Missed opportunities along the prevention of mother-to-child transmission services cascade in South Africa: Uptake, determinants, and attributable risk (the SAPMTCTE)

PLoS ONE, Volume 10, No. 7, Year 2015

Interpretação

Objectives: We examined uptake of prevention of mother-to-child HIV transmission (PMTCT) services, predictors of missed opportunities, and infant HIV transmission attributable to missed opportunities along the PMTCT cascade across South Africa. Methods: A cross-sectional survey was conducted among 4-8 week old infants receiving first immunisations in 580 nationally representative public health facilities in 2010. This included maternal interviews and testing infants’ dried blood spots for HIV. A weighted analysis was performed to assess uptake of antenatal and perinatal PMTCT services along the PMTCT cascade (namely: maternal HIV testing, CD4 count test/result, and receiving maternal and infant antiretroviral treatment) and predictors of dropout. The population attributable fraction associated with dropouts at each service point are estimated. Results: Of 9,803 mothers included, 31.7% were HIV-positive as identified by reactive infant antibody tests. Of these 80.4% received some form of maternal and infant antiretroviral treatment. More than a third (34.9%) of mothers dropped out from one or more steps in the PMTCT service cascade. In a multivariable analysis, the following characteristics were associated with increased dropout from the PMTCT cascade: adolescent (<20 years) mothers, low socioeconomic score, low education level, primiparous mothers, delayed first antenatal visit, homebirth, and non-disclosure of HIV status. Adolescent mothers were twice (adjusted odds ratio: 2.2, 95% confidence interval: 1.5-3.3) as likely to be unaware of their HIV-positive status and had a significantly higher rate (85.2%) of unplanned pregnancies compared to adults aged ≥20 years (55.5%, p = 0.0001). A third (33.8%) of infant HIV infections were attributable to dropout in one or more steps in the cascade. Conclusion: A third of transmissions attributable to missed opportunities of PMTCT services can be prevented by optimizing the uptake of PMTCT services. Identified risk factors for low PMTCT service uptake should be addressed through health facility and community-level interventions, including raising awareness, promoting women education, adolescent focused interventions, and strengthening linkages/referral-system between communities and health facilities. A cross-sectional survey was conducted from June-December 2010 among mother/caregiver-infant pairs visiting the immunisation service points of randomly selected public primary health care facilities (PHCs) and community health centres (CHCs) across the nine provinces of South Africa. The protocol and overall transmission rate findings have been published elsewhere.[8] At the time of the study guidelines in South Africa recommended that mothers be offered Zidovudine (AZT) from 28 weeks gestation and single dose nevirapine (sdNVP) at labour or triple (combination) antiretroviral therapy (cART) if CD4 cell count was ≤200 cells/mm3. Infants were offered sdNVP at birth and 7–28 days of postpartum AZT.[16] The sample size was calculated taking into account the 2009 antenatal HIV prevalence data[17], transmission rate estimates from two previous sub-national surveys[18, 19], and the coverage of ARV prophylaxis in each province from district health information system (DHIS) reports. A precision-based sample size was calculated for varying MTCT precision levels by province (ranging from 1% to 2%) and a design effect of 2 to account for clustering within health facilities. Based on this, the collection of interview data and infant dried blood spots (DBS) from 12,200 mother-infant pairs was needed to provide stable provincial and national level estimates of transmission rates and PMTCT services uptake. Further details on parameters used for sample size calculation are presented elsewhere.[6] The sampling frame comprised all public PHCs and CHCs throughout the country. Small facilities (with <130 annual Diptheria-Pertussis-Tetatus-1 (DTP1) immunisations) were excluded from the sampling frame [the proportion of annual six-week immunisation done in small facilities in 2007 was only 6.7%]. A multistage stratified cluster sampling method was used to select facilities. The 2007 DHIS immunisation data and the 2009 antenatal HIV prevalence estimates were used to stratify facilities into three groups: medium-sized facilities with 130–300 annual DTP1 immunisation number, large (≥ 300 annual DTP 1 immunisation number) facilities with HIV prevalence below the national HIV prevalence estimate (<29%), and large facilities with HIV prevalence ≥29%. A probability proportional to size sampling method was used to select 580 medium and large size facilities with both high and low HIV prevalence. At the final step, a fixed number (proportional to facility size) of individual mother-infant pairs were sampled consecutively from each selected facility within a specified period of time [3 (in 8 provinces) to 4 (in 1 province) weeks was spent in each facility]. Mother/caregiver-infant pairs at selected facilities were approached and screened for eligibility. Inclusion criteria were infants aged 4-8weeks, with no emergency illness and receiving their six-week immunisation on the visit day. Consented mothers were interviewed on antenatal and obstetric history, knowledge about PMTCT, history of antenatal HIV testing, HIV status, CD4 count testing and ARV