Implementation and outcomes of guideline revisions for the prevention of mother-to-child HIV transmission in Mother Support Programme, Addis Ababa, Ethiopia

PLoS ONE, Volume 13, No. 6, Year 2018

Interpretation

About 40% of the new HIV infections in Ethiopia are among children < 15 years of age. The great majority of these infections occur through Mother-to-child HIV transmission (MTCT). For prevention of MTCT, the national guidelines has been revised to incorporate scientific advances in HIV prevention, treatment and care. Since 2005, the country has been implementing a peer mentor programme called Mother Support Group (MSG), which provides psychosocial and adherence support for HIV positive mothers. This study examined implementation of PMTCT guidelines revisions and outcomes of HIV exposed babies in the MSG in Addis Ababa. Retrospective routine data were collected between 2005 and August 2013 from seven randomly selected primary health facilities. Odds ratios and 95% confidence intervals were calculated using logistic regression models. Several guidelines revisions were made between 2001 and 2013 in HIV testing approaches, prophylactic antiretroviral options, infant feeding recommendations and infant HIV testing algorithms. Revisions on the CD4 thresholds were associated with a significant increase in the proportion of women initiating antiretroviral treatment from 0 in 2005 to 62% in 2013. Revisions in infant feeding recommendations led to a 92.3% reported practice of exclusive breastfeeding in 2013 compared to 60.9% in 2005. Two and four percent of the HIV exposed babies were HIV positive by six and 18 months respectively. Not receiving prophylactic ART and receiving mixed feeding were independent predictors for babies having an HIV positive antibody test at 18 months. The rate of HIV status disclosure increased significantly year by year. Over the years, the PMTCT recommendations have moved from having a solo focus on PMTCT to holistic and inclusive approaches emphasizing survival beyond HIV prevention. The data reflect favourable outcomes of HIV exposed babies in terms of averted MTCT though serious gaps in data quality remain. For successful implementation of Option-B plus, the identified gaps in the MSG need to be addressed. Addis Ababa, the capital of Ethiopia has the highest HIV prevalence in the country. Although the HIV incidence has been steadily declining since 2005, still approximately 5% pregnant women in the city are living with the virus [12]. For the prevention of MTCT, a free PMTCT programme was launched in 2003. In 2004, 24 primary care facilities, referred in this study as health centers started implementing the programme. Following progress in the rolling out of the PMTCT programme more and more health facilities have started implementing every year. The programme has been implemented in accordance with the national PMTCT guidelines revisions and updates that follow scientific advances and global recommendations. The first national guideline recommended voluntary HIV counselling and testing to identify and enrol HIV positive women in PMTCT programme. Single dose nevirapine (NVP) prophylaxis at birth, exclusive formula as first line infant feeding choice and antibody testing of HIV exposed babies at 18 months of age were among the recommendations. This guidelines has supported the implementation of the national PMTCT programme between 2005 and 2007 (Table 1). AFASS—affordable, feasible, acceptable sustainable and safe, ART- antiretroviral therapy, HAART—highly active antiretroviral treatment, NVP—Nevirapine, ZDV—Zidovudine, 3TC- Lamuvudine A comprehensive revision of the guideline was made in 2007 that shifted the HIV testing approach from opt-in to opt-out. This has made antenatal HIV testing a routine standard of care [4]. The prophylaxis regimen has shifted from mono-therapy to multidrug therapy. This shift was in line with the 2004 WHO recommendations on antiretroviral drug for treating pregnant women and preventing HIV infection in infants [13]. Prophylaxis ART was initiated at 28 weeks of gestation in women with CD4 count ≥ 200 cells/mm2, while those who have a CD4 cell count < 200 cells/mm3 initiate HAART. This guideline promoted exclusive breastfeeding as the preferred infant feeding method for the first six months, then follows complementary feeding until 18 months of age. The revision also incorporated Deoxyribonucleic acid (DNA) Polymerase chain reaction (PCR) infant HIV testing at six weeks from dried blood sample (DBS) followed by confirmatory HIV antibody testing at 18 months or one week following complete cessation of breastfeeding. The 2007 versions guided the national PMTCT programme implementation from 2008 to 2010 (Table 1). The 2011 revision was mainly on prophylaxis