiST.

Methods

Using a five-step process, estimates of population level coverage for syphilis detection and treatment, case management of diabetes, malaria infection, hypertensive disorders, and pre-eclampsia, were computed by linking household and health facility surveys. Based on data characterizing antenatal care and estimates of coverage derived from the linking approach, predictive models for intervention coverage were developed. Updated estimates of coverage based on the predictive models were compared, first with current default proxies, then with estimates based on the linking approach. Model fit and accuracy were assessed using three measures: the coefficient of determination, Pearson’s correlation coefficient, and the root mean square error (RMSE).

Results

The ability to predict intervention coverage was fairly accurate across all interventions considered. Predictive models accounted for 20–63% of the variance in intervention coverages, and correlation coefficients ranged from 0.5 to 0.83. The predictive model used to estimate coverage of management of pre-eclampsia performed relatively better (RMSE = 0.11) than the model estimating coverage of diabetes case management (RMSE = 0.19).

Conclusions

The new approach to estimate coverage represents an improvement over current default proxies in LiST. As the availability of reliable coverage data improves, impact estimates generated by LiST will improve. This study underscores the need for continued efforts to improve coverage measurement, while bringing to the fore the importance of health facility assessments as complementary data sources.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4743-4) contains supplementary material, which is available to authorized users.

Effective coverage of primary care services in eight high-mortality countries

Introduction

Measurement of effective coverage (quality-corrected coverage) of essential health services is critical to monitoring progress towards the Sustainable Development Goal for health. We combine facility and household surveys from eight low-income and middle-income countries to examine effective coverage of maternal and child health services.

Methods

We developed indices of essential clinical actions for antenatal care, family planning and care for sick children from existing guidelines and used data from direct observations of clinical visits conducted in Haiti, Kenya, Malawi, Namibia, Rwanda, Senegal, Tanzania and Uganda between 2007 and 2015 to measure quality of care delivered. We calculated healthcare coverage for each service from nationally representative household surveys and combined quality with utilisation estimates at the subnational level to quantify effective coverage.

Results

Health facility and household surveys yielded over 40 000 direct clinical observations and over 100 000 individual reports of healthcare utilisation. Coverage varied between services, with much greater use of any antenatal care than family planning or sick-child care, as well as within countries. Quality of care was poor, with few regions demonstrating more than 60% average performance of basic clinical practices in any service. Effective coverage across all eight countries averaged 28% for antenatal care, 26% for family planning and 21% for sick-child care. Coverage and quality were not strongly correlated at the subnational level; effective coverage varied by as much as 20% between regions within a country.

Conclusion

Effective coverage of three primary care services for women and children in eight countries was substantially lower than crude service coverage due to major deficiencies in care quality. Better performing regions can serve as examples for improvement. Systematic increases in the quality of care delivered—not just utilisation gains—will be necessary to progress towards truly beneficial universal health coverage.

Unpredictability dictates quality of maternal and newborn care provision in rural Tanzania-A qualitative study of health workers' perspectives

Background

Health workers are the key to realising the potential of improved quality of care for mothers and newborns in the weak health systems of Sub Saharan Africa. Their perspectives are fundamental to understand the effectiveness of existing improvement programs and to identify ways to strengthen future initiatives. The objective of this study was therefore to examine health worker perspectives of the conditions for maternal and newborn care provision and their perceptions of what constitutes good quality of care in rural Tanzanian health facilities.

Methods

In February 2014, we conducted 17 in-depth interviews with different cadres of health workers providing maternal and newborn care in 14 rural health facilities in Tandahimba district, south-eastern Tanzania. These facilities included one district hospital, three health centres and ten dispensaries. Interviews were conducted in Swahili, transcribed verbatim and translated into English. A grounded theory approach was used to guide the analysis, the output of which was one core category, four main categories and several sub-categories.

Results

‘It is like rain’ was identified as the core category, delineating unpredictability as the common denominator for all aspects of maternal and newborn care provision. It implies that conditions such as mothers’ access to and utilisation of health care are unreliable; that availability of resources is uncertain and that health workers have to help and try to balance the situation. Quality of care was perceived to vary as a consequence of these conditions. Health workers stressed the importance of predictability, of ‘things going as intended’, as a sign of good quality care.