services received. PMTCT-related questions were answered by biological mothers only. Interview data were collected on hand-held devices (cell phone pre-programmed questionnaire). After the interview, individual pre-test counselling was given to each mother and if mothers consented, DBS were collected from infants using heel-prick. DBS specimens were tested for HIV antibodies by means of an enzyme immunoassay (EIA) (Genscreen HIV1/2 Ab EIA Version 2, Bio-Rad Laboratories, France). A positive EIA result indicated infant HIV exposure. A qualitative HIV polymerase chain reaction (PCR) (COBAS AmpliPrep/COBAS TaqMan (CAP/CTM) Qualitative assay version 1.0 assay, Roche Diagnostics, Branchburg, NJ) test was performed on all EIA-positive DBS to determine whether the infant was HIV PCR-positive (i.e. HIV-infected). Infants were included in this analysis if they had both maternal interviews on the PMTCT sections of the questionnaire and complete laboratory results for HIV testing (i.e. EIA test result was needed from all infants and for EIA-positive infants PCR test result was needed in order to be included in the analysis). Mothers who had an EIA-positive infant were considered to be HIV-positive. We identified four PMTCT cascade steps (also referred as ‘PMTCT cascade indicators’): maternal HIV-positive status knowledge (reporting HIV-positive status determined before or during pregnancy), maternal CD4 cell count testing and receipt of result, receipt of maternal ARV and infant nevirapine (NVP). The denominator for each of the 4 indicators was “total number of HIV-positive mothers, as identified from infant EIA test”. Dropout was calculated as a proportion of HIV-positive mothers who missed a step in the cascade regardless of returning to receive subsequent services. Mothers who miss multiple steps are considered as dropout only once, at their first missed step. Dropout does not take poor adherence into consideration; rather it only included instances where mother-infant pairs did not access a given service. We compared categorical responses using chi-square tests. Multivariable regression analysis was used to identify factors associated with missed opportunities and dropouts in the following PMTCT cascade indicators: (1) maternal HIV-positive status knowledge (2) CD4 cell count testing and receipt of result (as a single outcome of interest), and (3) an overall indicator for “at least one dropout at any of the four PMTCT cascade steps”. Initial univariable analysis included explanatory variables identified in similar studies and those with biological plausibility. All variables with a p-value below 0.2 were included in the starting variable set for multivariable regression. From a multivariable model, factors were dropped if they were non-significant (at p 0.05) and did not markedly alter (by 10% or more) estimates of other significant variables in the model. We created a socio-economic score from availability of assets (television, car, refrigerator, stove), and dwelling characteristics (type of water, toilet, fuel and building material) using the principal component analysis method. In order to assess the potential for prevention, this study used the method explained by Basu and Landis to estimate PAF.[20] Two types of PAF were estimated. The first PAF was estimated assuming that prevention efforts/interventions target each cascade step separately; the estimated PAF from this step reflects the transmission preventable by eliminating missed opportunities from one cascade step. The second PAF—which we refer as cumulative PAF- was estimated assuming prevention interventions target 2, 3 or all 4 cascade steps at once. We report incidence reductions that correspond to the cumulative PAF. To estimate both the PAF and the cumulative PAF, 8 models (1 PAF model and 1 cumulative PAF model for each of the 4 cascade steps) were fitted at each of the four PMTCT cascade indicators and the outcome ‘infant HIV infection’. Each model was adjusted for potential covariates from the literature, which included maternal age (10 year age groups), education (below secondary), socioeconomic score (the two lowest quintiles, middle and fourth quintile, vs. fifth/highest quintile), feeding pattern (exclusive breastfeeding or no breastfeeding vs. mixed breastfeeding), number of children (1, 2, ≥3), and type of delivery (caesarean section or vaginal delivery). Intermediary factors that are on the causal pathway between the PMTCT cascade indicators and HIV transmission risk were not included in the analysis. Covariates with missing data used for adjusting the PAF models were imputed sequentially using Monte Carlo multiple imputation technique. Cascade indicators with missing data were not imputed as the missing responses of these indicators are correlated. We had 4.7%, 1.4% and 2.2% missing responses for CD4 count testing, and maternal and infant ARV initiation indicators, respectively. The PAF estimates were analysed using all available data. The cumulative PAF was estimated using complete case analysis by excluding observations with missing cascade indicator data. Analyses were done using STATA SE (version 12, Texas, 77845 USA) and were adjusted for the complex survey design, including sample size realization, clustering and the 2010 live-birth distribution across provinces. The study protocol was approved by the United States Centers for Disease Control and Prevention and the institutional review board of the Medical Research Council of South Africa. All study participants provided written informed consent.