regimen in accordance with the WHO recommendations made in 2010 that introduced Option-A [5, 14, 15]. In Option-A, prophylaxis ART is initiated in early pregnancy and to be continued until cessation of breastfeeding. Pregnant women whose CD4 count is ≥ 350 cells/mm3 receive prophylaxis. Pregnant women whose count < 350 cells/mm3 irrespective of clinical stage and those in the WHO stage 3 and 4 initiate HAART (Table 1). The 2011 revision had guided the national PMTCT programme from 2011 to August 2013. In February 2013, Ethiopia officially launched Option-B plus to accelerate progress to achieve elimination of MTCT. In Option-B plus, women start lifelong ART from the time of HIV diagnosis irrespective of their CD4 cell count, viral load or WHO clinical stage. Single pill fixed dose combination of Tenofovirdisoproxilfumarate, lamuvididne and efavirenz (TDF/3TC/EFV) is the drug of choice. Option-B plus has high efficacy in reducing MTCT and horizontal transmission to sexual partners, potential to increase ART coverage, significant maternal health benefit and has high programme acceptability [2, 9]. Although, Ethiopia’s motivation to move from Option A to Option B plus was primarily to achieve its ambitious goal of eliminating MTCT by 2015, being a country with a generalized epidemic, the programmatic and operational advantages of it were also additional driving forces [9]. Since August 2013 the Option-B plus has been rolled out in public health facilities by replacing all the existing prophylactic ART options [9]. Partner involvement in PMTCT programme and HIV serostatus disclosure to partner have been an integral part of all the PMTCT guidelines in Ethiopia [4–6]. Several studies have shown improved adherence to PMTCT services among women whose partners were involved in the PMTCT programme and those who disclosed their HIV positive status to their partners [16–18]. Moreover, all the guidelines have emphasised the need for linking HIV positive women to treatment, care and support services. To optimize the effectiveness of the PMTCT programme, a MSG was launched in 2005 in public health facilities [8]. This peer mentor programme follows women who found to be HIV positive during their peri-partum visits in public health facilities. Only women who wish to participate in the programme are enrolled. The programme offers regular meetings and discussion sessions for the women to express their concerns, pose questions and clarify doubts and myths. Scheduled meetings are often accompanied by a traditional “coffee ceremony” where all women come together to share each other’s experience and to discuss psychosocial and medical issues. Mentor mothers provide peer counselling on: Moreover, the MSG providers do routine registration; link HIV positive women to appropriate services such as ART, family planning, nutrition programmes, social support and infant HIV testing services. They also dispense prophylactic cotrimoxazol for HIV exposed babies and condoms in some of the MSG sites. The MSG providers are volunteers who only receive transport allowances. The number of MSG providers in each site ranges from three to four. The MSG initiative receives support from international and local partners involved in the implementation of the PMTCT programme in the country. In the early years, IntraHealth is an international NGO used to provide consistent yet modest technical, financial and logistic supports for the coffee ceremonies, training and transportation allowance for mentor mothers [7]. Later, when Management Science for Health and John Hopkins University took over the programmes, such incentives were reduced [8]. Considering its significant contributions, the national PMTCT guidelines have incorporated the MSG activities since 2007. However, there was no direct support from the government for the programme until the launching of the Option-B plus in 2013. For the successful rollout of the Option-B plus initiative, currently the Federal HIV/AIDS prevention and control office and the Federal Ministry of health have been working jointly to fully integrate the MSG endeavour in the national PMTCT programme. This study, conducted in September 2013 had collected routine retrospective data from 2005 to August 2013 from health centers. Ten public primary care facilities were randomly selected one from each sub-city of Addis Ababa. Of these, three of the health centers were found not to have the MSG programme and hence excluded. The study also excluded hospitals, as they did not have the MSG programme. The study was ethically approved as part of a project conducted in Addis Ababa in collaboration with the Addis Ababa City Administration Health Bureau and the Addis Ababa University from 2013 to 2015. The project received Ethical approvals from