Maternal, Newborn, and Child Health
MNCH Service Delivery Interventions
Maternal, Newborn, and Child Health
MNCH Service Delivery InterventionsPreventing Mother-to-Child Transmission
Protecting the next generation
Mother-to-child transmission (MTCT) of HIV, syphilis, and hepatitis B remains a significant public health concern, yet it is highly preventable through timely and effective interventions. Without proper care, these infections can lead to serious maternal and neonatal outcomes, including stillbirth, preterm birth, and chronic illness that lasts a lifetime.
In 2022, an estimated 1.3 million pregnant women were living with HIV, with 130,000 new pediatric HIV infections resulting from MTCT. Syphilis continues to be a leading cause of adverse birth outcomes, contributing to over 200,000 stillbirths and neonatal deaths annually. Meanwhile, hepatitis B – a major cause of chronic liver disease – affects approximately 257 million people globally, with perinatal transmission accounting for a substantial proportion of new infections.
To tackle this burden, the World Health Organization (WHO) developed the Elimination of Mother-to-Child Transmission (EMTCT) validation framework, setting ambitious global targets to guide country action:
- HIV: MTCT rate <5% in breastfeeding populations and <2% in non-breastfeeding populations; fewer than 50 new pediatric HIV infections per 100,000 live births.
- Syphilis: Congenital syphilis rate of fewer than 50 cases per 100,000 live births.
- Hepatitis B: Prevalence of hepatitis B surface antigen (HBsAg) of less than 0.1% among children aged five years.
What Are the Benefits of Preventing MTCT?
- Reduces morbidity and mortality associated with HIV, syphilis, and hepatitis B.
- Contributes to reducing the burden/ incidence of HIV, syphilis, and hepatitis B, leading to achieving WHO’s EMTCT validation targets.
- Reduces healthcare costs by preventing long-term complications in mothers and infants.
How to Implement
1. Screen for HIV
- Offer HIV Testing and Counseling (HTC) to all pregnant women at their first antenatal care (ANC) visit, using an opt-out approach.
- For women who test HIV-negative, provide repeat HIV testing in the third trimester to identify any new infections.
- For infants born to women living with HIV, conduct HIV testing at birth or during the first health contact within two weeks after birth.
- Regardless of birth test results, repeat infant testing at the 6-week immunization visit.
- Use HIV DNA PCR as the confirmatory test for early infant diagnosis.
**Where possible/feasible use HIV-Syphilis dual test
2. Screen for Syphilis
- Conduct universal syphilis screeningfor all pregnant women using either point-of-care rapid syphilis tests or the VDRL (Venereal Disease Research Laboratory) test during ANC.
- For women who test negative during early ANC, repeat syphilis testing in the third trimester to detect new infections.
** Where possible/feasible use HIV-Syphilis dual test
3. Screen for Hepatitis B
- Test all pregnant women for Hepatitis B using the HBsAg (Hepatitis B Surface Antigen) test at their first ANC visit.
- If the HBsAg test is positive, follow up with additional testing for:
- Hepatitis B Virus (HBV) DNA
- Hepatitis B e-antigen (HBeAg)
These tests help determine viral replication status and infectivity, guiding further management and strategies to prevent mother-to-child transmission.
4. HIV Prevention and Treatment
- Initiate Antiretroviral Therapy (ART):
- Start Tenofovir + Lamivudine + Dolutegravir (TLD) for all pregnant and breastfeeding women living with HIV, regardless of gestational age, WHO stage, or CD4 count.
- Continue ART lifelong to maintain immune function and prevent transmission during pregnancy, delivery, and breastfeeding.
- Provide Infant Prophylaxis:
- Give Zidovudine (AZT) + Nevirapine (NVP) for the first 6 weeks of life.
- Continue Nevirapine until 6 weeks after the complete cessation of breastfeeding.
- Support Safe Breastfeeding:
- Encourage exclusive breastfeeding with ongoing ART adherence.
