Implementation of Option B and a fixed-dose combination antiretroviral regimen for prevention of mother-to-child transmission of HIV in South Africa: A model of uptake and adherence to care

PLoS ONE, Volume 13, No. 8, Year 2018

Interprétation

Introduction Initiating and retaining pregnant women on antiretroviral therapy (ART) to prevent mother-to-child HIV transmission (PMTCT) remains a major challenge facing African HIV programs, particularly during the critical final months prior to delivery. In 2013, South Africa implemented its “Option B” PMTCT regimen (three-drug ART throughout pregnancy and breastfeeding, regardless of maternal CD4 count) and introduced once-daily fixed-dose combinations and lifelong ART. Currently, the uptake of Option B and its possible impact on adherence to PMTCT during the critical final months of pregnancy is unclear. Materials and methods We prospectively collected visit data from a cohort of adult, HIV-infected, pregnant women between July 2013-August 2014 to estimate three models of adherence to PMTCT during the final 16 weeks immediately preceding delivery. Adherence was defined according to possession of antiretroviral drugs, which was inferred from clinic visit records under varying assumptions in each model. We describe uptake of the PMTCT regimen, gestational age at initiation, and model possible scenarios of adherence through delivery after the implementation of Option B. Results Among 138 women enrolled (median (IQR) age 28 years (24–32), median CD4 count 378 cells/mm3), median (IQR) gestational age at initiation was 22 weeks (16–26). Estimates of adherence during the final 16 weeks of pregnancy prior to delivery ranged from 75% (52–89%) under the best case scenario assumptions to 52% (30–75%) under the worst case scenario assumptions. Estimates of the proportion of women who would achieve 80% adherence to PMTCT were <50% across all models. Conclusions Despite the switch to Option B and once-daily dosing, South African women continue to initiate PMTCT late in pregnancy, and estimations of regimen adherence, as modelled using PMTCT visit attendance data, is poor, with <50% of women reaching 80% adherence during final months of pregnancy across all models. Further guideline changes and interventions are needed to achieve vertical transmission goals. The data utilized in this study were collected at a public-sector primary health clinic (PHC) in Johannesburg, South Africa. It is located in an informal settlement on the edge of the city with a large population of immigrants from neighboring countries and patients from other South African provinces. It provides a full range of primary healthcare services, including antenatal care (ANC), maternal and child health, HIV testing and counseling, ART initiation, and ART management. Under South African guidelines], women are advised to make at least four antenatal care visits prior to delivery, starting at 14 weeks’ gestation. PMTCT guidelines increased the required number of visits, however, as clinics standard practice was to provide only one month of ARV medication at a time during the study period. The clinic does not have a delivery ward; referral for delivery was to either a nearby hospital or one of three maternal obstetric units (MOUs) located 4, 5.5, and 7 kilometers from the clinic, respectively. At least one antenatal clinic visit was needed for a woman to obtain an antenatal care card, which is required to assure access to a hospital or MOU for delivery. We sequentially enrolled adult (≥18 years old), HIV-infected, pregnant women at the earliest clinic visit for a positive HIV test, provision of a blood sample for a CD4 count, or first ANC visit between July 4, 2013 and August 14, 2014. Women who were already on ART for their own health or who indicated that they did not intend to seek the remainder of their antenatal care at the study clinic were excluded. After informed consent, the women were administered a questionnaire eliciting information about demographic and socioeconomic characteristics; previous pregnancies, health-seeking behavior and exposure to PMTCT; normal activities and employment, and the costs the patient incurred per clinic visit. Study patients were then followed by passive medical record review, using the site’s and delivery facility’s routine patient records, until delivery. These records included antenatal and labour ward registries as well as an electronic medical record system, TherapyEdge-HIV™. Fields collected included dates of antenatal clinic visits, gravidity and parity, gestational age at first visit and predicted delivery date, date of HIV test, ARV regimen prescribed, and baseline CD4 count. Not all data for all study subjects could be found in the routine records maintained by the study site, nor could confirmation of all deliveries be found at the referral facilities. Viral load test results were not available for the majority of study participants, as most had spent fewer than 6 months on ART at the time of delivery. The primary defined outcome for this study was proportion of patients achieving 80% adherence to PMTCT in the 16 weeks immediately preceding date of delivery. For this analysis, we assumed 16 weeks to be a reasonable minimum duration of ART needed to achieve a high rate of viral suppression during pregnancy based on published South African data [12,13] and approximately 80% adherence to PMTCT to be the minimum required for successful viral suppression [14,15]. We focused the analysis on the final four months (16 weeks) before delivery on the assumption that viral suppression during this later period is more important for reducing the risk of MTCT [13] than earlier in the pregnancy. Adherence to PMTCT was estimated using clinic visit attendance under three different models with varying assumptions. Date of delivery was unknown for some of the women in the study. We instead assumed that for those without a known delivery date, delivery took place at either 1) 36 weeks’ gestation; 2) 38 weeks’ gestation; or 3) 40 weeks’ gestation. Based on these assumptions, delivery dates were imputed accordingly based on the gestational age at which a woman presented at her first antenatal visit. Using