Conclusions

Unpredictability emerged as a fundamental condition for maternal and newborn care provision, an important determinant and characteristic of quality in this study. We believe that this finding is also relevant for other areas of care in the same setting and may be an important defining factor of a weak health system. Increasing predictability within health services, and focusing on the experience of health workers within these, should be prioritised in order to achieve better quality of care for mothers and newborns.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1230-y) contains supplementary material, which is available to authorized users.

Implementation of co-trimoxazole preventive therapy policy for malaria in HIV-infected pregnant women in the public health facilities in Tanzania

Background

In 2011, Tanzania adopted a policy for provision of daily co-trimoxazole prophylaxis to HIV-infected pregnant women for prevention of malaria and other opportunistic infections. As per the policy, HIV-infected pregnant women should not be given sulfadoxine-pyrimethamine (SP) for intermittent preventive therapy. The challenges associated with this policy change and the extent to which the new policy for prevention of malaria in pregnant women coinfected with HIV was implemented need to be assessed.

Aim

To assess the implementation of malaria-preventive therapy policy among HIV-infected pregnant women in the public health facilities in Dar es Salaam, Tanzania.

Methodology

The study was conducted in Kinondoni Municipality, Dar es Salaam, Tanzania, from January 2015 to July 2015. Three hundred and fifty-three HIV-infected pregnant women who were attending antenatal clinics (ANCs) and using co-trimoxazole for prevention of malaria were interviewed. Twenty-six health care workers working at the ANCs were also interviewed regarding provision of co-trimoxazole prophylaxis to pregnant women. A knowledge scale was used to grade the level of knowledge of health care providers. Focus group discussions were also conducted with 18 health care workers to assess the level of implementation of the policy and the challenges encountered.

Results

Twenty-three (6.5%) pregnant women with known HIV serostatus were using co-trimoxazole for prevention of opportunistic infections even before they became pregnant. Out of the 353 HIV-infected pregnant women, eight (2.5%) were coadministered with both SP and co-trimoxazole. Sixty (16.7%) pregnant women had poor adherence to co-trimoxazole prophylaxis. Out of the 26 interviewed health care providers, 20 had high level of knowledge regarding malaria-preventive therapy in HIV-infected pregnant women. Lack of adequate supply of co-trimoxazole in health facilities and inadequate training of health care providers were among the factors causing poor implementation of co-trimoxazole prophylaxis for prevention of malaria in HIV-infected pregnant women.

Conclusion

There is a need to continue sensitization of pregnant women and communities about the importance of early attendance to the ANCs for testing of HIV and provision of co-trimoxazole prophylaxis. Availability of co-trimoxazole in the health facilities, regular training, and sensitization of health care providers are necessary for effective implementation of this policy.

Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide

On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too soon (TMTS). TLTL describes care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and morbidity. TMTS describes the routine over-medicalisation of normal pregnancy and birth. TMTS includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life saving when used appropriately, but harmful when applied routinely or overused. As facility births increase, so does the recognition that TMTS causes harm and increases health costs, and often concentrates disrespect and abuse. Although TMTS is typically ascribed to high-income countries and TLTL to low-income and middle-income ones, social and health inequities mean these extremes coexist in many countries. A global approach to quality and equitable maternal health, supporting the implementation of respectful, evidence-based care for all, is urgently needed. We present a systematic review of evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care, categorising them as recommended, recommended only for clinical indications, and not recommended. We also present prevalence data from middle-income countries for specific clinical practices, which demonstrate TLTL and increasing TMTS. Health-care providers and health systems need to ensure that all women receive high-quality, evidence-based, equitable and respectful care. The right amount of care needs to be offered at the right time, and delivered in a manner that respects, protects, and promotes human rights.

Laboratory evaluation of the Chembio Dual Path Platform HIV-Syphilis Assay

Background

Use of rapid diagnostic tests for HIV and syphilis has increased remarkably in the last decade. As new rapid diagnostic tests become available, there is a continuous need to assess their performance and operational characteristics prior to use in clinical settings.

Objectives

In this study, we evaluated the performance of the Chembio Dual Path Platform (DPP^®) HIV–Syphilis Assay to accurately diagnose HIV, syphilis, and HIV/syphilis co-infection.

Method

In 2013, 990 serum samples from the Georgia Public Health Laboratory in Atlanta, Georgia, United States were characterised for HIV and syphilis and used to evaluate the platform. HIV reference testing combined third-generation Enzyme Immunoassay and Western Blot, whereas reference testing for syphilis was conducted by the Treponema pallidum passive particle agglutination method and the TrepSure assay. We assessed the sensitivity and specificity of the DPP assay on this panel by comparing results with the HIV and syphilis reference testing algorithms.

