Background: Worldwide, an estimated 2.3 million children under the age of 15 are HIV positive. The main source of HIV infection in children is vertical transmission of HIV from mother-to-child during pregnancy, labor and delivery, or breastfeeding. Prevention of Mother-to-Child Transmission of HIV has been expanded in accelerated fashion throughout Ethiopia with all public hospitals and health centers providing the services. However, published studies on the services’ provision in the country are generally limited. If at all, they did not comprehensively examine quality of the services. Objective: The study aimed to assess the quality of Prevention of Mother-to-Child Transmission of HIV services in Gebretsadiq Shawo Memorial Hospital in Kafa Zone, Southwest Ethiopia. Methods: Facility based cross-sectional study involving both quantitative and qualitative methods was conducted in September 2012. A total of 311 pregnant mothers were interviewed and a one year (2011) record of PMTCT clients was reviewed and service provision processes were observed for 10 counseling sessions. Donabedian’s Structure-Process-Outcome model was used to conceptualize the study. Data were analyzed using SPSS for windows version 17 software. Descriptive statistics were computed to summarize the findings. Results: Almost all of the minimum required resources such as test kits, prophylactic drugs and other supplies were available in the hospital; counselors followed the national guideline in providing HIV counseling and testing services; and most (90%) of clients were satisfied or very satisfied by the PMTCT services they received. However, from 858 pregnant mothers who visited the ANC clinic in 2011, only 330(38.5%) were offered HIV pretest counseling, while 281 (33%) were tested. Conclusion: Although clients’ satisfaction by PMTCT service is very high, considerable proportion of pregnant mothers who utilize ANC services are not offered HIV counseling and testing services. Therefore, appropriate quality improvement interventions against the missed opportunities are highly recommended.
About 35 million people live with HIV in 2012 of these; 2.3 million are new HIV infections [
In Ethiopia, the trend of HIV incidence is decreasing; UNAIDS report shows that Ethiopia is one of the sub- Saharan countries demonstrating more than a 25% decline in new HIV infections [
Prevention of Mother to Child Transmission of HIV (PMTCT) service has been introduced with the objective of reducing vertical transmission with four major strategies: primary prevention of HIV infections among individuals of child-bearing age; prevention of unintended pregnancies among HIV-positive and HIV-negative females of child-bearing age; prevention of MTCT of HIV and provision of treatment, care and support for women living with HIV including children and families [
Ethiopia has begun implementing PMTCT service 2001 in four pilot hospitals and scaled it up to include most of public hospitals and health centers. It has developed PMTCT implementation guideline in the same year in line with the World Health Organization’s (WHO) recommendations, which focuses on opt-in approach and use of single dose Nevirapine (NVP) prophylaxis for the mother and the baby. The guideline was revised in 2007 and in 2012, taking into account the contemporary knowledge and recommendations from the WHO [
However, coverage of the PMTCT services persists to be low where 45% of pregnant mothers do not get HIV counseling and testing services [
The foundation of infection control is early diagnosis and effective treatment of infected people or patients based on standard procedures [
Several studies [
Successful implementation of evidence-based program guidelines can significantly improve patient safety and quality of care [
However, published studies on the PMTCT services’ provision in Ethiopia are generally limited. Even fewer studies do examine quality of the services. Therefore, this study has investigated the quality of PMTCT services’ provision using the Donabedian’s Structure-Process-Outcome model of health service quality assessment [
The study was conducted in Gebretsadiq Shawo Memorial Hospital. It is a zonal public hospital which is located in Southern Nations Nationalities and Peoples Region (SNNPR), Kafa zone, Bonga town; about 470 kilometers Southwest of Addis Ababa, Ethiopia. It provides both preventive and curative services to an estimated population of one million people. A facility based cross-sectional survey was conducted involving both qualitative and quantitative methods in September 2012. For the assessment of clients’ satisfaction, we interviewed a total of 311 clients at exit consecutively until the required sample was obtained. A one year (2011) PMTCT registers and delivery service records were reviewed. Adherence of service providers to the national PMTCT guideline was assessed and the volume of clients served, proportion of clients who accepted the PMTCT counseling and testing service, proportion of clients who had HIV positive results and those who got prophylaxis and who were professionally attended during child birth were determined. Observation of HIV counseling sessions was also performed to assess client counselor interaction, adequacy, compliance and quality of the counseling sessions. Accordingly, a total of 10 counseling sessions were randomly selected for this purpose. In addition, facility audit was done to assess the presence of the minimum required resources, including staffing, infrastructure, medicines and supplies. While a structured questionnaire was used for the exit interview, checklists were used for data abstraction from the PMTCT records and as well as for facility audit. The questionnaire was adapted from validated UNAIDS [
Quality of service is multidimensional concept and can be assessed in different ways. This study had employed Donabedian’s structure, process outcome model [
Data were checked for accuracy and completes; then, cleaned and coded and analyzed using SPSS for windows version 17 software. Descriptive statistics such as mean, standard deviation, median and proportions were computed as appropriate to summarize the findings and presented using frequency tables. Qualitative data obtained from resource inventory and direct observation were transcribed, summarized in to major thematic areas and presented in narrative form.