AI Digest

Study Justification:

The study aimed to examine the uptake of prevention of mother-to-child HIV transmission (PMTCT) services in South Africa, identify predictors of missed opportunities, and estimate the infant HIV transmission attributable to missed opportunities. This research is important because it provides valuable insights into the gaps in PMTCT services and the factors contributing to these gaps. By understanding the reasons for missed opportunities, interventions can be developed to optimize the uptake of PMTCT services and prevent infant HIV transmission.

Highlights:

– The study found that 34.9% of mothers dropped out from one or more steps in the PMTCT service cascade.
– Risk factors for low PMTCT service uptake included adolescent mothers, low socioeconomic score, low education level, primiparous mothers, delayed first antenatal visit, homebirth, and non-disclosure of HIV status.
– Adolescent mothers were more likely to be unaware of their HIV-positive status and had a higher rate of unplanned pregnancies compared to adults.
– A third (33.8%) of infant HIV infections were attributable to dropout in one or more steps in the PMTCT cascade.

Recommendations:

– Optimize the uptake of PMTCT services to prevent missed opportunities and reduce infant HIV transmission.
– Address identified risk factors for low PMTCT service uptake through health facility and community-level interventions.
– Raise awareness about PMTCT services and the importance of early antenatal care.
– Promote women’s education to empower them to make informed decisions about their health and the health of their infants.
– Implement adolescent-focused interventions to address the specific needs and challenges faced by young mothers.
– Strengthen linkages and referral systems between communities and health facilities to ensure seamless access to PMTCT services.

Key Role Players:

– Health facility staff: Healthcare providers, nurses, counselors, and support staff who deliver PMTCT services.
– Community health workers: Individuals who work within the community to raise awareness, provide education, and facilitate access to healthcare services.
– Policy makers: Government officials and organizations responsible for developing and implementing policies related to PMTCT services.
– Non-governmental organizations (NGOs): Organizations that provide support, resources, and advocacy for PMTCT services.
– Researchers: Experts who conduct studies and provide evidence-based recommendations for improving PMTCT services.

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare providers and community health workers.
– Development and dissemination of educational materials and campaigns.
– Infrastructure and equipment upgrades in health facilities.
– Outreach programs and community engagement activities.
– Monitoring and evaluation systems to track the implementation and impact of interventions.
– Research and data collection to inform evidence-based decision making.
– Collaboration and coordination efforts between stakeholders.
– Advocacy and policy development initiatives.
Please note that the cost items provided are general categories and not actual cost estimates. The specific costs will vary depending on the context and scale of the interventions.

Força da prova

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The study design is cross-sectional, which limits the ability to establish causality. Additionally, the abstract does not provide information on the representativeness of the sample or the response rate. To improve the evidence, future studies could consider using a longitudinal design to establish causality and provide more information on the sample characteristics and response rate.

