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Keywords:

  • maternal health services;
  • quality of care;
  • human immunodeficiency virus;
  • prevention;
  • mother-to-child transmission
  • services de santé maternelle;
  • qualité des soins;
  • VIH;
  • prévention;
  • transmission mère-enfant
  • servicios cuidado materno;
  • calidad del cuidado;
  • VIH;
  • prevención;
  • transmisión materno-infantil

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

Objective  To assess whether implementation of a prevention of mother-to-child HIV transmission (PMTCT) programme in Côte d’Ivoire improved the quality of antenatal and delivery care services.

Methods  Quality of antenatal and delivery care services was assessed in five urban health facilities before (2002–2003) and after (2005) the implementation of a PMTCT programme through review of facility data; observation of antenatal consultations (n = 606 before; n = 591 after) and deliveries (n = 229 before; n = 231 after) and exit interviews of women; and interviews of health facility staff.

Results  HIV testing was never proposed at baseline and was proposed to 63% of women at the first ANC visit after PMTCT implementation. The overall testing rate was 42% and 83% of tested HIV-infected pregnant women received nevirapine. In addition, inter-personal communication and confidentiality significantly improved in all health facilities. In the maternity ward, quality of obstetrical care at admission, delivery and post-partum care globally improved in all facilities after the implementation of the programme although some indicators remained poor, such as filling in the partograph directly during labour. Episiotomy rates among primiparous women dropped from 64% to 25% (P < 0.001) after PMTCT implementation. Global scores for quality of antenatal and delivery care significantly improved in all facilities after the implementation of the programme.

Conclusions  Introducing comprehensive PMTCT services can improve the quality of antenatal and delivery care in general.

Objectif:  Evaluer si la mise en place d’un programme de prévention de la transmission mère-enfant (PTME) du VIH en Côte d’Ivoire améliorait la qualité des soins prénataux et d’accouchement.

Méthodes:  La qualité des soins prénataux et des accouchements a étéévaluée dans cinq centres de santé urbains avant (2002-2003) et après (2005) la mise en place d’un programme de PTME à travers une analyse des données des services, l’observation des consultations prénatales (n=606 avant, n=591 après) et des accouchements (n=229 avant, n = 231 après), des interviews des femmes à la sortie et du personnel des services de santé.

Résultats:  Le dépistage du VIH n’avait jamais été proposé au départ et a été proposéà 63% des femmes dans la clinique anténatale lors de la première visite après la mise en place de la PTME. Le taux global des tests était de 42% et 83% des femmes enceintes testées positives pour le VIH ont reçu de la névirapine. En outre, la communication inter-personnelle et la confidentialité ont été significativement améliorées dans tous les services de santé. Dans la maternité, la qualité des soins obstétriques à l’admission, l’accouchement et les soins post-partum a en général été améliorée dans tous les services après la mise en place du programme bien que certains indicateurs demeurent encore faibles, tels que le remplissage systématique du partographe durant le travail. Le taux d’épisiotomie chez les primipares est passé de 64%à 25% (p <0,001) après la mise en œuvre de la PTME. Les scores globaux de la qualité des soins prénataux et de l’accouchement ont été significativement améliorés dans tous les services après la mise en œuvre du programme.

Conclusions:  L’introduction de services complets de la PTME peut améliorer la qualité des soins prénataux et de l’accouchement en général.

Objetivo:  Evaluar si la implementación de un programa de prevención vertical (PPV) en Costa de Marfil mejoraba la calidad de los servicios antenatales y de parto.

Métodos:  Se evaluó la calidad de los servicios antenatales y de parto en cinco centros sanitarios urbanos antes (2002-03) y después (2005) de la implementación de un PPV mediante la revisión de datos del centro; la observación de consultas antenatales (n=606 antes; n=591 después) y partos (n= 229 antes; n= 231 después) y entrevistas en el momento del alta de las mujeres; y entrevistas a la plantilla de sanitarios.