the data described above, we then estimated three models with varying assumptions about medication dispensed at each observed antenatal clinic visit (Table 1). Because we cannot observe actual adherence, we used medication possession to proxy adherence, assuming that if a 28-day supply of medication was dispensed, then the patient could be considered fully adherent for the next 28 days [16]. In Model A (100% dispensing), we assumed that all women with a documented clinic visit received 28 days’ worth of medication at each visit (i.e., that the stipulated clinic practice was adhered to perfectly) except the last documented visit, as explained below. For Model B (90% dispensing) we assume that 90% of women who attended a visit received 28 days’ worth of medication while the remaining 10% attended a visit but were not dispensed medication. To model this, 90% of women were randomly allocated 28 days’ medication while the remaining 10% were allocated 0 days’ medication at each visit except the last documented visit, and women who were allocated 0 days’ medication at a given visit were not permitted to be randomized to the 0 days’ medication allocation at the next visit, so that that no woman attended two consecutive visits without receiving medication at one of the visits at a minimum. Model C (80% dispensing) followed a similar structure to Model B: at each visit except the last documented visit, 80% of women were randomly allocated 28 days’ medication while the remaining 20% were allocated 0 days’ medication. Again, we assumed that no women attended two consecutive visits without receiving medication during at least one of the visits. For any visit that occurred < 28 days prior to a subsequent visit (in other words, an unscheduled visit prior to a routine scheduled visit), we allocated the women sufficient pills for the gap between the visits and then continued the model allocation at the subsequent (scheduled) visit. * All models—Last visit pill dispensing: Women with observed clinic visits up to delivery date or estimated delivery date are allocated 28 days’ worth of pills at the last visit according to the primary assumption for each model (100%, 90% or 80% dispensing). Women with > one month unobserved time prior to delivery date or estimated delivery date—assume 40% of these women remain in care during unobserved time ((they get sufficient pills up to known or estimated delivery date) while 60% get the allocated 28 days’ worth of pills dispensed at their last visit according to the model allocation (100%, 90% or 80% dispensing). ** Assumption applied to n = 34 women with unknown delivery date We handled the last observed visit differently. For women with observed clinic visits within one month of their delivery date or estimated delivery date, medication dispensing continued according to the primary assumption for each model (Model A—100% women got 28 days’ allocation, Model B—90% women got 28 days’ allocation, or Model C—80% women got 28 days’ allocation). For women with more than one month of unobserved time prior to their delivery date (i.e., those who were considered lost from care more than one month prior to their known or estimated delivery date), however, several possibilities exist for medication adherence during the unobserved time. First, a woman may truly be lost from care and not taking any medication during the entire period. Second, the woman may have transferred to another facility, such as the maternity unit where she intended to deliver, and continued treatment at the new facility. Finally, the woman may have been in possession of some medication from her previous visits, due to less than full adherence earlier in the pregnancy, and continued to take the leftover medications until that supply was depleted. A previous report from South Africa estimated that almost 40% of women who appeared lost from care at the original antenatal care facility were in fact receiving on-going care at another facility where they ultimately delivered]. To account for this, in all models we adjusted dispensing at the last observed visit among women with more than one-month unobserved time prior to delivery date or estimated delivery date (i.e. those apparently lost to care). We randomly selected 40% of these women and assumed that they remained in care during the entire period of unobserved time prior to delivery, while the remaining 60% got only the medications dispensed at their last visit according to the model allocation (Model A—100% women got 28 days’ pill dispensing, Model B—90% women got 28 days’ pill dispensing, or Model C—80% women got 28 days’ pill dispensing). We initially summarized characteristics at study enrolment with descriptive statistics. Next, for each of the three models’ set of assumptions, we estimated the proportion of women considered adherent to PMTCT during the final 16 weeks immediately preceding delivery using medians and interquartile ranges (IQR). We then categorized adherence for each woman in the last 16 weeks of pregnancy (weeks 24 to 40) as >80% or not and described the proportion of women achieving 80% adherence during this period for each of the levels in the three models. Finally, we fitted a log-binomial regression model to estimate the risk ratios (and 95% confidence intervals) of potential baseline predictors of achieving 80% adherence to PMTCT during the final 16 weeks of pregnancy. ClinicalTrials.gov {“type”:”clinical-trial”,”attrs”:{“text”:”NCT01710397″,”term_id”:”NCT01710397″}}NCT01710397 South African National Clinical Trials Register DOH-27-0213-4177 This study was nested within the original RapIT randomized controlled trial which was registered on ClinicalTrials.gov (Registration number) {“type”:”clinical-trial”,”attrs”:{“text”:”NCT01710397″,”term_id”:”NCT01710397″}}NCT01710397 on September 7, 2012 and the South African National Clinical Trials Register DOH-27-0213-4177. The first participant in the RapIT study was enrolled on May 8th, 2013. All study participants provided written informed consent and the consent procedure as well as all other study procedures received ethics approval from the institutional review boards of Boston University and the University of the Witwatersrand.