the Addis Ababa City Administration, Health Bureau ethics committee and from the regional ethics committee in Western Norway. For this study, retrospective routine data was collected anonymously from logbooks using client medical registration number as unique identifier. To access the MSG logbooks; study permit was first obtained first from the Addis Ababa City Administration, Health Bureau, then from respective sub-city health bureau’s and from each health center. The principal investigator, who has been working closely with the Addis Ababa City Administration, Health Bureau and Addis Ababa University since 2009, collected all the data. In each of the selected health facilities, the MSG programme logbooks used for recording routine PMTCT data were reviewed. In the early phase of the programme, there were two major logbooks; one for recording data during pregnancy and the other for recording data after birth. The two logbooks have the mother record number as a unique code. This study used these codes to link the two logbooks. In recent years, the entries in the two logbooks were merged together with the most recent logbook recording both pre-partum and post-partum information including infant HIV testing. There were inconsistencies in the recording and reporting across the MSG sites. This was partly due to different stakeholders running the programmes at different times. Gaps in the quality of data were commonplace, and some sites were worse than others. Despite the changes in PMTCT interventions across the years, there were limited updates in the MSG logbooks. The aforementioned factors also presented challenges to ensure data quality and might have introduced bias to the study. In total, there were 1,084 women registered in the MSG logbooks in the seven health facilities from 2005 to August 2013. Of these, 321 (42%) of the data did not have complete information. Missing data is a common problem in studies using routine data collected for reporting purposes. Missing data not only introduce bias but also compromises the statistical power of a study [19–21]. It is more problematic when the missing data is related to an outcome or exposure. In the present study, the missing data appeared to be related to practical and logistic issues within the MSG programme than attrition and study outcomes. Low literacy of the mentor mothers in recording observations and their poor awareness about its significance, inconsistencies in the logbooks, poor monitoring and evaluation of the programme, limited technical and logistic supports to the programme and the challenges surrounding DBS testing (eg. drawing blood sample, taking sample to central laboratory, collecting test results, recording results on logbooks and communicating test results to mothers) had contribution for the poor quality of the MSG reports and for the missing data. To minimize bias due to missing data and to yield least biased estimates, studies use different missing data analysis methods including deletion also called conventional, nonstochastic imputation and stochastic imputation methods [19, 20, 21]. The present study has employed the conventional approach, assuming that the missing data have occurred at random. The study presented only cases with complete data on exposed babies HIV testing outcomes [19, 20]. In a review, Kang indicates, “missing at random does not mean the missing data can be ignored” [19]. In this regard, the present study undertook sensitivity analysis in addition, to account for potential bias due to the missing data. [22]. Data were analysed using the SPSS statistical package version 21. The number and percentages of women and babies who received prophylaxis in relation to PMTCT guidelines revisions, trend in infant feeding practices in relation to PMTCT guidelines revisions, percentage of babies having DNA PCR and HIV antibody testing, number and percentage of women who disclosed their HIV status to partner and partner HIV test results were calculated. Using bivariate and multivariate logistic regression analyses, odds ratio (OR) and 95% confidence interval (CI) were calculated to determine predictors for exposed infant HIV test status. The predictor variables entered in the bivariate model were year enrolled in MSG, women ART medicine, infant prophylaxis, infant feeding methods, partner HIV test status and disclosure to partner. Of these, infant prophylaxis, infant feeding methods and partner HIV test status showed a chi square statistical p-value ≤ 0.2 and hence entered into the multivariables model to control for potential confounding. A variable having CIs including one for adjusted OR was not considered as an independent predictor. Sensitivity analysis was done to account for potential bias due to missing data as described above.