Resultados:  La prueba de VIH nunca fue propuesta desde el inicio y se propuso a un 63% de las mujeres en la primera visita prenatal después de la implementación del PPV. La tasa total de testaje fue del 42%, y un 83% de las mujeres embarazadas que dieron positivo para VIH recibieron nevirapina. Adicionalmente, la comunicación interpersonal y la confidencialidad mejoraron significativamente en todos los centros sanitarios. En la sala de maternidad, la calidad del cuidado obstétrico al momento de la admisión, del parto y del post-parto mejoró gradualmente y de forma global en todos los centros después de la implementación del programa, aunque algunos indicadores, tales como el rellenar el partógrafo directamente durante el trabajo de parto, continuaron siendo pobres. La tasa de episotomía entre mujeres primíparas bajó del 64% al 25% (p<0.001) después de la implementación del PPV. Los puntajes globales de calidad para los cuidados antenatales y de parto mejoraron significativamente en todos los centros después de la implementación del programa.

Conclusiones:  La introducción de los servicios de PPV puede mejorar la calidad del cuidado antenatal y del parto en general.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

Since 2000, many low-income countries have made considerable progress in scaling-up programmes of prevention of mother-to-child HIV transmission (PMTCT) (CDC 2004; Johnson et al. 2004; Tarwireyi 2004; Welty et al. 2005; TRAC Rwanda 2006; WHO/UNAIDS/UNICEF 2007). However, the coverage of PMTCT remains low, especially in Africa where most cases of mother-to-child transmission occur (WHO/UNAIDS/UNICEF 2007). It has become clear that PMTCT programmes cannot be effective without a good follow-up of mothers during pregnancy and delivery; and both mothers and infants in the post-partum period (Stringer et al. 2003; Perez et al. 2004; Manzi et al. 2005; Delva et al. 2006). Calls for collaboration and synergies between HIV and sexual and reproductive health programmes have been made, arguing that such relationships may yield mutual gain and improve maternal and child health (Graham & Newell 1999; Horizons Programs 2002; Israel & Kroeger 2003; WHO & UNFPA 2004; WHO/UNFPA/UNAIDS/IPPF 2005). Linkages between PMTCT and family planning programmes have received particular attention, since prevention of unplanned pregnancies among women living with HIV could substantially reduce the number of HIV infections among infants (Rutenberg & Baek 2004; Sweat et al. 2004; Reynolds et al. 2006). PMTCT programmes have also brought renewed attention to the content of a basic package of antenatal care; PMTCT programmes may result in broader access to high-quality antenatal care by inducing changes in policies, service delivery practices and resource allocation (Horizons Programs 2002; Israel & Kroeger 2003). However, there is little empirical evidence so far that PMTCT programmes can strengthen antenatal and delivery care services. The way PMTCT packages are designed and implemented – in particular whether they focus on PMTCT activities alone or whether they strengthen overall maternal health-care services – is also likely to influence the extent to which PMTCT affects the quality of services.

In Côte d’Ivoire, PMTCT is a public health priority. At the end of 2005, HIV prevalence among adults was estimated at 7.1% with women of child-bearing age representing more than 50% of all HIV-infected people [Institut National de la Statistique (INS), Ministère de la Lutte contre le Sida (MLS), Côte d'Ivoire, OCR Macro 2006]. Maternal mortality is also extremely high, around 600 per 100 000 live births in 2006 (Institut National de la Statistique (INS), Ministère de la Lutte contre le Sida (MLS), Côte d’Ivoire, OCR Macro 2006). Studies conducted in Abidjan and elsewhere have shown that the quality of maternal health services is poor (Portal et al. 1996; Duponchell 2001; Gohou et al. 2004). In 2000, a national programme of PMTCT was launched. The strategy was to integrate PMTCT activities into the existing maternal health services and to strengthen those services (Projet Retro-CI 2001; MSP & MLS Côte d’Ivoire 2006). The aim of this study was to evaluate changes in the quality of maternal health services before and after the implementation of a PMTCT programme in five health facilities in Côte d’Ivoire.