Résumé de l’IA

Study Justification:

– The study aims to assess the implementation of Option B and a fixed-dose combination antiretroviral regimen for prevention of mother-to-child transmission of HIV in South Africa.
– It addresses the challenge of initiating and retaining pregnant women on antiretroviral therapy (ART) to prevent mother-to-child HIV transmission, particularly during the critical final months prior to delivery.
– The study evaluates the uptake of Option B and its impact on adherence to PMTCT during the final months of pregnancy.

Study Highlights:

– The study enrolled 138 HIV-infected pregnant women in South Africa.
– The median gestational age at initiation of the PMTCT regimen was 22 weeks.
– Adherence to PMTCT during the final 16 weeks of pregnancy ranged from 52% to 75% under different assumptions.
– Less than 50% of women achieved 80% adherence to PMTCT during the final months of pregnancy across all models.
– The findings suggest that despite the implementation of Option B and once-daily dosing, there is a need for further guideline changes and interventions to improve adherence and achieve vertical transmission goals.

Study Recommendations:

– Further guideline changes and interventions are needed to improve the uptake and adherence to PMTCT during the critical final months of pregnancy.
– Strategies should be implemented to encourage early initiation of PMTCT and improve adherence to the regimen.
– Efforts should be made to ensure that pregnant women have access to an adequate supply of antiretroviral medication throughout the pregnancy.
– Interventions should be tailored to address the specific challenges faced by South African women in initiating and adhering to PMTCT.

Key Role Players:

– Policy makers and government officials responsible for developing and implementing guidelines for PMTCT.
– Healthcare providers, including doctors, nurses, and counselors, who play a crucial role in educating and supporting pregnant women in adhering to the PMTCT regimen.
– Community health workers who can provide outreach and support services to pregnant women in their communities.
– Non-governmental organizations and community-based organizations that can contribute to awareness campaigns and provide additional support to pregnant women.

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare providers on PMTCT guidelines and best practices.
– Procurement and distribution of antiretroviral medication to ensure an adequate supply for pregnant women.
– Development and implementation of educational materials and awareness campaigns targeting pregnant women.
– Monitoring and evaluation activities to assess the impact of interventions and track progress towards vertical transmission goals.
– Support services, such as counseling and psychosocial support, for pregnant women to improve adherence and address barriers to care.
– Research and data collection to inform evidence-based interventions and guide policy decisions.

Force de la preuve

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study collected visit data from a cohort of HIV-infected pregnant women and estimated adherence to PMTCT during the final 16 weeks of pregnancy. However, the study only included data from one primary health clinic in Johannesburg, South Africa, which may limit the generalizability of the findings. To improve the strength of the evidence, future studies could include data from multiple clinics and a larger sample size to increase the representativeness of the results.

