Fragmentation of maternal, child and HIV services: A missed opportunity to provide comprehensive care

Abstract

BackgroundIn South Africa, coverage of services for mothers and babies in the first year of life is suboptimal despite high immunisation coverage over the same time period. Integration of services could improve accessibility of services, uptake of interventions and retention in care.AimThis study describes provision of services for mothers and babies aged under 1 year.SettingPrimary healthcare clinics in one rural district in KwaZulu-Natal, South Africa.MethodsAll healthcare workers on duty and mothers exiting the clinic after attending well-child services were interviewed. Clinics were mapped to show the route through the clinic taken by mother–baby pairs receiving well-child services, where these services were provided and by whom.ResultsTwelve clinics were visited; 116 health workers and 211 mothers were interviewed. Most clinics did not provide comprehensive services for mothers and children. Challenges of structural layout and deployment of equipment led to fragmented services provided by several different health workers in different rooms. Well-child services were frequently provided in public areas of the clinic or with other mothers present. In some clinics mothers and babies did not routinely see a professional nurse. In all clinics HIV-positive mothers followed a different route. Enrolled nurses led the provision of well-child services but did not have skills and training to provide comprehensive care.ConclusionsFragmentation of clinic services created barriers in accessing a comprehensive package of care resulting in missed opportunities to provide services. Greater integration of services alongside immunisation services is needed.

Evaluation of the effectiveness of a quality improvement intervention to support integration of maternal, child and HIV care in primary health care facilities in South Africa

“…In South Africa (SA), despite several policies supporting integration of PHC services such as the Ideal Clinic Realisation and Maintenance programme (ICRM) [3] and PHC Re-engineering [4], services for mothers and children are often fragmented, and essential services for mothers and children are frequently provided by different health practitioners in different areas of the clinic [5]. Furthermore, the physical structure of the clinic can be a limitation.…”

“…Furthermore, the physical structure of the clinic can be a limitation. Fragmentation of services leads to missed opportunities to provide comprehensive care to mothers and children, increased cost for the patient in transport and time off work, increased cost for the health system, and poor health outcomes [5]. To improve health delivery, it is important that health systems use existing resources more effectively and efficiently to improve coverage of health services and retention in care, and to improve outcomes for mothers and children [6].…”

Integrating services for impact and sustainability: a proof-of-concept project in KwaZulu-Natal, South Africa

“…At baseline most mother-baby pairs were seen only by enrolled nurses and the visit consisted of weighing and immunisation only, consistent with the exploratory work around integration previously described. 10 Registered nurses provide oversight for enrolled nurses and, because the proportion of mother-baby pairs seen by a registered nurse increased, there should have been more scope for registered nurses to support enrolled nurses providing growth monitoring. A possible reason for failure to provide the full cascade of growth monitoring services could be due to an increased emphasis on providing additional services to improve integration and uptake of HIV services.…”

“…Prior to the intervention, services were fragmented with many missed opportunities for providing care to mothers and their babies. 10 Partnering with the Department of Health at provincial and district level, we conducted a series of workshops to agree the package of essential services that should be provided to mothers and their babies. To address the missed opportunities, we implemented a multi-pronged, health systems strengthening intervention using a quality improvement approach to support the provision of an integrated package of services for mothers and babies.…”

“…In many instances, fragmentation of services continues to lead to missed opportunities to provide comprehensive integrated care. 10 Maternal, child and women's health (MCWH) services in South Africa are well established and widely used. Attendance at antenatal clinics is almost universal among pregnant women 11 and well-child services, including immunisation services, are well attended.…”