Methods

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

The study followed a before-and-after intervention design. Baseline surveys were conducted between July 2002 and May 2003 in five urban health facilities (Delvaux et al. 2007). PMTCT was implemented in the health facilities in the first semester of 2004 and the second round of data collection took place in the second semester of 2005.

Study sites

The study was conducted in Abidjan, the capital of Côte d’Ivoire, and in San Pedro, a large port city 300 km West of Abidjan, in five health facilities where the National Programme had planned to implement PMTCT activities: the Regional Hospital (CHR) of San Pedro, two health centres in San Pedro (Maternité Bardot and PMI Bardot) and two health centres in Abidjan (Formation Sanitaire Urbaine (FSU) Jean Delafosse and the Centre de Santé Urbain (CSU) Koumassi Grand Campement). All facilities were publicly funded, performed 3000 to 9000 ANC consultations per year and 1300 to 3000 deliveries per year, except PMI Bardot, which did not do deliveries. Three health facilities performed normal deliveries; CHR San Pedro, as a secondary referral hospital, also managed complicated deliveries.

Intervention: implementation of PMTCT

A preparatory phase preceded the launch of PMTCT activities by the National Programme and Projet Retro-CI in the five health facilities, consisting of renovating or constructing buildings, supplying equipment and training health staff (Projet Retro-CI 2001; Ministère de la Santé et de l’Hygiène Publique (MSP) & Ministère de la lutte contre le SIDA (MLS) 2006). Construction works were needed in order to meet PMTCT programme standards, such as having adequate rooms to conduct group sessions for health education and individual pre- and post-test counselling and to accommodate a small laboratory. Using a standard list of equipment and supplies provided by the PMTCT team, each health facility established its needs, including furniture, air-conditioning devices and fans, refrigerators, examination lamps and medical instruments such as delivery sets. The training consisted of a theoretical (3 days) and an on-site (6 weeks) component, followed by frequent supervision visits. The theoretical training was provided by PMTCT specialized staff from Projet Retro-CI to 63 health-care workers, including all maternity care services staff. The number of staff trained depending on the size of the facility. The theoretical component covered information on the PMTCT national programme, strategies to prevent MTCT, individual and group counselling techniques, safe obstetric practices, prevention of blood transmission of HIV, care of neonates and HIV positive women as well as psychosocial support. Detailed infection prevention procedures, labour monitoring and the use of the partograph were not included in the formal PMTCT training. The on-site training consisted of day-to-day assistance, feedback and support by experienced PMTCT staff mainly during antenatal care and in the laboratory. PMTCT activities were launched in January and May 2004 in San Pedro and Abidjan, respectively.

Study hypothesis

We hypothesized that while PMTCT intervention would result in increased uptake of HIV counselling and testing at antenatal clinic, it would also improve inter-personal communication, maintenance of confidentiality and provision of health information during antenatal care and at delivery. We also hypothesized that safer obstetric procedures such as a reduction in episiotomies would occur and that universal precautions for infection prevention would improve during antenatal and delivery care. Finally and more generally, we hypothesized that staff would feel more motivated and that their overall performance and the indicators of the quality of antenatal and delivery care would improve (Grembowski et al. 2005).

Data collection

Methods and instruments used at baseline and at follow-up were as described elsewhere (INSP/IMT 2004; Delvaux et al. 2007). The health facilities were assessed using a checklist and routine statistics were collected. In each health facility, consecutive antenatal care consultations and deliveries were observed and the same women were interviewed at exit by medical doctors who were trained on study tools and did not practice at the health facility. The target was 100 antenatal care consultations and 50 deliveries per health facility for each round of data collection. Observation and interview schedules were designed to obtain a representative sample of antenatal consultations (i.e. including all days of the week) and of deliveries (i.e. from all shifts including at night or during weekends). Health staff were also interviewed, that is all staff members in small facilities; maternity – laboratory staff, pharmacist and health facility manager in bigger health facilities.