Abstrait

The data utilized in this study were collected at a public-sector primary health clinic (PHC) in Johannesburg, South Africa. It is located in an informal settlement on the edge of the city with a large population of immigrants from neighboring countries and patients from other South African provinces. It provides a full range of primary healthcare services, including antenatal care (ANC), maternal and child health, HIV testing and counseling, ART initiation, and ART management. Under South African guidelines], women are advised to make at least four antenatal care visits prior to delivery, starting at 14 weeks’ gestation. PMTCT guidelines increased the required number of visits, however, as clinics standard practice was to provide only one month of ARV medication at a time during the study period. The clinic does not have a delivery ward; referral for delivery was to either a nearby hospital or one of three maternal obstetric units (MOUs) located 4, 5.5, and 7 kilometers from the clinic, respectively. At least one antenatal clinic visit was needed for a woman to obtain an antenatal care card, which is required to assure access to a hospital or MOU for delivery. We sequentially enrolled adult (≥18 years old), HIV-infected, pregnant women at the earliest clinic visit for a positive HIV test, provision of a blood sample for a CD4 count, or first ANC visit between July 4, 2013 and August 14, 2014. Women who were already on ART for their own health or who indicated that they did not intend to seek the remainder of their antenatal care at the study clinic were excluded. After informed consent, the women were administered a questionnaire eliciting information about demographic and socioeconomic characteristics; previous pregnancies, health-seeking behavior and exposure to PMTCT; normal activities and employment, and the costs the patient incurred per clinic visit. Study patients were then followed by passive medical record review, using the site’s and delivery facility’s routine patient records, until delivery. These records included antenatal and labour ward registries as well as an electronic medical record system, TherapyEdge-HIV™. Fields collected included dates of antenatal clinic visits, gravidity and parity, gestational age at first visit and predicted delivery date, date of HIV test, ARV regimen prescribed, and baseline CD4 count. Not all data for all study subjects could be found in the routine records maintained by the study site, nor could confirmation of all deliveries be found at the referral facilities. Viral load test results were not available for the majority of study participants, as most had spent fewer than 6 months on ART at the time of delivery. The primary defined outcome for this study was proportion of patients achieving 80% adherence to PMTCT in the 16 weeks immediately preceding date of delivery. For this analysis, we assumed 16 weeks to be a reasonable minimum duration of ART needed to achieve a high rate of viral suppression during pregnancy based on published South African data [12,13] and approximately 80% adherence to PMTCT to be the minimum required for successful viral suppression [14,15]. We focused the analysis on the final four months (16 weeks) before delivery on the assumption that viral suppression during this later period is more important for reducing the risk of MTCT [13] than earlier in the pregnancy. Adherence to PMTCT was estimated using clinic visit attendance under three different models with varying assumptions. Date of delivery was unknown for some of the women in the study. We instead assumed that for those without a known delivery date, delivery took place at either 1) 36 weeks’ gestation; 2) 38 weeks’ gestation; or 3) 40 weeks’ gestation. Based on these assumptions, delivery dates were imputed accordingly based on the gestational age at which a woman presented at her first antenatal visit. Using the data described above, we then estimated three models with varying assumptions about medication dispensed at each observed antenatal clinic visit (Table 1). Because we cannot observe actual adherence, we used medication possession to proxy adherence, assuming that if a 28-day supply of medication was dispensed, then the patient could be considered fully adherent for the next 28 days [16]. In Model A (100% dispensing), we assumed that all women with a documented clinic visit received 28 days’ worth of medication at each visit (i.e., that the stipulated clinic practice was adhered to perfectly) except the last documented visit, as explained below. For Model B (90% dispensing) we assume that 90% of women who attended a visit received 28 days’ worth of medication while the remaining 10% attended a visit but were not dispensed medication. To model this, 90% of women were randomly allocated 28 days’ medication while the remaining 10% were allocated 0 days’ medication at each visit except the last documented visit, and women who were allocated 0 days’ medication at a given visit were not permitted to be randomized to the 0 days’ medication allocation at the next visit, so that that no woman attended two consecutive visits without receiving medication at one of the visits at a minimum. Model C (80% dispensing) followed a similar structure to Model B: at each visit except the last documented visit, 80% of women were randomly allocated 28 days’ medication while the remaining 20% were allocated 0 days’ medication. Again, we assumed that no women attended two consecutive visits without receiving medication during at least one of the visits. For any visit that occurred one month unobserved time prior to delivery date or estimated delivery date—assume 40% of these women remain in care during unobserved time ((they get sufficient pills up to known or estimated delivery date) while 60% get the allocated 28 days’ worth of pills dispensed at their last visit according to the model allocation (100%, 90% or 80% dispensing). ** Assumption applied to n = 34 women with unknown delivery date We handled the last observed visit differently. For women with observed clinic visits within one month of their delivery date or estimated delivery date, medication dispensing continued according to the primary assumption for each model (Model A—100% women got 28 days’ allocation, Model B—90% women got 28 days’ allocation, or Model C—80% women got 28 days’ allocation). For women with more than one month of unobserved time prior to their delivery date (i.e., those who were considered lost from care more than one month prior to their known or estimated delivery date), however, several possibilities exist for medication adherence during the unobserved time. First, a woman may truly be lost from care and not taking any medication during the entire period. Second, the woman may have transferred to another facility, such as the maternity unit where she intended to deliver, and continued treatment at the new facility. Finally, the woman may have been in possession of some medication from her previous visits, due to less than full adherence earlier in the pregnancy, and continued to take the leftover medications until that supply was depleted. A previous report from South Africa estimated that almost 40% of women who appeared lost from care at the original antenatal care facility were in fact receiving on-going care at another facility where they ultimately delivered]. To account for this, in all models we adjusted dispensing at the last observed visit among women with more than one-month unobserved time prior to delivery date or estimated delivery date (i.e. those apparently lost to care). We randomly selected 40% of these women and assumed that they remained in care during the entire period of unobserved time prior to delivery, while the remaining 60% got only the medications dispensed at their last visit according to the model allocation (Model A—100% women got 28 days’ pill dispensing, Model B—90% women got 28 days’ pill dispensing, or Model C—80% women got 28 days’ pill dispensing). We initially summarized characteristics at study enrolment with descriptive statistics. Next, for each of the three models’ set of assumptions, we estimated the proportion of women considered adherent to PMTCT during the final 16 weeks immediately preceding delivery using medians and interquartile ranges (IQR). We then categorized adherence for each woman in the last 16 weeks of pregnancy (weeks 24 to 40) as >80% or not and described the proportion of women achieving 80% adherence during this period for each of the levels in the three models. Finally, we fitted a log-binomial regression model to estimate the risk ratios (and 95% confidence intervals) of potential baseline predictors of achieving 80% adherence to PMTCT during the final 16 weeks of pregnancy. ClinicalTrials.gov {“type”:”clinical-trial”,”attrs”:{“text”:”NCT01710397″,”term_id”:”NCT01710397″}}NCT01710397 South African National Clinical Trials Register DOH-27-0213-4177 This study was nested within the original RapIT randomized controlled trial which was registered on ClinicalTrials.gov (Registration number) {“type”:”clinical-trial”,”attrs”:{“text”:”NCT01710397″,”term_id”:”NCT01710397″}}NCT01710397 on September 7, 2012 and the South African National Clinical Trials Register DOH-27-0213-4177. The first participant in the RapIT study was enrolled on May 8th, 2013. All study participants provided written informed consent and the consent procedure as well as all other study procedures received ethics approval from the institutional review boards of Boston University and the University of the Witwatersrand.