Last, the proposal was has got ethical approval from Jimma University Ethical Review Board. All study participants were informed about the objective and purpose of the study and written consent was obtained before data collection. The study subjects were given the chance to decline the participation or interrupt at any time if they didn’t feel comfortable. As HIV is still a stigmatizing condition, first service providers got consent from clients before they were approached by data collectors. In addition, the clients name was not retrieved from clinical registers.
A total of 311 clients responded to the questionnaire. The age of respondents ranges from 15 to 45 with a mean (±SD) age of 25.5 (±5.5) years. Ninety six percent of them were married and most of them were literate with only 8% being unable to read and write. More than half (53.4%) of the respondents were Orthodox Christians followed by Muslims (19.6%) and Protestants (18%). Kafa was the major ethnic group which accounted for 69% of the respondents, followed by Gurage (11%) and Amhara (9%). Majority (72%), of the respondents were urban dwellers. While 69.8% of the respondents had experienced a total of one or two pregnancies, only 4.2% had five and more pregnancies (
Most of the respondents (98%), knew about the presence of PMTCT service before they came to the hospital for ANC service. The commonest sources of information were health workers which accounted for 72% of the time, followed by family or friends (17%). Majority (76.5%), of the clients got the service in less than 30 minutes time with a range of 2 to 60 minutes. The duration of the counseling sessions ranged from 5 to 60 minutes with a median duration of 20 minutes.
In almost all cases, both pretest and posttest counseling sessions were given by the same counselor and during the counseling sessions no language barrier was reported by majority (87%), of the respondents. Clients’ perception about the benefit of the counseling sessions was positive where 99% believed that the counseling was beneficial and 96% said that they would recommend the service to pregnant mothers (
Majority (85%), of the respondents believed that the waiting room was comfortable where they were either very satisfied or satisfied with it. Almost, similar number of clients was satisfied by the counseling room’s comfort and privacy during counseling. Regarding the waiting time to see the PMTCT counselor, 38.6% of clients were very satisfied and 54% were just satisfied. More than 80% of the clients were either satisfied or very satisfied with the adequacy of the duration of the counseling session (
Regarding the counselors characteristics, most clients believed that the counselor was respectful (94%) and trustworthy (90%). Moreover, most of them were satisfied by the counselors’ explanation during counseling and his/her overall competency. When clients were asked to rate their satisfaction by the overall PMTCT services provision, about 90% of them were either satisfied or very satisfied (
In all of the 10 observations that were made, the counselor had received the women in welcoming manner and created a trusting or supportive rapport with the women. It was observed that the counselor listened to women’s ideas and concerns in eight of the 10 sessions; and invited them to ask questions in six sessions. The counselor had attempted to respond to each of the questions in all of these six sessions.
In all of the sessions, the counselor had avoided judgment or disapproval; treated women with empathy, dignity, and respect; used language and words that could be easily understood by the women and; maintained privacy. The counselor checked to be sure that the women understood the information provided in eight of the 10 observed sessions.
Regarding pretest counseling, the counselor had introduced and oriented the session to the women, prepared them well for the HIV test, explored options for reducing risk and assessed them for possible risks in all of the observed sessions. Post-test counseling for negative results was performed similarly in all of the observed sessions. Negative HIV-test results were provided, risk-reduction plan was negotiated, support for risk-reduction plan was identified; disclosure and partner referral was negotiated and, the importance of retesting following window period was discussed in all sessions.
However, the counselors didn’t give enough time for the counseling sessions which was by far lower than the recommended time. Moreover, they had repeatedly been missing some important components in the counseling manual during both pretest and posttest counseling sessions.