The observation checklists for both antenatal and delivery care were based on best practice guidelines from Côte d’Ivoire and elsewhere (WHO 1996; Ministère de la Santé Publique (MSP) République de Côte d’Ivoire 2000). Observation checklists covered the dimensions of care of a regular antenatal visit and a normal delivery in Côte d’Ivoire. Structured patient and health staff questionnaires included questions on socio-demographic characteristics, perception of health-care services including HIV testing and PMTCT services.

Data analysis

We first compared uptake of HIV testing and PMTCT prophylaxis before and after implementation of PMTCT, using routine statistics and data from interviews. Socio-demographic characteristics of patients were compared using data from interviews. We then compared indicators of quality of antenatal and delivery care based on data from observations. Regarding delivery care, only normal deliveries were included in the analysis; deliveries ending up in C-sections at CHR San Pedro, were excluded (n = 6 before; n = 4 after). Data from all health facilities were pooled and proportions were compared, using the chi-squared test. Total scores for quality of antenatal and delivery care were calculated for each woman using all the quality indicators listed in Tables 1 and 2. We assigned a value of one if the activity had been performed according to standards and summed all the values for each woman in order to generate a total quality score. Median scores were compared by study period in each health facility and globally, using the Mann–Whitney U-test. A multivariate linear regression model with score as dependent variable was constructed both for antenatal and delivery care, adjusting for study period, health facility and the women’s characteristics which differed between both study phases (education and gravidity for antenatal care; and age and number of antenatal visits for delivery care). Models with and without interaction term (health facility*period) were compared. Data were analysed using spss 15.00.

Table 1.   Indicators of quality of antenatal care before and after PMTCT implementation in five health facilities in Côte d’Ivoire, 2002–2005
 Before PMTCT (N = 606)After PMTCT (N = 591)P-value
%Range†%Range†
  1. †Throughout the five health facilities.

  2. ‡Restricted to second and third trimester pregnancies.

Inter-personal communication
 Respectful greeting448–597025–91<0.001
 Invitation to sit6938–979376–99<0.001
 Language of communication understood9896–1009797–1000.155
 Goodbye by staff to patient at departure246–405313–70<0.001
Confidentiality – intimacy
 Absence of another patient while asking questions6328–988143–99<0.001
 Only provider and patient are present during examination9897–10010098–1000.035
Individual counselling
 Nutrition during pregnancy11–33529–44<0.001
 Family planning30–82822–41<0.001
 Prevention of sexually transmitted diseases70–333628–51<0.001
IEC group sessions
 Received IEC session that day20No IEC–474224–63<0.001
Among those who received IEC
 Prevention of STI/HIV–HIV test mentioned390–457553–93<0.001
 Nutrition was addressed 20–13157–24<0.001
 Family planning was addressed300–27104–9<0.001
Infection prevention
 Wash hands before or after examination30–12110–37<0.001
 Wear gloves for examination100100
Medical interview at first antenatal visit
 Previous pregnancies4415–635834–780.028
 History of caesarean section3515–525534–73<0.001
 Last menstrual period385–885515–900.002
 Age of pregnancy estimated7646–1008164–980.302
Clinical examination at antenatal visit
 Check blood pressure8232–1007625–970.019
 Vaginal examination99.598–1009997–1000.49
 Check uterine height‡9590–999894–1000.01
 Check foetal heart rate‡6761–757963–89<0.001
 Check foetal position‡6761–748166–93<0.001
Table 2.   Indicators of quality of delivery care before and after PMTCT implementation in four health facilities in Côte d’Ivoire, 2002–2005
 Before PMTCT (N = 229)After PMTCT (N = 231)P-value
%Range†%Range†
  1. †Throughout the four health facilities.

