Studies have suggested that adherence to ART may be lower among postpartum women compared to non-pregnant adults started on ART[5][6]. There is also mounting evidence that postpartum retention in care of new mothers is poor. A study in the nearby township of Gugulethu suggested that nearly 30% of mothers default on ART in the first six months after delivery[6]. 

Non-adherence leads to viral rebound and an increased risk of postpartum MTCT through breastfeeding. Reasons for poor maternal retention in care are summarized in Figure 1 and are thought to include: long waiting times and high patient volumes at the antiretroviral (ARV) clinic, younger maternal age, non-disclosure of HIV status, travel costs, inadequate knowledge about postnatal MTCT, stigma, regimen fatigue, and lack of partner involvement[4] [5] [6] [7]. 

Furthermore, the literature suggests post-delivery responsibilities including stresses and demands of caring for a newborn may be a potential barrier for adherence to treatment[8]. Also, negative staff attitude is considered to be a reason for declining retention in care rate among pregnant and postpartum women[6][9].

Studies have suggested that adherence to ART may be lower among postpartum women compared to non-pregnant adults started on ART. There is also mounting evidence that postpartum retention in the care of new mothers is poor. A study in the nearby township of Gugulethu suggested that nearly 30% of mothers default on ART in the first six months after delivery. 

Non-adherence leads to viral rebound and an increased risk of postpartum MTCT through breastfeeding. Reasons for poor maternal retention in care are summarized in Figure 1 and are thought to include: long waiting times and high patient volumes at the antiretroviral (ARV) clinic, younger maternal age, non-disclosure of HIV status, travel costs, inadequate knowledge about postnatal MTCT, stigma, regimen fatigue, and lack of partner involvement. Furthermore, the literature suggests post-delivery responsibilities including stresses and demands of caring for a newborn may be a potential barrier for adherence to treatment. 

Also, negative staff attitude is considered to be a reason for declining retention in care rate among pregnant and postpartum women. One strategy to improve postnatal care and postpartum HIV care is an integration of services. In 2011, UNAIDS recommended the integration of prevention of mother to child transmission(PMTCT) with maternal, newborn and child health services[8]. South Africa produced a national PMTCT integrated model in 2011, recommending “integration of PMTCT into the existing maternal and child health interventions”. However, the implementation of integrated postnatal maternal and child health has been generally poor and ineffective.

In recent years, adherence clubs have been adopted in South Africa as a differentiated model of care for clinically stable adults on ART. Adherence clubs serve the dual purpose of decongesting health facilities by scheduling group prescription pick-up of ART and health checks and also provide an environment of peer support to patients on ART. Clubs have shown good patient retention in care and virological outcomes compared to standard of care[10][11]. Different models of clubs have since been assessed, such as community-based adherence clubs, which also showed good adherence and retention in care[12].

Following lessons learnt from implementing adult adherence clubs, Doctors Without Borders (MSF) in partnership with mothers2mothers (m2m) and City of Cape Town (CoCT) Health decided to create a new differentiated model of care called “Postnatal Clubs” (PNC). The objective of the toolkit entails:
 

The objective of the toolkit entails:

1. To provide programmatic information and advice on what is required to start PNCs in other facilities.
2. To provide a practical guide implementing and managing PNCs to assisting the health care staff in supporting mother-infant pairs (MIPs) in clinical care and early childhood development (ECD) as part of First Thousand Days.

1. Retention in care (RIC) of MIPs 
2. Maternal HIV viral load suppression
3. Prevention of mother to child transmission (PMTCT) of HIV
4. Infant HIV testing uptake
5. Full vaccination of infant
6. Improved quality of healthcare for mother and infant 
    

The PNC model relies on a number of different healthcare workers to run smoothly.

Figure 3 provides an overview of each staff member involved in PNCs and a detailed explanation are in the text on the next page.

Next to each component we have written required or recommended as a guide to assist with designing and planning a new PNC.

What is required below is what we think is needed for a medium clinic of between 120-250 HIV exposed babies (PMTCT babies) attending per year to form 12 clubs a year (once a month) with a maximum of 15 mother-infant pairs per club. This means that at least 70% of PMTCT babies should be in PNC for the model to work properly (as with adherence clubs, the model is otherwise too cumbersome if only a few babies are in the PNC).

A PNC consists of 3-15 MIPs and should not exceed the maximum number to ensure the emotional and psychological peer support and ECD activities can be carried out in an appropriate way.

1. Who do we recruit for PNC?

Any HIV-positive mother, regardless of age, VL and drug regimen, can join a PNC with her HIV-negative infant if she wants to have integrated mother-child care.

The eligibility criteria can be adapted based on what is required and needed from the mothers and the community.