AI Digest

Study Justification:

– The study aims to examine the implementation of guideline revisions for the prevention of mother-to-child HIV transmission (PMTCT) in Addis Ababa, Ethiopia.
– The justification for the study is the high prevalence of new HIV infections among children in Ethiopia, with the majority of these infections occurring through mother-to-child transmission.
– The study focuses on the Mother Support Group (MSG) program, which provides psychosocial and adherence support for HIV-positive mothers.
– The study aims to assess the outcomes of HIV-exposed babies in the MSG program and identify gaps in data quality.

Highlights:

– The study found that revisions in PMTCT guidelines, including changes in HIV testing approaches, antiretroviral options, and infant feeding recommendations, led to positive outcomes.
– The proportion of women initiating antiretroviral treatment increased significantly from 0% in 2005 to 62% in 2013.
– Exclusive breastfeeding practices increased from 60.9% in 2005 to 92.3% in 2013.
– The rate of HIV status disclosure also increased significantly over the years.
– The study highlights the favorable outcomes of HIV-exposed babies in terms of averted mother-to-child transmission, but also identifies gaps in data quality that need to be addressed.

Recommendations:

– The study recommends addressing the identified gaps in the Mother Support Group (MSG) program for successful implementation of Option-B plus, which involves lifelong antiretroviral therapy for HIV-positive women.
– Recommendations include improving data quality, providing support for mentor mothers in the MSG program, and integrating the MSG program fully into the national PMTCT program.
– The study emphasizes the need for a holistic and inclusive approach to PMTCT, focusing on survival beyond HIV prevention.

Key Role Players:

– Federal HIV/AIDS prevention and control office
– Federal Ministry of Health
– Addis Ababa City Administration Health Bureau
– Addis Ababa University
– International and local partners involved in the implementation of the PMTCT program

Cost Items for Planning Recommendations:

– Training and capacity building for mentor mothers in the MSG program
– Transportation allowances for MSG providers
– Support for data quality improvement
– Integration of the MSG program into the national PMTCT program
– Provision of antiretroviral therapy, family planning, nutrition programs, and social support services for HIV-positive women
– Prophylactic cotrimoxazole and condoms for HIV-exposed babies
Please note that the cost items provided are general suggestions and may vary depending on the specific context and resources available.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is strong, but there are some limitations that can be addressed to improve it. The study collected retrospective routine data, which may have introduced bias and compromised data quality. There were inconsistencies in the recording and reporting of data across the Mother Support Group (MSG) sites, and missing data was a common problem. To improve the evidence, future studies can consider using prospective data collection methods and implementing measures to improve data quality, such as standardized recording and monitoring procedures. Additionally, addressing the challenges surrounding infant HIV testing, such as improving logistics and communication of test results, can help ensure more complete and accurate data.