Professional attendance at delivery
 Doctor20–810–50.002
 Midwife8656–1007958–89
 Other120–362011–37
Inter-personal relationship
 Explain how to lie down on delivery table7151–978165–920.014
 Help patient to climb on examination table102–184428–60<0.001
 Information given on progress of labour80–154121–67<0.001
 Someone is present to provide support1915–302713–590.062
 Delivery is not seen by other patients6522–918152–96<0.001
Safe obstetric procedures
 Episiotomy: all women2411–60147–250.006
 Primiparous women6420–962513–36<0.001
Infection prevention
 Wash hands before delivery42–875–250.172
 Wash perineum before delivery96–112715–40<0.001
 Wear gloves for delivery9898–100 9897–1000.990
 Box of sterile instruments for each delivery570–956914–970.007
 Instruments in decontamination solution9587–1006648–82<0.001
Evaluation of general condition at first exam
 Blood pressure4115–946545–92<0.001
 Pulse30–9160–42<0.001
 Conjunctiva4728–646147–930.002
Examination at admission
 Check antenatal card (if available)9181–1009894–1000.001
 Asked about onset of labour pains2713–405037–78<0.001
 Asked if membranes had ruptured3318–514333–590.018
 Determine uterine height6548–778072–100<0.001
 Determine position of foetus5320–768474–100<0.001
 Measure foetal heart rate6030–738067–100<0.001
 Vaginal examination9693–989794–1000.426
Monitoring of labour – record keeping
 Partograph filled in during labour52–890–140.08
 Partograph ever filled in5219–897745–100<0.001
Delivery and third stage of labour
 Administer oxytocics after delivery8354–1009087–920.028
 Manual exploration of the uterus3217–586439–75<0.001
Post-partum care
 Check uterine retraction2812–435048–63<0.001
 Check blood pressure at least once347–673815–800.441
Newborn care
 Apply antimicrobial ointment to eyes210–81312–930.021
 Disinfect cord8365–1009994–100<0.001

Ethics

Verbal informed consent was obtained from all women and health-care providers before they were enrolled in the study. The protocol was approved by the ‘Comité d’éthique du Programme National de Lutte contre le VIH/SIDA (PNLS)’ in Côte d’Ivoire and by the Ethics Committee of the London School of Hygiene and Tropical Medicine.

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

HIV testing and PMTCT uptake

Before the implementation of the PMTCT programme, HIV testing was never proposed to women attending antenatal clinics. After the implementation of the programme, 63% (ranging from 42% to 81% throughout the five health facilities) of women attending the clinic for the first time were offered an HIV test. Analysis of routine statistics revealed that in the first half of 2005, 42% (range 27–56%) of new antenatal care users were tested for HIV. Among those testing positive for HIV, 83% of mothers and 78% of infants received nevirapine. Of 102 health facility staff interviewed before and 99 interviewed after PMTCT implementation, the proportion in favour of recommending an HIV test increased significantly in all health facilities after PMTCT implementation, overall from 82% to 98% (P < 0.001). The proportion of staff who (or their wife) would be willing to be tested when pregnant increased from 59% to 86% (P < 0.001) after PMTCT implementation.

Antenatal consultations

We studied 606 antenatal consultations before and 591 after PMTCT implementation. There was no significant difference between women attending antenatal care before and after PMTCT implementation in terms of age (on average 25 years), marital status (about 80% were married), gestational age at time of consultation (median, 6 months) and number of antenatal care visits (median, three visits). However, the women attending antenatal care after implementation of the PMTCT programme tended to be more educated (any education 53%vs. 47% at baseline, P = 0.055) and were of lower gravidity (median 2.0 vs. 3.0 at baseline, P < 0.001).

