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

在肯尼亚，特别是在农村人口和青少年中，怀孕早期接受产前保健的比例很低。所有孕妇都应该对可能对母亲或婴儿造成伤害的常见疾病进行检测，以便在怀孕期间尽早诊断和治疗，最好是在怀孕20周之前。肯尼亚的指导方针建议对艾滋病毒、梅毒、疟疾（如果发烧）和贫血进行检测。实际上，只有持续进行艾滋病毒检测，甚至可能很晚才进行（有时检测呈阳性的妇女可能无法及时得到治疗）。由于农村地区的妇女没有足够的时间和金钱去遥远设施的实验室进行检查，并且由于服务质量差而推迟到较低设施（如药房）进行产前保健，因此经常完全错过其他检查。所有这些问题加在一起可能导致母亲及其新生儿的妊娠结局不佳，特别是在这些弱势群体中。不需要训练有素的实验室人员的低成本技术可以在护理点进行快速检测，在20分钟内给出结果，并且克服了前往可能很远或费用昂贵的实验室的需要。这种诊断艾滋病毒的快速检测方法在肯尼亚已经使用了近20年。梅毒、疟疾和贫血也有类似的检测方法，尽管不太常用。我们（在不同的地点和不同的时间）成功地证明了以下几点：首先，可以与社区卫生工作者合作，改善将孕妇转到卫生机构接受初级保健服务的情况；第二，综合护理点检测可以减少等待时间，改善最低一级卫生设施的工作流程，分别提高产前护理和检测的接受程度。由于缺乏相应设施或社区的干预，这些单独的项目都受到了阻碍。在这项早期阶段的研究中，我们将首次将这两种经过验证的干预措施结合为一种综合方法，以改善产前保健，提高农村人口对产前保健的接受程度。我们的目标是使孕妇接受所有四种疾病检测的人数至少增加50%。在这一早期阶段，我们将评估联合模式是否在现有卫生系统内有效，以及它是否为使用它的社区成员和实施它的卫生工作者所接受。如果我们能够成功地将这两种方法结合成一种可行的干预措施（我们已经设定了目标来定义我们的意思），那么我们计划通过在肯尼亚西部进行的一项实用的集群随机对照试验（主要研究），继续测试这种组合方法对怀孕结果的影响。我们的主要研究已经提交给欧洲联盟，并被列入候选名单，我们希望它能在这个早期阶段的研究基础上成功地获得资助。

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.