Abstract

Addis Ababa, the capital of Ethiopia has the highest HIV prevalence in the country. Although the HIV incidence has been steadily declining since 2005, still approximately 5% pregnant women in the city are living with the virus [12]. For the prevention of MTCT, a free PMTCT programme was launched in 2003. In 2004, 24 primary care facilities, referred in this study as health centers started implementing the programme. Following progress in the rolling out of the PMTCT programme more and more health facilities have started implementing every year. The programme has been implemented in accordance with the national PMTCT guidelines revisions and updates that follow scientific advances and global recommendations. The first national guideline recommended voluntary HIV counselling and testing to identify and enrol HIV positive women in PMTCT programme. Single dose nevirapine (NVP) prophylaxis at birth, exclusive formula as first line infant feeding choice and antibody testing of HIV exposed babies at 18 months of age were among the recommendations. This guidelines has supported the implementation of the national PMTCT programme between 2005 and 2007 (Table 1). AFASS—affordable, feasible, acceptable sustainable and safe, ART- antiretroviral therapy, HAART—highly active antiretroviral treatment, NVP—Nevirapine, ZDV—Zidovudine, 3TC- Lamuvudine A comprehensive revision of the guideline was made in 2007 that shifted the HIV testing approach from opt-in to opt-out. This has made antenatal HIV testing a routine standard of care [4]. The prophylaxis regimen has shifted from mono-therapy to multidrug therapy. This shift was in line with the 2004 WHO recommendations on antiretroviral drug for treating pregnant women and preventing HIV infection in infants [13]. Prophylaxis ART was initiated at 28 weeks of gestation in women with CD4 count ≥ 200 cells/mm2, while those who have a CD4 cell count < 200 cells/mm3 initiate HAART. This guideline promoted exclusive breastfeeding as the preferred infant feeding method for the first six months, then follows complementary feeding until 18 months of age. The revision also incorporated Deoxyribonucleic acid (DNA) Polymerase chain reaction (PCR) infant HIV testing at six weeks from dried blood sample (DBS) followed by confirmatory HIV antibody testing at 18 months or one week following complete cessation of breastfeeding. The 2007 versions guided the national PMTCT programme implementation from 2008 to 2010 (Table 1). The 2011 revision was mainly on prophylaxis regimen in accordance with the WHO recommendations made in 2010 that introduced Option-A [5, 14, 15]. In Option-A, prophylaxis ART is initiated in early pregnancy and to be continued until cessation of breastfeeding. Pregnant women whose CD4 count is ≥ 350 cells/mm3 receive prophylaxis. Pregnant women whose count < 350 cells/mm3 irrespective of clinical stage and those in the WHO stage 3 and 4 initiate HAART (Table 1). The 2011 revision had guided the national PMTCT programme from 2011 to August 2013. In February 2013, Ethiopia officially launched Option-B plus to accelerate progress to achieve elimination of MTCT. In Option-B plus, women start lifelong ART from the time of HIV diagnosis irrespective of their CD4 cell count, viral load or WHO clinical stage. Single pill fixed dose combination of Tenofovirdisoproxilfumarate, lamuvididne and efavirenz (TDF/3TC/EFV) is the drug of choice. Option-B plus has high efficacy in reducing MTCT and horizontal transmission to sexual partners, potential to increase ART coverage, significant maternal health benefit and has high programme acceptability [2, 9]. Although, Ethiopia’s motivation to move from Option A to Option B plus was primarily to achieve its ambitious goal of eliminating MTCT by 2015, being a country with a generalized epidemic, the programmatic and operational advantages of it were also additional driving forces [9]. Since August 2013 the Option-B plus has been rolled out in public health facilities by replacing all the existing prophylactic ART options [9]. Partner involvement in PMTCT programme and HIV serostatus disclosure to partner have been an integral part of all the PMTCT guidelines in Ethiopia [4–6]. Several studies have shown improved adherence to PMTCT services among women whose partners were involved in the PMTCT programme and those who disclosed their HIV positive status to their partners [16–18]. Moreover, all the guidelines have emphasised the need for linking HIV positive women to treatment, care and support services. To optimize the effectiveness of the PMTCT programme, a MSG was launched in 2005 in public health facilities [8]. This peer mentor programme follows women who found to be HIV positive during their peri-partum visits in public health facilities. Only women who wish to participate in the programme are enrolled. The programme offers regular meetings and discussion sessions for the women to express their concerns, pose questions and clarify doubts and myths. Scheduled meetings are often accompanied by a traditional “coffee ceremony” where all women come together to share each other’s experience and to discuss psychosocial and medical issues. Mentor mothers provide peer counselling on: Moreover, the MSG providers do routine registration; link HIV positive women to appropriate services such as ART, family planning, nutrition programmes, social support and infant HIV testing services. They also dispense prophylactic cotrimoxazol for HIV exposed babies and condoms in some of the MSG sites. The MSG providers are volunteers who only receive transport allowances. The number of MSG providers in each site ranges from three to four. The MSG initiative receives support from international and local partners involved in the implementation of the PMTCT programme in the country. In the early years, IntraHealth is an international NGO used to provide consistent yet modest technical, financial and logistic supports for the coffee ceremonies, training and transportation allowance for mentor mothers [7]. Later, when