The ‘Mama Mshauri’ effect: keeping mothers in HIV care after birth

Women living with HIV who benefitted from the support of a ‘Mama Mshauri’ reduced their risk of healthcare drop out by around one-third, reveals a study from Kenya.

The Mother-Infant Retention for Health (MIR4Health) study looked at the effectiveness of a combination care package, delivered by trained lay workers known as ‘Mama Mshauris’, in retaining HIV-positive women and their infants in prevention of mother-to-child transmission (PMTCT) care at six months after birth.

Despite PMTCT programmes making huge strides in reducing HIV infections among women and infants, keeping women engaged in PMTCT programmes after labour can be challenging. As a result, proportionally more infant infections are now occurring during the postnatal period as more women drop out of care. For example, in Kenya where the study took place, the majority of new infections in infants now occur during breastfeeding rather than pregnancy or labour.

From September 2013 to June 2014, 340 HIV-positive pregnant women starting antenatal care at 10 facilities in western Kenya were enrolled in the study.

Through random selection, half of the women were assigned a Mama Mshauri who provided individualised PMTCT health education, support in attending appointments and adhering to treatment, phone and SMS appointment reminders, and followed up if women missed clinic visits. The Mama Mshauris also provided psychosocial support and counselling and helped women to access services quickly, while enhancing communication between each woman and health facility staff.

The other half of the women formed the study’s control group. They received the standard package of PMTCT care in Kenya, which consists of at least four antenatal care visits during pregnancy, and monthly post-delivery clinic appointments for both mothers and infants for six months. Participants in the control group also received group health education during antenatal visits, and had the option to enrol in a monthly support group led by facility staff.

Six months after birth, the intervention package delivered by the Mama Mshauris resulted in a 33% reduction in the risk of dropout (or ‘attrition’) among women and their infants. Overall, 23% of mother-infant pairs dropped out of care at six months, but this was significantly lower in the intervention group compared to the control group (19% vs. 28%).

Attrition was defined as either no documented clinic visits in the three months prior to, or after, the six month visit (described as ‘lost to follow-up’) or due to the death of the woman or infant. Over a third (36%) of all drop-outs were the result of pregnancy losses.

Almost all mothers reported breastfeeding (above 90%), although less than half were doing so exclusively. The proportion of women still breastfeeding at six weeks fell to 70% and 46% at six months, with no difference between study arms.

More than three-quarters (82%) of infants had an HIV test at six weeks. Among those with a negative result, 69% retested at six months as advised, with no difference between study arms.

The rate of HIV transmission from mother-to-child was low overall, with only 3% of infants having acquired HIV at six months. This equates to nine infants, of whom seven began antiretroviral treatment and two died.

Overall, only 53% of women were virally suppressed six months after giving birth, although the proportion was slightly higher in the intervention group (58%) compared to the control arm (50%).

All of these findings indicate that lay counsellors who are trained, mentored, and provided with the necessary tools can improve PMTCT services and their outcomes. By evaluating results relating to both mothers and infants, researchers have designed a study that highlights the importance of improved lay counsellor support in PMTCT programming and also underscores the contribution of early pregnancy losses to the rate of women dropping out of PMTCT care.

This is also the first PMTCT study to assess a combination of interventions provided by the Mama Mshauri package, rather than look at interventions in isolation. However, because of this it is not possible to determine which specific intervention decreased attrition the most, or which sub-populations of women benefit from each specific intervention.