A one year record of ANC clients and delivery registers were reviewed. The review revealed that a total of 858
Characteristics (n = 311) | Frequency | Percent | |
---|---|---|---|
Age | 15 - 20 | 60 | 19.3 |
21 - 25 | 113 | 36.3 | |
26 - 30 | 92 | 29.6 | |
31 - 35 | 29 | 9.3 | |
36 - 40 | 14 | 4.5 | |
41 and above | 3 | 1.0 | |
Marital status | Married | 298 | 96 |
Single | 5 | 1.5 | |
Divorced | 2 | 0.6 | |
Widowed | 1 | 0.3 | |
Unmarried couples | 5 | 1.5 | |
Level of education | Unable to read and write | 25 | 8 |
Read and write only | 15 | 4.8 | |
Grade 1 - 6 | 68 | 21.9 | |
Grade 7 - 12 | 167 | 53.7 | |
College/University | 36 | 11.6 | |
Ethnicity | Kafa | 215 | 69 |
Gurage | 33 | 11 | |
Amhara | 28 | 9 | |
Oromo | 27 | 8.7 | |
Others | 8 | 2.5 | |
Religion | Orthodox | 166 | 53.4 |
Muslim | 61 | 19.6 | |
Protestant | 56 | 18 | |
Catholic | 28 | 9 | |
Occupation | Housewife | 113 | 36.3 |
Civil servant | 89 | 28.6 | |
Farmer | 61 | 19.6 | |
Merchant | 25 | 8 | |
Student | 21 | 6.8 | |
No job | 2 | 0.6 | |
Residence | Urban | 224 | 72 |
Rural | 87 | 28 | |
Total pregnancy | 1 - 2 | 217 | 69.8 |
3 - 4 | 81 | 26 | |
5 and above | 13 | 4.2 |
Variable | Frequency | Percent |
---|---|---|
Waiting time to see a service provider | ||
<30 minutes | 238 | 76.5 |
30 - 60 minutes | 73 | 23.5 |
Median = 10 minutes; Range = 2 - 60 minutes | ||
Duration of pre and posttest counseling sessions | ||
>15 minutes | 86 | 27.5 |
15 - 30 minutes | 191 | 61.5 |
>30minutes | 34 | 11.0 |
Median = 20 minutes; Range = 5 - 60 minutes | ||
Pretest and posttest counseling was given by the same counselor | 310 | 99.7 |
There was no language barrier | 271 | 87 |
The counseling session was beneficial | 308 | 99 |
Would recommend the service to others | 301 | 96.8 |
Item: how do you rate your satisfaction with: | Very satisfied | Satisfied | Neutral | Dissatisfied | Very dissatisfied | |||||
---|---|---|---|---|---|---|---|---|---|---|
No. | % | No. | % | No. | % | No. | % | No. | % | |
Comfort of the waiting room | 84 | 27.0 | 183 | 58.8 | 30 | 9.6 | 13 | 4.2 | 1 | 0.3 |
Waiting time | 120 | 38.6 | 168 | 54.0 | 20 | 6.4 | 2 | 0.6 | 1 | 0.3 |
Comfort of the counseling room | 121 | 38.9 | 160 | 51.4 | 27 | 8.7 | 2 | 0.6 | 1 | 0.3 |
Privacy of the counseling room | 125 | 40.2 | 152 | 48.9 | 29 | 9.3 | 4 | 1.3 | 1 | 0.3 |
Adequacy of duration of the counseling session | 164 | 52.7 | 125 | 40.2 | 17 | 5.5 | 3 | 1.0 | 2 | 0.6 |
Item: how do you rate your satisfaction with: | Very satisfied | Satisfied | Neutral | Dissatisfied | Very dissatisfied | |||||
---|---|---|---|---|---|---|---|---|---|---|
No. | % | No. | % | No. | % | No. | % | No. | % | |
Respectfulness of the counselor | 167 | 53.7 | 127 | 40.8 | 13 | 4.2 | 2 | 0.6 | 2 | 0.6 |
Trustworthiness of the counselor | 160 | 51.4 | 122 | 39.2 | 19 | 6.1 | 8 | 2.6 | 2 | 0.6 |
Clarity of the counselor’s explanation | 159 | 51.1 | 129 | 41.5 | 19 | 6.1 | 2 | 0.6 | 2 | 0.6 |
The counselor’s competency | 164 | 52.7 | 117 | 37.6 | 28 | 9.0 | 0 | 0 | 2 | 0.6 |
The overall services | 147 | 47.3 | 133 | 42.8 | 23 | 7.4 | 6 | 1.9 | 2 | 0.6 |
had at least first ANC visit at the hospital in the year 2011. Out of these mothers, only 330 (38.5%) were offered pre-test counseling and 281 (85.15%) got HIV test. Six (2.14%), mothers tested positive. All of the mothers who were tested were also post-test counseled, regardless of their serostatus. And only 33 partners got tested for HIV and one of them was HIV positive.