Indicators for quality of antenatal care

Observations showed that inter-personal communication and confidentiality improved in all health facilities (Table 1). For example, 81% of antenatal consultations took place without another patient being present after PMTCT implementation, compared to 63% before (P < 0.001). Individual health information and promotion on nutrition, HIV prevention and family planning improved substantially, mostly because very few midwives did any health promotion before the implementation of PMTCT. The proportion of women who took part in an IEC group session increased from 20% to 42% after PMTCT implementation. During those sessions, issues around HIV were more frequently addressed (39% before vs. 75% after, P < 0.001) but this was at the cost of other health information such as family planning (30% before vs. 10% after, P < 0.001).

Regarding infection prevention, the use of gloves was universal but the proportion of health workers who washed their hands remained extremely low (11% after vs. 3% before, P < 0.001). The midwives asked more questions during the medical interview and clinical examination somewhat improved. Checking blood pressure increased in the two sites in Abidjan but significantly decreased in one health facility in San Pedro (because one sphygmomanometer was not operating). Some important obstetrical practices such as checking the foetal heart rate and foetal position during the second or third trimester increased in all health facilities, and overall from 67% to 79% (P < 0.001) and from 67% to 81% (P < 0.001), respectively.

Delivery care

A total of 229 and 231 normal deliveries were studied before and after PMTCT implementation, respectively (Table 2). Women included after PMTCT implementation were older (26 vs. 24 years, P = 0.02) and had attended more antenatal care visits (median 3.4 vs. 2.7, P < 0.001) than those included at baseline. However, they did not differ in terms of marital status (about 80% were married), education level (about 50% had received any education) and gravidity (median, three pregnancies).

Indicators of quality of delivery care

Most deliveries were carried out by trained personnel (doctor or midwife) in both study phases although the percentage dropped in all health facilities, particularly in Maternité Bardot and FSU Jean Delafosse where midwife students were attending deliveries in the second round of the study (Table 2).

Inter-personal communication and privacy during labour improved substantially in all health facilities. For example, 41% of women observed after PMTCT implementation were given information about the progress of labour, compared to only 8% at baseline (P < 0.001). Episiotomy rates among primiparous women dropped in all health facilities, and overall from 64% to 25% (P < 0.001) after PMTCT implementation. The use of gloves for delivery was almost universal, but very few health workers washed their hands (7% after vs. 4% before). Instruments were soaked in decontamination solution less frequently after than before the intervention.

The quality of the clinical examination at admission improved after the implementation of the programme. Importantly, monitoring of the foetal heart rate and checking the foetal position improved in all health facilities. On the other hand, the proportion of partographs directly filled in during labour, although improved, remained low (9% of cases after vs. 5% before, P < 0.001). Administration of oxytocics during the third stage of labour reached 90% in all health facilities and particularly increased at the referral maternity (from 54% before to 87%) after the programme implementation. However, the rate of manual exploration of the uterus (to check for retained placenta fragments) which was already too high at baseline increased even further.

Quality scores for antenatal and delivery care

Scores calculated for both antenatal (25 variables) and delivery care (29 variables) significantly increased after PMTCT implementation (Figures 1 and 2). Median scores increased by 2 to 5 points for antenatal care and by 1.5 to 4 points for delivery care in the different health facilities. Nevertheless, scores remained low since slightly more than 50% of acts were carried out as recommended by the guidelines after PMTCT implementation. The difference between both study phases remained significant after adjusting for potential confounding in a multiple linear regression model, and the change, or period effect, in each health facility are shown in Table 3 (2). The model with the interaction term was significantly different from the model without it, meaning that period effect, although going in the same direction, differed in size between health facilities.

image

Figure 1.  Box plot of quality scores for antenatal care before and after PMTCT implementation, by health facility. Median quality score differs by study period in each facility (Mann–Whitney U-test, P < 0.001). Box shows median and interquartile range (IQR); whiskers indicate values 1.5 × IQR above Q75 and below Q25.

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image

Figure 2.  Box plot of quality scores for delivery care before and after PMTCT implementation, by health facility. Median quality score differs by study period in each facility (Mann–Whitney U-test, P < 0.001). Box shows median and interquartile range (IQR); whiskers indicate values 1.5 × IQR above Q75 and below Q25.

