Kenya Quality Model for Community Health: a unique model for quality improvement in Antenatal Care

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The uptake of antenatal care in early pregnancy is low, especially among rural populations and adolescents in Kenya. All pregnant women should be tested for common conditions that can cause harm to the mother or the baby so that these can be diagnosed and treated as early as possible in the pregnancy, ideally before 20 weeks of pregnancy. Kenyan guidelines recommend testing for HIV, syphilis, malaria (if they have fever) and anaemia. In practice, only HIV testing is done consistently and even this may be done late (and sometimes women who test positive may not get treatment in time). The other tests are very often missed altogether as women from rural areas cannot afford the time and money to go to laboratories at distant facilities and are put off attending antenatal care at lower facilities (like dispensaries) due to poor quality of services. All of these issues combined can lead to poor pregnancy outcomes for mothers and their newborns, especially among these vulnerable populations. Low cost technology that does not require trained laboratory personnel is available to do rapid testing at the point-of-care, giving a result in 20 minutes and overcoming the need to travel to a laboratory that may be far away or expensive to get to. Such rapid tests for the diagnosis of HIV have been in use in Kenya for close to 20 years. Similar tests for syphilis, malaria and anaemia are also available, though less commonly used. We have successfully shown (in separate locations and at separate times) the following: first that it is possible to work with community health workers to improve referral of pregnant women to health facilities for primary care services; and second, that integrated point of care testing can reduce waiting times and improve workflows at the lowest level of the health facility, improving uptake of ANC (Antenatal Care) and of testing respectively. Each of these separate projects was hampered by the absence of an intervention in the corresponding facility or community. In this early phase study, we will for the first time combine these two proven interventions into one combined approach to improve antenatal care, increasing its uptake among rural populations. Our ambition is to increase the number of women being tested for all four conditions in pregnancy by at least 50%. In this early phase we will assess if the combined model works within the existing health systems and if it is acceptable to the community members who utilised it and the health workers who implemented it. If we are successfully able to combine the two into a single feasible intervention that works (we have set targets to define what we mean by this) then we plan to go on to test the impact of this combined approach on pregnancy outcomes through a pragmatic cluster randomised controlled trial in western Kenya (the main study). Our main study has been submitted to, and shortlisted by, the European Union and we hope it will be successfully funded building on this early phase study.