Management Science for Health and John Hopkins University took over the programmes, such incentives were reduced [8]. Considering its significant contributions, the national PMTCT guidelines have incorporated the MSG activities since 2007. However, there was no direct support from the government for the programme until the launching of the Option-B plus in 2013. For the successful rollout of the Option-B plus initiative, currently the Federal HIV/AIDS prevention and control office and the Federal Ministry of health have been working jointly to fully integrate the MSG endeavour in the national PMTCT programme. This study, conducted in September 2013 had collected routine retrospective data from 2005 to August 2013 from health centers. Ten public primary care facilities were randomly selected one from each sub-city of Addis Ababa. Of these, three of the health centers were found not to have the MSG programme and hence excluded. The study also excluded hospitals, as they did not have the MSG programme. The study was ethically approved as part of a project conducted in Addis Ababa in collaboration with the Addis Ababa City Administration Health Bureau and the Addis Ababa University from 2013 to 2015. The project received Ethical approvals from the Addis Ababa City Administration, Health Bureau ethics committee and from the regional ethics committee in Western Norway. For this study, retrospective routine data was collected anonymously from logbooks using client medical registration number as unique identifier. To access the MSG logbooks; study permit was first obtained first from the Addis Ababa City Administration, Health Bureau, then from respective sub-city health bureau’s and from each health center. The principal investigator, who has been working closely with the Addis Ababa City Administration, Health Bureau and Addis Ababa University since 2009, collected all the data. In each of the selected health facilities, the MSG programme logbooks used for recording routine PMTCT data were reviewed. In the early phase of the programme, there were two major logbooks; one for recording data during pregnancy and the other for recording data after birth. The two logbooks have the mother record number as a unique code. This study used these codes to link the two logbooks. In recent years, the entries in the two logbooks were merged together with the most recent logbook recording both pre-partum and post-partum information including infant HIV testing. There were inconsistencies in the recording and reporting across the MSG sites. This was partly due to different stakeholders running the programmes at different times. Gaps in the quality of data were commonplace, and some sites were worse than others. Despite the changes in PMTCT interventions across the years, there were limited updates in the MSG logbooks. The aforementioned factors also presented challenges to ensure data quality and might have introduced bias to the study. In total, there were 1,084 women registered in the MSG logbooks in the seven health facilities from 2005 to August 2013. Of these, 321 (42%) of the data did not have complete information. Missing data is a common problem in studies using routine data collected for reporting purposes. Missing data not only introduce bias but also compromises the statistical power of a study [19–21]. It is more problematic when the missing data is related to an outcome or exposure. In the present study, the missing data appeared to be related to practical and logistic issues within the MSG programme than attrition and study outcomes. Low literacy of the mentor mothers in recording observations and their poor awareness about its significance, inconsistencies in the logbooks, poor monitoring and evaluation of the programme, limited technical and logistic supports to the programme and the challenges surrounding DBS testing (eg. drawing blood sample, taking sample to central laboratory, collecting test results, recording results on logbooks and communicating test results to mothers) had contribution for the poor quality of the MSG reports and for the missing data. To minimize bias due to missing data and to yield least biased estimates, studies use different missing data analysis methods including deletion also called conventional, nonstochastic imputation and stochastic imputation methods [19, 20, 21]. The present study has employed the conventional approach, assuming that the missing data have occurred at random. The study presented only cases with complete data on exposed babies HIV testing outcomes [19, 20]. In a review, Kang indicates, “missing at random does not mean the missing data can be ignored” [19]. In this regard, the present study undertook sensitivity analysis in addition, to account for potential bias due to the missing data. [22]. Data were analysed using the SPSS statistical package version 21. The number and percentages of women and babies who received prophylaxis in relation to PMTCT guidelines revisions, trend in infant feeding practices in relation to PMTCT guidelines revisions, percentage of babies having DNA PCR and HIV antibody testing, number and percentage of women who disclosed their HIV status to partner and partner HIV test results were calculated. Using bivariate and multivariate logistic regression analyses, odds ratio (OR) and 95% confidence interval (CI) were calculated to determine predictors for exposed infant HIV test status. The predictor variables entered in the bivariate model were year enrolled in MSG, women ART medicine, infant prophylaxis, infant feeding methods, partner HIV test status and disclosure to partner. Of these, infant prophylaxis, infant feeding methods and partner HIV test status showed a chi square statistical p-value ≤ 0.2 and hence entered into the multivariables model to control for potential confounding. A variable having CIs including one for adjusted OR was not considered as an independent predictor. Sensitivity analysis was done to account for potential bias due to missing data as described above.