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Table 3.   Multiple linear regression coefficients of quality scores for antenatal and delivery care
VariableAntenatal care (score included 25 variables)Delivery care (score included 29 variables)
CoefficientP-valueCoefficientP-value
  1. †Average period effect among all sites.

  2. ‡Period effect (i.e. after PMTCT - before PMTCT) in each facility.

  3. (1) (2) Antenatal care: Y = Intercept for HF (1) + Slope for HF (2) * Period (0, Before; 1, After) + 0.4 *Edu + 0.1 *Gravidity.

  4. Delivery care: Y = Intercept for HF (1) + Slope for HF (2) *Period + 0.007 *Age + 0.13 *Number ANC visits.

  5. §Gravidity rescaled as gravidity -1 and age centred to obtain meaningful intercepts.

Study period (main effect†)3.7<0.0012.7<0.001
Intercept for each health facility (HF) (before PMTCT) (1)
 CHR San Pedro10.0 12.0 
 Maternité Bardot9.1 14.8 
 PMI Bardot11.9  
 FSU Jean Delafosse10.3 15.4 
 CSU Koumassi8.3 13.0 
Change‡ in each health facility (2)
 CHR San Pedro3.3<0.0012.5<0.001
 Maternité Bardot3.5<0.0011.60.005
 PMI Bardot2.1<0.001
 FSU Jean Delafosse3.7<0.0014.3<0.001
 CSU Koumassi5.7<0.0012.4<0.001
Education (yes vs. no)0.40.01
Gravidity (linear)§0.10.003
Age (linear)§0.0070.769
Number of antenatal care visits (linear)0.130.185

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

Our results show that while the introduction of a comprehensive PMTCT programme led to increased uptake of HIV testing and PMTCT, aspects of antenatal and delivery care not directly related to HIV care also improved, suggesting that the beneficial effects of PMTCT programmes may reach far beyond HIV care per se.

The magnitude of the changes in the quality of antenatal and delivery care after the introduction of the PMTCT programme was remarkable. For example, health promotion and counselling increased, the medical history taking was more comprehensive and many more women were informed about the progress of labour after PMTCT implementation. The improvements in the technical standards of delivery care were perhaps even more striking. Most notably, unnecessary episiotomies decreased substantially and staff were much more likely to evaluate the general condition of the woman at admission or to monitor foetal well-being during labour. A few studies have looked at changes in some HIV and maternity care indicators related to PMTCT implementation (Horizons Programs 2002; Israel & Kroeger 2003), but this is the first study to compare a comprehensive set of quality indicators, both in antenatal and delivery care services, before and after PMTCT implementation.

The reasons for improvement in quality of care after the implementation of PMTCT are manifold. The comprehensive nature of the PMTCT strategy, including substantial on site training, intense supervision, improvement in work conditions, provision of sufficient equipment or instruments for routine activities not always directly linked to PMTCT and involvement of the staff in decision making regarding their needs may have contributed to motivating the staff and increasing the quality of care (Stekelenburg et al. 2004; Grembowski et al. 2005). These five health facilities were among the first ones where PMTCT activities were integrated in Côte d’Ivoire and benefited from particular attention in terms of financial resources and training investment. Interestingly, the highest score for delivery care was reached by the health facility (FSU Jean Delafosse) where investment during PMTCT implementation was most important and where staff received additional training on obstetric care (outside PMTCT training) at the time or after PMTCT implementation.