Resumo

A cross-sectional survey was conducted from June-December 2010 among mother/caregiver-infant pairs visiting the immunisation service points of randomly selected public primary health care facilities (PHCs) and community health centres (CHCs) across the nine provinces of South Africa. The protocol and overall transmission rate findings have been published elsewhere.[8] At the time of the study guidelines in South Africa recommended that mothers be offered Zidovudine (AZT) from 28 weeks gestation and single dose nevirapine (sdNVP) at labour or triple (combination) antiretroviral therapy (cART) if CD4 cell count was ≤200 cells/mm3. Infants were offered sdNVP at birth and 7–28 days of postpartum AZT.[16] The sample size was calculated taking into account the 2009 antenatal HIV prevalence data[17], transmission rate estimates from two previous sub-national surveys[18, 19], and the coverage of ARV prophylaxis in each province from district health information system (DHIS) reports. A precision-based sample size was calculated for varying MTCT precision levels by province (ranging from 1% to 2%) and a design effect of 2 to account for clustering within health facilities. Based on this, the collection of interview data and infant dried blood spots (DBS) from 12,200 mother-infant pairs was needed to provide stable provincial and national level estimates of transmission rates and PMTCT services uptake. Further details on parameters used for sample size calculation are presented elsewhere.[6] The sampling frame comprised all public PHCs and CHCs throughout the country. Small facilities (with <130 annual Diptheria-Pertussis-Tetatus-1 (DTP1) immunisations) were excluded from the sampling frame [the proportion of annual six-week immunisation done in small facilities in 2007 was only 6.7%]. A multistage stratified cluster sampling method was used to select facilities. The 2007 DHIS immunisation data and the 2009 antenatal HIV prevalence estimates were used to stratify facilities into three groups: medium-sized facilities with 130–300 annual DTP1 immunisation number, large (≥ 300 annual DTP 1 immunisation number) facilities with HIV prevalence below the national HIV prevalence estimate (<29%), and large facilities with HIV prevalence ≥29%. A probability proportional to size sampling method was used to select 580 medium and large size facilities with both high and low HIV prevalence. At the final step, a fixed number (proportional to facility size) of individual mother-infant pairs were sampled consecutively from each selected facility within a specified period of time [3 (in 8 provinces) to 4 (in 1 province) weeks was spent in each facility]. Mother/caregiver-infant pairs at selected facilities were approached and screened for eligibility. Inclusion criteria were infants aged 4-8weeks, with no emergency illness and receiving their six-week immunisation on the visit day. Consented mothers were interviewed on antenatal and obstetric history, knowledge about PMTCT, history of antenatal HIV testing, HIV status, CD4 count testing and ARV services received. PMTCT-related questions were answered by biological mothers only. Interview data were collected on hand-held devices (cell phone pre-programmed questionnaire). After the interview, individual pre-test counselling was given to each mother and if mothers consented, DBS were collected from infants using heel-prick. DBS specimens were tested for HIV antibodies by means of an enzyme immunoassay (EIA) (Genscreen HIV1/2 Ab EIA Version 2, Bio-Rad Laboratories, France). A positive EIA result indicated infant HIV exposure. A qualitative HIV polymerase chain reaction (PCR) (COBAS AmpliPrep/COBAS TaqMan (CAP/CTM) Qualitative assay version 1.0 assay, Roche Diagnostics, Branchburg, NJ) test was performed on all EIA-positive DBS to determine whether the infant was HIV PCR-positive (i.e. HIV-infected). Infants were included in this analysis if they had both maternal interviews on the PMTCT sections of the questionnaire and complete laboratory results for HIV testing (i.e. EIA test result was needed from all infants and for EIA-positive infants PCR test result was needed in order to be included in the analysis). Mothers who had an EIA-positive infant were considered to be HIV-positive. We identified four PMTCT cascade steps (also referred as ‘PMTCT cascade indicators’): maternal HIV-positive status knowledge (reporting HIV-positive status determined before or during pregnancy), maternal CD4 cell count testing and receipt of result, receipt of maternal ARV and infant nevirapine (NVP). The denominator for each of the 4 indicators was “total number of HIV-positive mothers, as identified from infant EIA test”. Dropout was calculated as a proportion of HIV-positive mothers who missed a step in the cascade regardless of returning to receive subsequent services. Mothers who miss multiple steps are considered as dropout only once, at their first missed step. Dropout does not take poor adherence into consideration; rather it only included instances where mother-infant pairs did not access a given service. We compared categorical responses using chi-square tests. Multivariable regression analysis was used to identify factors associated with missed opportunities and dropouts in the following PMTCT cascade indicators: (1) maternal HIV-positive status knowledge (2) CD4 cell count testing and receipt of result (as a single outcome of interest), and (3) an overall indicator for “at least one dropout at any of the four PMTCT cascade steps”. Initial univariable analysis included explanatory variables identified in similar studies and those with biological plausibility. All variables with a p-value below 0.2 were included in the starting variable set for multivariable regression. From a multivariable model, factors were dropped if they were non-significant (at p 0.05) and did not markedly alter (by 10% or more) estimates of other significant variables in the model. We created a socio-economic score from availability of assets (television, car, refrigerator, stove), and dwelling characteristics (type of water, toilet, fuel and building material) using the principal component analysis method. In order to assess the potential for prevention, this study used the method explained by Basu and Landis to estimate PAF.[20] Two types of PAF were estimated. The first PAF was estimated assuming that prevention efforts/interventions target each cascade step separately; the estimated PAF from this step reflects the transmission preventable by eliminating missed opportunities from one cascade step. The second PAF—which we refer as cumulative PAF- was estimated assuming prevention interventions target 2, 3 or all 4 cascade steps at once. We report incidence reductions that correspond to the cumulative PAF. To estimate both the PAF and the cumulative PAF, 8 models (1 PAF model and 1 cumulative PAF model for each of the 4 cascade steps) were fitted at each of the four PMTCT cascade indicators and the outcome ‘infant HIV infection’. Each model was adjusted for potential covariates from the literature, which included maternal age (10 year age groups), education (below secondary), socioeconomic score (the two lowest quintiles, middle and fourth quintile, vs. fifth/highest quintile), feeding pattern (exclusive breastfeeding or no breastfeeding vs. mixed breastfeeding), number of children (1, 2, ≥3), and type of delivery (caesarean section or vaginal delivery). Intermediary factors that are on the causal pathway between the PMTCT cascade indicators and HIV transmission risk were not included in the analysis. Covariates with missing data used for adjusting the PAF models were imputed sequentially using Monte Carlo multiple imputation technique. Cascade indicators with missing data were not imputed as the missing responses of these indicators are correlated. We had 4.7%, 1.4% and 2.2% missing responses for CD4 count testing, and maternal and infant ARV initiation indicators, respectively. The PAF estimates were analysed using all available data. The cumulative PAF was estimated using complete case analysis by excluding observations with missing cascade indicator data. Analyses were done using STATA SE (version 12, Texas, 77845 USA) and were adjusted for the complex survey design, including sample size realization, clustering and the 2010 live-birth distribution across provinces. The study protocol was approved by the United States Centers for Disease Control and Prevention and the institutional review board of the Medical Research Council of South Africa. All study participants provided written informed consent.

