Improving care for syphilis and malaria among pregnant women: Tested changes and guidance from East Central Uganda
Syphilis in pregnancy has contributed to over 300,000 stillbirths and fetal and neonatal deaths worldwide, while putting an additional 215,000 neonates at risk of low birth weight, prematurity, and other syphilis related complications (WHO 2012). These deaths and complications could have been prevented through screening and treatment with a single dose of penicillin before the third trimester of pregnancy. In Uganda, approximately 6.4% of pregnant women attending antenatal care (ANC) are infected with syphilis, but only 14.1% of women who attend ANC are tested for the disease during their first visit (WHO 2015).
Malaria is a major public health problem and an indirect cause of maternal mortality. Malaria infection in pregnancy carries serious risks for pregnant women, fetuses and newborns, including anemia; severe malaria; spontaneous abortion; stillbirth; prematurity; neonatal mortality; low birthweight; and maternal death. A study conducted in southwestern Uganda showed that malaria in pregnancy was the most common indirect cause of maternal mortality, accounting for 8.92% maternal deaths (Ngonzi et al. 2016). As overall malaria prevalence in the country declines, adverse consequences will likely increase in pregnant women as a result of delayed acquisition of immunity due to reduced exposure. In addition, addressing malaria in pregnancy is key to malaria elimination efforts as the placenta can be a reservoir of infection.
From June 2015 through March 2017 the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project implemented an improvement activity in a “slice” of the health care system in Jinja, Uganda to improve the quality of primary antenatal care services through implementing an integrated package of ANC best practices. This included early detection and case management of the most common obstetric conditions as well as frequent infections in pregnancy such as syphilis and malaria. ASSIST implemented the activity in 10 randomly selected facilities, across all levels of the health system, within the catchment area of the Jinja Regional Referral Hospital which included: Buwenge General Hospital, Buwenge health center (HC) IV, Budondo HC IV, Mpumudde HC IV, Lukolo HC III, Kakaire HC III, Magamaga HC III, Butagaya HC III, and Budima HC III.
This activity generated important learning about effective models for improving delivery of quality care for syphilis and malaria during pregnancy including prevention, early detection, and treatment. The changes implemented by quality improvement (QI) teams that are discussed in this document demonstrate effective ways to overcome commonly found gaps in a low-resource environment, improve the quality of antenatal care for pregnant women, and reduce maternal and newborn mortality.