Matériaux

Innovations

Based on the provided description, here are some potential innovations that can be used to improve access to maternal health:

1. Mobile Health (mHealth) Solutions: Implementing mobile health technologies, such as SMS reminders and mobile apps, to improve communication and adherence to antiretroviral therapy (ART) for pregnant women. These technologies can provide reminders for clinic visits, medication adherence, and provide educational resources.

2. Telemedicine: Introducing telemedicine services to provide remote consultations and follow-ups for pregnant women, especially those in remote or underserved areas. This can help overcome geographical barriers and improve access to healthcare professionals.

3. Community Health Workers: Training and deploying community health workers to provide maternal health education, support, and follow-up care in local communities. These workers can help bridge the gap between healthcare facilities and pregnant women, ensuring they receive the necessary care and support.

4. Integration of Services: Integrating maternal health services with other existing healthcare services, such as HIV testing and counseling, to provide comprehensive care for pregnant women. This can improve efficiency and reduce the burden of multiple clinic visits.

5. Task Shifting: Expanding the roles and responsibilities of healthcare workers, such as nurses and midwives, to perform certain tasks traditionally done by doctors. This can help alleviate the shortage of healthcare professionals and improve access to maternal health services.

6. Improved Supply Chain Management: Implementing efficient supply chain management systems to ensure an uninterrupted supply of essential medications and supplies for maternal health. This can help prevent stockouts and ensure that pregnant women have access to the necessary medications.

7. Health Education and Awareness: Conducting targeted health education campaigns to raise awareness about the importance of maternal health and the available services. This can help reduce stigma, increase knowledge, and encourage pregnant women to seek timely care.

8. Strengthening Referral Systems: Improving the coordination and communication between healthcare facilities to ensure smooth referrals for pregnant women who require specialized care or delivery services. This can help ensure that pregnant women receive appropriate care at the right facility.