Materiais

N/A

Inovações

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

1. Mobile health (mHealth) interventions: Develop mobile applications or text messaging services to provide pregnant women and new mothers with information, reminders, and support related to maternal health, including PMTCT services. These interventions can help improve knowledge, adherence to treatment, and overall engagement in care.

2. Community health worker programs: Implement community-based programs that train and deploy community health workers to provide education, counseling, and support to pregnant women and new mothers in their own communities. These workers can help bridge the gap between health facilities and communities, improving access to and utilization of maternal health services.

3. Integrated antenatal care services: Integrate PMTCT services with routine antenatal care to ensure that all pregnant women receive comprehensive care that includes HIV testing, counseling, and treatment. This can help reduce missed opportunities for PMTCT services and improve overall maternal and child health outcomes.

4. Peer support groups: Establish peer support groups for pregnant women and new mothers living with HIV. These groups can provide emotional support, share experiences, and provide practical advice on managing HIV and accessing PMTCT services. Peer support has been shown to improve adherence to treatment and retention in care.

5. Strengthening health systems: Invest in strengthening health systems to ensure that health facilities have the necessary infrastructure, equipment, and trained staff to provide high-quality maternal health services. This includes improving supply chain management for essential medicines and commodities, as well as ensuring that health workers are adequately trained and supported.

These are just a few examples of innovations that could be used to improve access to maternal health. It is important to consider the specific context and needs of the population when designing and implementing these interventions.

AI Innovations Description

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

1. Strengthening Linkages and Referral Systems: Develop a comprehensive system to improve the coordination and communication between communities and health facilities. This can include establishing clear referral pathways for pregnant women to access maternal health services, ensuring that information about available services is easily accessible to the community, and providing training to healthcare providers on effective referral processes.