Materials

https://efashare.b-cdn.net/materials/2311f0eddd38822081435faca3634bc643cbad2aef8b7e420307c7148bfc509d/pone.0198438.s001.docx

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Solutions: Implementing mobile health technologies, such as SMS reminders for antenatal care appointments and medication adherence, can help improve access to maternal health services. These reminders can be sent directly to pregnant women’s mobile phones, ensuring they receive timely and important information.

2. Telemedicine: Using telemedicine platforms, healthcare providers can remotely monitor and provide consultations to pregnant women, especially those in remote or underserved areas. This can help overcome geographical barriers and increase access to quality maternal healthcare.

3. Community Health Workers: Training and deploying community health workers (CHWs) can help bridge the gap between healthcare facilities and pregnant women in rural or hard-to-reach areas. CHWs can provide basic antenatal care, education, and support, and refer women to healthcare facilities when necessary.

4. Integrated Health Information Systems: Implementing integrated health information systems can improve coordination and communication between different healthcare providers involved in maternal health. This can help ensure continuity of care and reduce duplication of services.

5. Public-Private Partnerships: Collaborating with private sector organizations, such as pharmaceutical companies or technology companies, can help leverage their resources and expertise to improve access to maternal health services. This can include providing affordable or subsidized medications, medical equipment, or technology solutions.

6. Maternal Health Vouchers: Introducing maternal health vouchers or subsidies can help reduce financial barriers to accessing maternal health services. These vouchers can be distributed to pregnant women, allowing them to access essential services, such as antenatal care, delivery, and postnatal care, at reduced or no cost.

7. Maternal Health Education and Awareness Campaigns: Conducting targeted education and awareness campaigns can help improve knowledge and understanding of maternal health issues among pregnant women and their families. This can empower women to make informed decisions about their health and seek appropriate care.

8. Strengthening Health Systems: Investing in strengthening healthcare infrastructure, training healthcare providers, and ensuring the availability of essential medicines and supplies can improve overall access to maternal health services. This includes improving the quality and availability of antenatal care, skilled birth attendance, emergency obstetric care, and postnatal care.

It’s important to note that the specific context and needs of the community should be considered when implementing these innovations. Additionally, ongoing monitoring and evaluation should be conducted to assess the effectiveness and impact of these interventions.

AI Innovations Description

Based on the information provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthen the Mother Support Group (MSG) program: The study highlights the positive outcomes of the MSG program in providing psychosocial and adherence support for HIV positive mothers. To improve access to maternal health, it is recommended to further strengthen and expand the MSG program. This can be done by increasing the number of trained mentor mothers, providing ongoing training and support, and ensuring consistent funding and resources for the program.

2. Improve data quality and monitoring: The study identified gaps in data quality and inconsistencies in recording and reporting across the MSG sites. To address this, it is important to implement measures to improve data quality and monitoring. This can include providing training on data collection and recording, implementing standardized data collection tools, and conducting regular audits to ensure accuracy and completeness of data.

3. Enhance partner involvement and HIV status disclosure: The study highlights the importance of partner involvement in the PMTCT program and HIV status disclosure to partners. To improve access to maternal health, it is recommended to promote and support partner involvement in the PMTCT program. This can be done through targeted education and awareness campaigns, providing counseling and support services for couples, and addressing barriers to HIV status disclosure.