9. Financial Support: Providing financial support or incentives, such as transportation vouchers or cash transfers, to pregnant women to overcome financial barriers and improve access to maternal health services.

10. Quality Improvement Initiatives: Implementing quality improvement initiatives at healthcare facilities to ensure that maternal health services are delivered in a timely, efficient, and patient-centered manner. This can help improve the overall quality of care and patient satisfaction.

AI Innovations Description

The recommendation to improve access to maternal health based on the study is to implement interventions that address the late initiation of antiretroviral therapy (ART) for pregnant women and improve adherence to the PMTCT regimen during the final months of pregnancy. This can be achieved through the following strategies:

1. Early initiation of ART: Encourage pregnant women to seek antenatal care and HIV testing early in their pregnancy. This will allow for timely initiation of ART, reducing the risk of mother-to-child transmission of HIV.

2. Improved medication dispensing: Ensure that pregnant women receive an adequate supply of antiretroviral medication during each clinic visit. Implement strategies to minimize stockouts and ensure consistent availability of medication.

3. Enhanced counseling and education: Provide comprehensive counseling and education to pregnant women about the importance of adherence to the PMTCT regimen. This should include information on the benefits of early initiation of ART and the potential risks of non-adherence.

4. Supportive interventions: Implement interventions to support pregnant women in adhering to the PMTCT regimen. This may include reminder systems, peer support groups, and community-based interventions to address barriers to adherence.

5. Strengthened healthcare system: Improve the capacity of healthcare facilities to provide comprehensive maternal health services, including antenatal care, HIV testing, and ART initiation. This may involve training healthcare providers, improving infrastructure, and ensuring the availability of necessary resources.

By implementing these recommendations, it is expected that access to maternal health will be improved, leading to better outcomes for both mothers and their infants in terms of HIV prevention and overall health.

AI Innovations Methodology

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

1. Strengthening Antenatal Care (ANC) Services: Enhance ANC services by increasing the number of visits and providing comprehensive care, including HIV testing and counseling, ART initiation, and management.

2. Improving Medication Dispensing: Implement strategies to ensure that pregnant women receive an adequate supply of antiretroviral medication during each clinic visit, such as providing a 28-day supply of medication at each visit.

3. Enhancing Patient Education and Counseling: Develop educational materials and conduct counseling sessions to improve awareness and understanding of the importance of adherence to PMTCT regimens.

4. Streamlining Referral Systems: Improve coordination between primary health clinics and delivery facilities to ensure a smooth referral process for pregnant women, reducing delays in accessing delivery services.

5. Community Engagement and Support: Engage community health workers and support groups to provide additional support and guidance to pregnant women, promoting adherence to PMTCT regimens and encouraging early initiation of ANC.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define Key Metrics: Identify key metrics to measure the impact, such as the proportion of pregnant women initiating ANC early, the proportion receiving a 28-day supply of medication at each visit, and the proportion achieving 80% adherence to PMTCT regimens.

2. Data Collection: Collect data on the current state of access to maternal health services, including ANC initiation rates, medication dispensing practices, and adherence levels. This can be done through surveys, interviews, and analysis of existing health records.

3. Develop Simulation Models: Use the collected data to develop simulation models that simulate the impact of the recommended interventions on access to maternal health. These models can be based on statistical techniques, such as regression analysis or predictive modeling.

4. Scenario Testing: Test different scenarios by adjusting the parameters in the simulation models. For example, simulate the impact of increasing the number of ANC visits or improving medication dispensing rates. Evaluate the potential impact of each scenario on the key metrics identified in step 1.

5. Analyze Results: Analyze the results of the simulation models to determine the potential impact of the recommended interventions on improving access to maternal health. Identify the most effective interventions and their expected outcomes.

6. Recommendations: Based on the analysis of the simulation results, make recommendations for implementing the interventions that are expected to have the greatest impact on improving access to maternal health. Consider the feasibility, cost-effectiveness, and scalability of each recommendation.

7. Monitoring and Evaluation: Implement the recommended interventions and establish a monitoring and evaluation system to track progress and measure the actual impact on access to maternal health. Continuously review and update the simulation models based on new data and feedback from the implementation process.

By following this methodology, policymakers and healthcare providers can make informed decisions on implementing interventions to improve access to maternal health based on evidence and simulations of their potential impact.

Auteurs et co-auteurs

Statistics:

Citations: 2

Authors: 10

Identifiers:

DOI: 10.1371/journal.pone.0201955

Research Areas:

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

Study Countries:

South Africa

Study Design:

Cohort Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female

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