2. Raising Awareness: Implement targeted awareness campaigns to educate women and communities about the importance of maternal health services, including prevention of mother-to-child transmission (PMTCT) services. These campaigns should address common misconceptions, promote the benefits of early antenatal care visits, and emphasize the availability and effectiveness of PMTCT interventions.

3. Promoting Women’s Education: Recognize the correlation between low education levels and low uptake of PMTCT services. Implement programs that focus on improving women’s education, particularly among adolescent mothers and those with low socioeconomic status. This can include providing educational resources, vocational training, and support for continuing education during pregnancy and early motherhood.

4. Adolescent-Focused Interventions: Develop targeted interventions specifically designed to address the unique needs and challenges faced by adolescent mothers. These interventions should provide comprehensive support, including access to reproductive health education, counseling services, and peer support networks. Additionally, efforts should be made to address the high rate of unplanned pregnancies among adolescent mothers through comprehensive sexual and reproductive health education and access to contraception.

By implementing these recommendations, it is possible to optimize the uptake of PMTCT services and reduce the number of missed opportunities, ultimately improving access to maternal health and reducing the transmission of HIV from mother to child.

AI Innovations Methodology

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

1. Strengthening Linkages and Referral Systems: Improve the coordination and communication between communities and health facilities to ensure that pregnant women are aware of and have access to maternal health services. This can include establishing clear referral pathways and providing transportation options for women who may face barriers in accessing healthcare.

2. Raising Awareness: Implement targeted awareness campaigns to educate women and communities about the importance of maternal health services, including antenatal care, HIV testing, and antiretroviral treatment. These campaigns can use various channels such as community meetings, radio, and social media to reach a wide audience.

3. Promoting Women’s Education: Address the low education levels among mothers by implementing programs that promote women’s education and empowerment. This can include providing scholarships, vocational training, and adult literacy programs to improve women’s knowledge and decision-making abilities regarding their own health and the health of their children.

4. Adolescent-Focused Interventions: Develop specific interventions targeted at adolescent mothers, who are at higher risk of dropping out of the PMTCT cascade. These interventions can include age-appropriate education, peer support groups, and access to youth-friendly healthcare services.

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

1. Define the indicators: Identify key indicators that measure access to maternal health services, such as the percentage of pregnant women receiving antenatal care, the percentage of HIV-positive mothers receiving antiretroviral treatment, and the percentage of infants receiving nevirapine.

2. Collect baseline data: Gather data on the current status of these indicators in the target population. This can be done through surveys, interviews, and analysis of existing health records.

3. Develop a simulation model: Create a mathematical model that simulates the impact of the recommended interventions on the selected indicators. The model should take into account factors such as population size, demographic characteristics, and the effectiveness of the interventions.

4. Input intervention parameters: Define the parameters of the interventions, such as the coverage and duration of the awareness campaigns, the number of scholarships or training programs to be implemented, and the resources allocated to strengthening linkages and referral systems.

5. Run the simulation: Use the model to simulate the impact of the interventions over a specified time period. The simulation should generate estimates of how the indicators would change based on the implemented interventions.

6. Analyze the results: Analyze the simulation results to determine the potential impact of the recommended interventions on improving access to maternal health services. This can include assessing the percentage increase in the indicators, identifying any disparities or gaps that may still exist, and evaluating the cost-effectiveness of the interventions.

7. Refine and adjust: Based on the simulation results, refine and adjust the interventions as needed to optimize their impact. This may involve reallocating resources, modifying the implementation strategies, or targeting specific subpopulations that may require additional support.

8. Monitor and evaluate: Continuously monitor and evaluate the implementation of the interventions to assess their effectiveness and make any necessary adjustments. This can include tracking the selected indicators, conducting surveys or interviews to gather feedback from the target population, and engaging stakeholders to ensure ongoing support and collaboration.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of recommended interventions on improving access to maternal health services and make informed decisions on resource allocation and program implementation.

Autor

Dima Health

Statistics:

Citations: 57

Identifiers:

DOI: 10.1371/journal.pone.0132425

Research Areas:

Community Interventions, Environmental, 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:

Case-Control Study, Cohort Study, Cross Sectional Study

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Female

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