- Start Cotrimoxazole Preventive Therapy (CPT):
- Begin CPT in pregnant and breastfeeding women and HIV-exposed infants, regardless of gestational age.
- Do not co-administer sulfadoxine-pyrimethamine (SP) with CPT for malaria prevention.
- Ensure Safe Delivery Practices:
- Limit vaginal exams, use aseptic techniques, avoid artificial rupture of membranes, and use the partograph to monitor labor and avoid prolonged labor and genital tract trauma.
- Offer Pre-Exposure Prophylaxis (PrEP):
- Provide PrEP to HIV-negative pregnant and postpartum women at high risk of HIV infection.
- Conduct Viral Load Monitoring:
- For new ART initiates, test 3 months after starting ART, then every 6 months until breastfeeding stops.
- For those already on ART, test at pregnancy confirmation, then every 6 months during breastfeeding.
5. Syphilis Screening and Treatment
- Treat Pregnant Women with Antibiotics:
- Administer Penicillin G 2.4 million units IM stat.
- If allergic, use Ceftriaxone 1g IM daily for 8–10 days.
- Treat Congenital Syphilis:
- For infants <7 days: Crystalline Penicillin 50,000 IU/kg twice daily for 10 days. • For infants >7 days: Crystalline Penicillin 50,000 IU/kg three times daily for 10 days.
- Engage Male Partners:
- Encourage partner notification, testing, and treatment to prevent reinfection.
6. Hepatitis B Prevention and Treatment
- Treat High Viral Load in Pregnancy:
- For HBsAg-positive women with high HBV DNA, initiate Tenofovir therapy during pregnancy.
- Prevent Congenital HBV Infection in Newborns:
- Administer Hepatitis B Immunoglobulin (HBIG), 0.5ml IM, within 12 hours of birth.
- Provide the Hepatitis B vaccine at birth, 1 month, and 6 months.
- Ensure Timely Infant Vaccination:
- Administer the birth dose of the Hepatitis B vaccine within 24 hours, followed by routine immunization per national schedule.
Key Indicators
- HIV Testing Coverage: Percentage of pregnant women tested for HIV at ANC.
- ART Uptake: Proportion of HIV-positive pregnant women on ART.
- Syphilis Testing and Treatment Rates: Number of women screened and treated.
- Hepatitis B Birth Dose Coverage: Proportion of infants receiving timely birth-dose vaccination.
- Retention in EMTCT Services: Proportion of mother-infant pairs retained in follow-up care.
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Tips
- Strengthen Health Systems: Integrate EMTCT into routine maternal and child health services.
- Strengthen use of Data: Inform on gaps, and decision-making for the program.
- Community Engagement: Foster awareness and demand for services through education and advocacy.
- Task Shifting and Training: Train midwives, nurses, and community health workers to provide EMTCT services.
- Digital Health Solutions: Use mobile health (mHealth) tools for patient reminders and follow-ups.
Challenges
- Stigma and Discrimination: Implement confidentiality measures and train staff on non-discriminatory care.
- Vertical Programming: Integrate maternal-child health with PMTCT to optimize care and reduce missed opportunities.
- Supply Chain Gaps: Strengthen procurement and distribution of test kits, ARVs, and vaccines.
- Healthcare Worker Shortages: Utilize task-sharing strategies and telemedicine support.
- Retention in Care: Develop peer-support programs and follow-up mechanisms.
Key Resources
- HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach. WHO 2021
- HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for key populations. WHO 2022
- Global guidance on elimination of mother-to-child transmission of HIV, syphilis and hepatitis B virus. WHO 2021
- Prevention of mother-to-child transmission of hepatitis B virus: guidelines on antiviral prophylaxis. WHO 2020
- WHO guideline on syphilis screening and treatment for pregnant women. WHO 2017
- Introducing a framework for implementing triple elimination of mother-to-child transmission of HIV, syphilis and hepatitis B virus. WHO 2023
- Mother-to-child transmission of HIV. WHO
- Antiretroviral therapy coverage among HIV-infected pregnant women for PMTCT. Global Health Observatory
