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

BMC Public Health. 2020 Mar 12;20(1):318. doi: 10.1186/s12889-020-8397-2.


Background: Despite policies and guidelines recommending integration of health services in South Africa, provision of maternal and child health services remains fragmented. This study evaluated a rapid, scaleable, quality improvement (QI) intervention to improve integration of maternal and child health and HIV services at a primary health level, in KwaZulu-Natal, South Africa.

Methods: A three-month intervention comprised of six QI mentoring visits, learning sessions with clinic staff to share learnings, and a self-administered checklist aimed to assist health workers monitor and implement an integrated package of health services for mothers and children. The study evaluated 27 clinics in four sub-districts using a stepped-wedge design. Each sub-district received the intervention sequentially in a randomly selected order. Five waves of data collection were conducted in all participating clinics between December 2016-February 2017. A multi-level, mixed effects logistic regression was used to account for random cluster fixed time and group effects using Stata V13.1.

Results: Improvements in some growth monitoring indicators were achieved in intervention clinics compared to control clinics, including measuring the length of the baby (77% vs 63%; p = 0.001) and health workers asking mothers about the child's feeding (74% vs 67%; p = 0.003), but the proportion of mothers who received feeding advice remained unchanged (38% vs 35%; p = 0.48). Significantly more mothers in the intervention group were asked about their baby's health (44% vs 36%; p = 0.001), and completeness of record keeping improved (40% vs 26%; I = < 0.0001). Discussions with the mother about some maternal health services improved: significantly more mothers in the intervention group were asked about HIV (26.5% vs 19.5%; p = 0.009) and family planning (33.5% vs 19.5%; p < 0.001), but this did not result in additional services being provided to mothers at the clinic visit.

Conclusion: This robust evaluation shows significant improvements in coverage of some services, but the QI intervention was unable to achieve the substantial changes required to provide a comprehensive package of services to all mothers and children. We suggest the QI process be adapted to complex under-resourced health systems, building on the strengths of this approach, to provide workable health systems strengthening solutions for scalable implementation.

Trial registration: ClinicalTrials.gov NCT04278612. Date of Registration: February 19, 2020. Retrospectively registered.

Keywords: Child growth; Child health; Growth monitoring; HIV/AIDS; Integrated care; Maternal health; Nutrition; Quality improvement; South Africa.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Child, Preschool
  • Delivery of Health Care, Integrated*
  • Female
  • HIV Infections / prevention & control*
  • HIV Infections / transmission
  • Health Facilities
  • Humans
  • Infant
  • Infectious Disease Transmission, Vertical / prevention & control*
  • Maternal-Child Health Services / organization & administration*
  • Pregnancy
  • Pregnancy Complications, Infectious / prevention & control*
  • Primary Health Care / organization & administration*
  • Program Evaluation
  • Quality Improvement*
  • South Africa
  • Young Adult

Associated data

  • ClinicalTrials.gov/NCT04278612

Grants and funding