Scaling Up Antenatal Syphilis Testing in Mozambique
Screening for syphilis infection during pregnancy is the official standard of care in most African countries, yet as many as 1 million women with active syphilis are not screened each year. Syphilis poses serious risks for mothers and babies, including miscarriage, stillbirth and neonatal death. Congenital syphilis (infection passed from mother to fetus) can cause blindness, deafness, seizures and developmental disabilities. Early identification and treatment during pregnancy can cure the mother and prevent transmission to the baby.
In central Mozambique in the early 1990s, syphilis screening rates hovered around 40% for a variety of reasons. A pilot project increased screening temporarily, but obstacles to maintaining this improvement included a patient charge for the rapid test (RPR) and treatment, test shortages, nurse and lab technician absences, and transportation barriers for patients to come for antenatal care, or to go to the lab for testing or results.
Addressing the Challenges
The Ministry of Health prioritized syphilis screening for pregnant women as part of their national 5-year plan in 1995.
We helped to identify barriers to patients entering care, bottlenecks, and where they were lost to follow-up, and worked with the Ministry of Health to resolve these problems. For instance, when health workers realized that many women were not going from the clinic site to the separate lab site, often requiring a second wait in line, the clinic started doing blood draws at the beginning of the antenatal session to permit batch testing and transport of samples. This resulted in women learning their results in the same day, and being able to start treatment if positive.
Other challenges included:
- Delay of first antenatal visit until after 24 weeks, at which point treatment is not as successful
- Shortages of tests, syringes and penicillin
- "Competition" as vertical programs such as special STD programs or prevention of mother-to-child transmission (PMTCT) for HIV disrupted antenatal care flow, created separate clinics and registration systems and further strained the workforce
- Limited success with partner notification, testing and treatment
The Ministry of Health, with the help of HAI, PATH and the Bill and Melinda Gates Foundation, piloted use of a treponemal immunochromatographic strip (ICS) rapid test to enable fast, accurate testing in antenatal care sites that did not have labs ("peripheral health facilities"). The pilot was conducted at all 164 sites that offer antenatal care in the two central provinces (Manica and Sofala). In 132 sites without labs, the Ministry of Health assessed the introduction of the ICS test, while in the 32 sites with labs, the ICS test was compared with the RPR test.
Testing increased to 93% in all facilities (main difference was in sites that didn't have labs). The greater numbers of women tested and treated likely contributed, along with other factors, to a drop in the antenatal prevalence of syphilis from 12% in 1988 to 5% in 2005.
In addition to having a positive impact on women and their children, this project also helped to bolster primary health care and the supporting systems in government health facilities. Several factors key to successful operation within the existing health system (rather than setting up outside narrowly-focused programs) included:
- Support for health workers - rather than training workers on the new test and procedure at one off-site training event, HAI staff worked with Ministry of Health counterparts to conduct a short training followed by on-the-job supervision and follow up on a regular basis. This improved performance as well as morale, because staff were no longer constantly short due to repeated off-site trainings. Integrating supervision reinforced the concept that comprehensive antenatal care includes multiple interventions, including syphilis screening.
- Improved procurement and management systems - better systems to track supply usage and prevent stock-outs of tests, syringes, medications were essential. Monitoring systems help to emphasize to health workers and their supervisors what activities are prioritized.
- Aligned goals - As an NGO, we worked closely with the Ministry of Health to identify bottlenecks and propose solutions that Ministry managers approved at a policy level. New technologies, such as the ICS test, were useful but could not have been effectively implemented absent a functioning health system that included a trained and supported workforce, necessary supplies and drugs, and the policies and measurable targets to indicate improvement.
For more detail on this project, see Gloyd et al, Scaling up antenatal syphilis screening in Mozambique: Transforming policy into action, 2007.