Results

For HIV, sensitivity was 99.8% and specificity was 98.4%; for syphilis, sensitivity was 98.8% and specificity was 99.4%. Of the 348 co-infected sera, 344 (98.9%) were detected accurately by the DPP assay, but 11 specimens had false-positive results (9 HIV and 2 syphilis) due to weak reactivity.

Conclusion

In this evaluation, the Chembio DPP HIV–Syphilis Assay had high sensitivity and specificity for detecting both HIV and treponemal antibodies. Our results indicate that this assay could have a significant impact on the simultaneous screening of HIV and syphilis using a single test device for high-risk populations or pregnant women needing timely care and treatment.

Integrating Human Immunodeficiency Virus and Reproductive, Maternal and Child, and Tuberculosis Health Services Within National Health Systems

Joint United Nations Programme on HIV/AIDS (UNAIDS) established 90-90-90 HIV treatment targets for 2020 including the following: 90 % of HIV-infected people know their HIV status, 90 % of HIV-infected people who know their status are on treatment, and 90 % of people on HIV treatment have a suppressed viral load. Integration of HIV and other programs into the national health system provides an important pathway to reach those targets. We examine the case for integrating HIV and other health services to ensure sustainability and improve health outcomes within national health systems. In this non-systematic review, we examined recent studies on integrating HIV, tuberculosis (TB), maternal-child health (MCH), and sexually transmitted infection (STI) programs. Existing evidence is limited about the effectiveness of integration of HIV and other services. Most studies found that service integration increased uptake of services, but evidence is mixed about the effect on health outcomes or quality of health services. More rigorous studies of different strategies to promote integration over a wider range of services and settings are needed. Research on how best to maximize benefits, including sustainability, of integrated services is necessary to help inform international and national policy. We recommend additional interventions to test how best to integrate HIV and MCH services, HIV and TB services, HIV testing and treatment, and STI testing and treatment.

Current Perspectives on Prevention of Mother-to-Child Transmission of Syphilis

This article aims to provide an update on the prevention of mother-to-child transmission of syphilis by drawing upon some important basic concepts and reviewing the most recent literature on the diagnosis and treatment of syphilis in pregnancy. New technologies, such as automated and point-of-care immunologic tests, are shifting some paradigms, which will certainly be further investigated in the forthcoming years. This is the time to carefully evaluate traditional as well as new strategies to prevent congenital syphilis. Adverse outcomes of mother-to-child transmission of syphilis can be prevented with antenatal screening and penicillin therapy, which proved to have an excellent cost-benefit ratio even in populations with a low prevalence of syphilis. However, syphilis epidemiology is influenced by socioeconomic and cultural factors, and major challenges are faced by poor and developing countries in which the severity of the problem is extremely alarming. On the other hand, the emergence of new technologies has raised doubts about the best algorithm to be used when proper laboratory resources are available. Conditions are quite heterogeneous across populations, and some procedures should not be generalized while there is no evidence that supports some changes and while in-depth studies about local conditions are not conducted. Official organizations need to be alert in order to avoid isolated decisions and ensure that evidence-based guidelines be used in the management of syphilis in pregnancy.

Flexible opto-electronics enabled microfluidics systems with cloud connectivity for point-of-care micronutrient analysis

In developing countries, the deployment of medical diagnostic technologies remains a challenge because of infrastructural limitations (e.g. refrigeration, electricity), and paucity of health professionals, distribution centers and transportation systems. Here we demonstrate the technical development and clinical testing of a novel electronics enabled microfluidic paper-based analytical device (EE-μPAD) for quantitative measurement of micronutrient concentrations in decentralized, resource-limited settings. The system performs immune-detection using paper-based microfluidics, instrumented with flexible electronics and optoelectronic sensors in a mechanically robust, ultrathin format comparable in size to a credit card. Autonomous self-calibration, plasma separation, flow monitoring, timing and data storage enable multiple devices to be run simultaneously. Measurements are wirelessly transferred to a mobile phone application that geo-tags the data and transmits it to a remote server for real time tracking of micronutrient deficiencies. Clinical tests of micronutrient levels from whole blood samples (n=95) show comparable sensitivity and specificity to ELISA-based tests. These results demonstrate instantaneous acquisition and global aggregation of diagnostics data using a fully integrated point of care system that will enable rapid and distributed surveillance of disease prevalence and geographical progression.