4. Expand access to antiretroviral treatment (ART): The study showed that revisions in CD4 thresholds were associated with an increase in the proportion of women initiating antiretroviral treatment. To further improve access to maternal health, it is recommended to expand access to ART for HIV positive pregnant women. This can be done by ensuring availability of antiretroviral drugs in health facilities, providing training on ART initiation and management, and addressing barriers to ART adherence.

5. Promote exclusive breastfeeding and safe infant feeding practices: The study found that revisions in infant feeding recommendations led to an increase in the reported practice of exclusive breastfeeding. To improve access to maternal health, it is important to continue promoting exclusive breastfeeding and safe infant feeding practices. This can be done through education and counseling for mothers, providing support for breastfeeding, and addressing cultural and social barriers to exclusive breastfeeding.

By implementing these recommendations, it is expected that access to maternal health, particularly for HIV positive mothers, can be improved, leading to better health outcomes for both mothers and their babies.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthening the Mother Support Group (MSG) Program: The MSG program has shown positive outcomes in terms of psychosocial and adherence support for HIV positive mothers. To improve access to maternal health, it is recommended to expand and strengthen the MSG program by increasing the number of mentor mothers, providing them with adequate training and support, and ensuring consistent funding and resources for the program.

2. Improving Data Quality: The study identified gaps in data quality, which can hinder effective monitoring and evaluation of maternal health programs. It is recommended to implement measures to improve data collection, recording, and reporting, such as standardized data collection tools, regular training for healthcare providers, and regular monitoring and evaluation of data quality.

3. Enhancing Partner Involvement: Partner involvement in the PMTCT program has been shown to improve adherence to services. To improve access to maternal health, it is recommended to promote and support partner involvement in the PMTCT program, including encouraging HIV testing and counseling for partners, providing education and support for partners, and addressing barriers to partner involvement.

4. Strengthening Linkages to Treatment, Care, and Support Services: To optimize the effectiveness of the PMTCT program, it is important to ensure that HIV positive women are linked to appropriate treatment, care, and support services. This includes providing access to antiretroviral therapy (ART), family planning services, nutrition programs, social support, and infant HIV testing services. Efforts should be made to strengthen the coordination and integration of these services within the PMTCT program.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify key indicators that reflect access to maternal health, such as the proportion of HIV positive women receiving antiretroviral treatment, the percentage of women practicing exclusive breastfeeding, or the rate of HIV status disclosure to partners.

2. Collect baseline data: Gather data on the selected indicators before implementing the recommendations. This can be done through retrospective data collection from health facilities or surveys conducted among the target population.

3. Implement the recommendations: Roll out the recommended interventions, such as strengthening the MSG program, improving data quality, enhancing partner involvement, and strengthening linkages to treatment, care, and support services.

4. Monitor and collect data: Continuously monitor the implementation of the recommendations and collect data on the selected indicators. This can be done through routine data collection, surveys, or qualitative assessments.

5. Analyze the data: Use statistical analysis techniques to analyze the collected data and assess the impact of the recommendations on the selected indicators. This can include calculating odds ratios, confidence intervals, and conducting multivariate regression analyses to determine predictors for improved access to maternal health.

6. Evaluate the impact: Assess the impact of the recommendations based on the analysis of the data. This can involve comparing the baseline data with the post-intervention data to determine any significant changes or improvements in access to maternal health.

7. Adjust and refine: Based on the evaluation results, make any necessary adjustments or refinements to the recommendations to further improve access to maternal health. This can include scaling up successful interventions, addressing any identified challenges or barriers, and continuously monitoring and evaluating the program to ensure ongoing improvement.

By following this methodology, it is possible to simulate the impact of the recommendations on improving access to maternal health and make evidence-based decisions for further program improvement.

Author


Dima Health

Statistics:

Citations: 8

Identifiers:

DOI: 10.1371/journal.pone.0198438

Research Areas:

Community Interventions, Disparities, Food Security, Genetics and Genomics, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female