Some specific components of the PMTCT training, such as its emphasis on communication skills to enable providers to perform adequate individual pre-/post-test and group counselling (Israel & Kroeger 2003; Ministère de la Santé et de l’Hygiène Publique (MSP) and Ministère de la lutte contre le SIDA (MLS) 2006), may have alerted the staff to the need for better communication in general. Similarly, PMTCT guidelines (WHO 2003; Ministère de la Santé et de l’Hygiène Publique (MSP) and Ministère de la lutte contre le SIDA (MLS) 2006) recommend the avoidance of episiotomies among HIV-infected women, and this may have led to an overall awareness that routine episiotomies are not required. This suggests that programmatic messages related to a change of practices in a targeted group may influence health-care providers’ practices as a whole.

The overall antenatal HIV testing rate of 42% is in line with previous studies (Ramon et al. 1998; Msellati et al. 2001) and more recent reports at national level in Côte d’Ivoire (DIPE & MSP 2007), but it falls short of the 80% reported more recently in a research setting in Abidjan and other African countries such as Rwanda (Ekouevi et al. 2004; TRAC Rwanda 2006). In our study, testing rates were lower in San Pedro than in Abidjan. In Côte d’Ivoire low acceptance may in part be due to women’s fears of the reactions of their husbands, worries about breaches of confidentiality, difficulties reported with clinic staff or procedures (Msellati et al. 2001; Painter et al. 2004), the desire to ask their husband first and to avoid the anguish of a positive test (Desgrées du Loûet al. 2007). Increasing HIV testing uptake among pregnant women remains a challenge in Côte d’Ivoire.

A number of general obstetric practices remained worryingly substandard. Hand washing in particular was extremely poor. Infection prevention was not covered as such in the formal PMTCT training, nor did the supervision by the PMTCT team include systematic checking of universal hygiene precautions, such as the presence of functioning autoclaves. This is surprising, given the increased importance of sterilized instruments in times of HIV. Filling in the partograph immediately during labour also remained very rare. This is unfortunately in line with previous studies which have consistently shown rare or incorrect use of the partograph (Maimbolwa et al. 1997; Bulatao & Ross 2002; Burkhalter et al. 2006) and calls for increased attention to improving labour monitoring.

Caution is required in attributing the observed changes to the PMTCT intervention per se, since factors external to the programme and methodological issues may explain the differences. First, some staff were newly deployed, unrelated to PMTCT implementation. For example, the unexpected increase in manual explorations of the uterus can be partly explained in one health facility (FSU Jean Delafosse) by the presence of a new midwife who had been taught to do such as systematic procedure after delivery. However, this does not explain the overall increase and such worryingly high rates of manual explorations of the uterus (WHO 2000). Second, baseline survey results were presented in Abidjan in October 2004 (between the two study phases) to reproductive health and quality of care programmes managers at central level (not to health facility staff). Some feedback and modification in some practices may have occurred. Finally, observation bias cannot be excluded: there is no reason to think that the bias due to the presence of an external observer differed between both study phases; however, medical staff observing the quality of care differed before and after the PMTCT intervention. Although the use of standard checklists, observation guidelines and close on-site supervision remained unchanged, some questions might not have been equally understood and results equally reported between both study phases.

Conclusions

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

Despite the study limitations, our results show that the introduction of comprehensive PMTCT services can also lead to an improvement of quality of antenatal and delivery care in general. However, some aspects of quality of services such as labour monitoring and infection prevention need more attention. PMTCT should be taken as an opportunity to strengthen overall maternity care services if one wants to reach Millenium Development Goals 4, 5 and 6 and improve maternal and child health. This should not only be written in guidelines but translated into action with an enhanced collaboration between HIV and maternal/reproductive health programmes and increased funding for maternal/reproductive health services.

Acknowledgements

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

We thank the clients and staff at the participating health facilities for making the study possible and the regional/national health authorities and Projet Retro-CI for their collaboration. We are grateful to Dominique Béhague for her valuable help in designing the study questionnaires and to Simon Collin and Joris Menten for useful advices for data analysis. This study was funded by the Belgian Development Cooperation (DGDC) and by MEASURE, United States Agency for International Development (USAID). The funders have no responsibility for the information provided or views expressed in this article.

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  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References
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