Barriers and enablers to integrating maternal and child health services to antenatal care in low and middle income countries

Abstract

Antenatal care (ANC) represents a delivery platform for a broad range of health services; however, these opportunities are insufficiently utilised. This review explores key barriers and enablers for successful integration of health s"ervices with ANC in different contexts. Data from peer‐reviewed and grey literature were organised using the SURE checklist. We identified 46 reports focusing on integration of HIV, tuberculosis, malaria, syphilis or nutrition services with ANC from Asia, Africa and the Pacific. Perspectives of service users and providers, social and political factors, and health system characteristics (such as resource availability and organisational structures) affected ease of integration.Tweetable abstractHealth system factors, context and stakeholders must be considered for integrated antenatal care services.

Achieving development goals for HIV, tuberculosis and malaria in sub-Saharan Africa through integrated antenatal care: barriers and challenges

“…Such a focus on single-diseases has extended to ANC; rather than focusing on integrated services that address multi-disease health priorities in maternal, newborn and child health, the literature largely describes integrated services that combine ANC with a single-disease focus (reviewed in [18]). We argue that, despite WHO recommendations, there is a remarkable lack of evidence on best practice approaches of program implementation for integrated ANC models in sub-Saharan Africa and beyond.…”

“…Controlled trials and observational studies generally demonstrated relative increases in pregnant women and infants being tested for HIV (range 40–200%), initiating treatment for the PMTCT (35–400% relative increase) and reductions in loss-to-follow-up (50% relative reduction) within integrated versus non-ANC-integrated approaches across a number of sub-Saharan African countries [11, 18, 21–33]. Integration of HIV into ANC is likely to have contributed significantly to achieving an ART coverage to prevent PMTCT of 73% among pregnant women living with HIV globally [34].…”

“…Structural barriers often manifest in the characteristics of the health system (Table 3). Weak program links, health systems, and financial infrastructure are cited as a prominent barriers to ANC attendance and integrated ANC service delivery (systematically reviewed in [18, 39, 40]). For example, the provision of HIV treatment at specialised ART clinics separate to ANC clinics reduced uptake of HIV services in pregnant women by around 50% [21, 29, 30].…”

“…For example, the provision of HIV treatment at specialised ART clinics separate to ANC clinics reduced uptake of HIV services in pregnant women by around 50% [21, 29, 30]. To counter this problem, governments, in conjunction with non-governmental organisations, have begun integrating HIV services and PMTCT into primary healthcare and ANC with the recognition that HIV-specific resources could be allocated diagonally (aiming for disease-specific results through enhanced health systems) [18, 41]. However, integration of these services can be hindered if not accompanied by sufficient additional funding to ensure cohesive and effective service integration; limited resources remain a major barrier in the integration of malaria treatment and prevention into ANC [42].…”

“…While IPTp is given presumptively in ANC, thus removing the need for testing, women are often required to purchase the drug elsewhere or are not directly observed taking therapy having been given the drug to take home, both of which have been identified as a significant barrier to IPTp coverage [45–47]. Effective procurement and distribution systems are also important determinants of success for integrated services, with inadequate and irregular supplies of essential drugs and interventions, in both the public and private healthcare sector, representing a major barrier in the uptake of both integrated HIV and malaria services [18, 39, 40]. …”