Out of the 858 pregnant mothers who had at least first ANC visit at Gebretsadiq Shawo Memorial hospital, 288 (33.6%), received labor and delivery services within the hospital. While 115 (39.9%), of these mothers had HIV test from ANC, of which, three (2.6%), were known HIV-positive; 173 (60.1%), were tested during or after delivery. Out of the 173 women who were tested during or after delivery, nine (5.2%), were positive for HIV. There were 12 HIV-positive women in total, making HIV prevalence rate among pregnant women who were attended their child birth at the hospital in the reference period to be 12 (4.17%). Three, (25%), of the 12 positive mothers had already been taking AZT in ANC whereas, the rest, nine (75%), were given the drug during labor. Infants exposed to 10(83.3%), positive mothers had received NVP at birth, and all of the positive mothers intended to breastfeed their infants.
There was no separate counseling room for PMTCT services provision in the hospital. As a result, the counseling room did not ensure auditory and visual privacy. Otherwise, the labour and delivery as well as the laboratory units were observed to be functional and available for PMTCT services delivery. There were also running water and electricity supplies.
Nevirapine in both its tablet and syrup forms was available neither in ANC nor in delivery room. All of the laboratory supplies that are required for the service provision were available. Similarly, all the basic obstetric care supplies, that is, delivery couches, delivery sets and Oxytocine were available in the hospital. Among the supplies that are required for infection prevention, gloves, aprons and autoclave were available while goggles and sharp boxes were lacking.
Except for pediatric follow-up register and referral linkage slip, all other recording and reporting formats related to PMTCT services were available in the hospital including; monthly summary reporting format, counseling registration book, ANC-PMTCT enrolment register, labour and delivery register, Lab log book, Lab referral slips and ANC-PMTCT appointment card. However, the following job aids and Information, Education, Communication/Behavioral Change Communication (IEC/BCC) materials were not available: PMTCT guideline, PMTCT performance standard, client education materials like brochures and leaflets, PMTCT cue card, and birth preparedness checklist.
Patient or client satisfaction is one of the desired outcomes of health care, a measure of the quality of care, and essential to assessments of quality Satisfaction of clients by the service determine effectiveness of health care [
Satisfaction of clients in this study was generally very high; most were either satisfied or very satisfied by all satisfaction items, which may be due to different factors besides genuine rating of clients. First satisfaction of clients could be affected by their HIV test result. Although the proportion of positive and negative test results is not assessed in this study, literatures showed that less than 5% [
Different studies have found a significant association between waiting time and satisfaction [
This study revealed that considerable proportion of ANC clients were missed opportunities. Only one third of the 858 pregnant mothers were offered pre-test counseling and only 281 of them got tested for HIV, of which, six mothers tested positive. If we consider that those mothers who were not tested for HIV had similar characteristics with the tested ones, around 12 HIV positive pregnant mothers were missed untested. Thus, considering the national rate of MTCT of HIV [
Most of the minimum required resources were available in the hospital; however, the counseling room was not separate as opposed to the recommendation of the national guideline [
This study used different methods to assess the quality of PMTCT services; however, the scope is limited to one hospital which is also an urban setting and this limitation should be considered in applying the finding to different settings. Moreover, the study employed exit interview techniques that could potentially reserve respondents from expressing their true feelings about the services.
The level of satisfaction with the PMTCT service provision was very high. Most of the minimum required resources to conduct the service were available in the hospital. However, the counseling room was not private and sound proof as recommended by the national PMTCT guideline. Moreover, more than half of pregnant mothers who came to the hospital for ANC service didn’t get HIV counseling and testing service as counselors failed to offer them the service and became missed opportunities. Therefore, Gebretsadiq Shawo Memorial Hospital should design appropriate quality improvement interventions to ensure that both the facility and the providers optimally adhered to the national PMTCT implementation guideline.
The authors declare that they have no competing interests.
Both authors contributed equally to this work.
We would like to acknowledge the administration and staff of Gebretsadiq Shawo Memorial hospital.
Negalign Berhanu Bayou,Yohannes Ejigu Tsehay, (2015) Quality of PMTCT Services in Gebretsadiq Shawo Memorial Hospital, Kafa Zone, South West Ethiopia: A Descriptive Study. Open Access Library Journal,02,1-12. doi: 10.4236/oalib.1101499
AIDS: Acquired Immunodeficiency Syndrome
ANC: Antenatal Care
HIV: Human Immunodeficiency Virus
NVP: Nevirapine
PMTCT: Prevention of Mother to Child Transmission of HIV
UNAIDS: United Nations Program on HIV and AIDS
WHO: World Health Organization
Part I. Socio-demographic characteristics of respondents.
Part 2. Source of information about the PMTCT service and clients experience at the PMTCT site.
Part 3. Satisfaction items.