High-risk mothers

According to the South African PMTCT guidelines of 2020, a mother is considered at high risk of HIV transmission if:

• mother on ART with most recent VL>=1,000 copies/ml
• mother HIV positive but not on ART:
• newly diagnosed HIV-positive while breastfeeding
• previously diagnosed HIV-positive but not initiated on ART or discontinued ART

When the HIV-positive mother first presents to the clinic (usually at 6 weeks), she is given the option of joining a PNC and given a date and time for the first session of the PNC. However, the time of recruitment should be flexible depending on the facility and its capacity for recruitment. The recruitment is usually done either by the club facilitator or by the nurse seeing the MIP. Babies are grouped into clubs per the same month of the date of birth.

Posters about clubs and the eligibility criteria are one strategy to keep mothers informed about the PNC system. Patients who are already members of a PNC could disseminate knowledge about PNCs by word of mouth and by functioning as patient advocates. Additionally, mothers could receive information about PNCs during their pregnancy.

Duties or actions that are required before a club session are explained below as well as the responsible person for action.

Action and Responsible Person

Club facilitator:

• Ensure pre-packed ART medication is available at least a day before the club meeting
• Check the room is available and ready for the club meeting
• Collecting mother and infant folders
• Collecting the club register before the start of the club meeting
• Collection of pre-packed medication on the day of the club
• Ensure you have the materials required for ECD activities
• Ensure preparation of the health talk topic for each session according to the schedule

Club nurse:

• Scripts need to be issued a few days before the club meeting so that medication can be pre-packed

Pharmacist/Assistant/ CDU system:

Pre-packing ART medication a few days before the club meeting.

On arrival at the facility, mothers and babies go directly to the club room, without having to queue at the reception. The mothers’ folders, as well as their babies’ folders, are kept in separate club crates or separate shelves. The fact that a mother and her child are enrolled in the PNC is clearly identified on the mother’s and baby’s card so that their folders are easily retrievable should they come to the clinic outside the PNC.

The nurse prescribes the mother’s ARVs a few days before the PNC. The pharmacy will pre-package medication, using pharmacy stock or supplies from CDU (a central pre-packaging facility dispensing chronic medications for clients in the Western Cape). The club facilitator collects the prepacked ARVs from the pharmacy on the day of the PNC.

At the first visit, mothers are provided with an ART buffer stock of an extra two weeks, as some of the clubs are spaced more than multiples of 28 days apart.

As in the adult club model, the PNC starts with a peer support session, which is led by a club facilitator. ECD activities and promoting the “First 1000 Days”/”Side by side” campaign are included. MIPs will then have a doubly integrated clinical session provided by the PNC nurse. Each visit’s interventions will depend on the age of the baby. The mother’s clinical care schedule is also adapted around the baby’s visits. To facilitate the process, integrated stationery helps map the clinical care requirements for each visit.

When the child reaches 18 months of age, the MIPs graduate from the PNC. The mother's transition as a group into an adult club, so that they keep up the peer support they created within their PNC. The babies go back to a standard of care services.

The mothers and babies start by sitting in a circle and the PNC facilitator then facilitates a health education and ECD activities session as per the guide below.

Full session guides are found here.

The PNC facilitator will weigh the mother and baby. Mothers are asked about symptoms of TB at every visit and screened for depression every 6 months. The facilitators complete a depression screening form to identify mothers at risk. This is then reviewed by the nurse at the clinical visit. The Perinatal Mental Health Project (PMHP) provides instruction on mental illness and psychosocial risk screening in postnatal women.

Download the PMHP maternal risk screening tool and see the link to the PMHP website here.

The babies are screened for general illness. If the baby shows signs of acute severe illness, they are fast-tracked to see the nurse. Everything is recorded into the club register by the PNC facilitator.

Each session includes information on adherence, infant feeding (encouraging exclusive breastfeeding) and health promotion messages which change at each visit—some messages are HIV-related topics whilst others are not. Some topics covered include HIV status disclosure, sexual violence, family planning and education on VL suppression. 

Each session ends with education about ECD. The PNC facilitator talks about developmental milestones and shows the mothers how to do some ECD activities. Mothers and PNC staff are encouraged to bring recyclable material to the sessions to do the ECD activities. 

Whilst the MIPs wait to see the nurse, the PNC facilitator distributes the ART (pre-packed for one month or three months depending on the club) to the mother and they inform them of their next appointment date. The mothers also receive a schedule of all the PNC visits at the first visit

High-risk mothers* receive extra psychosocial support. Even when the clubs are three-monthly, high-risk mothers are seen monthly. 

The PNC facilitator records PNC data into the club register. The club nurse completes the integrated paediatric stationery, which encourages integrated care and prompts the nurse as to which services should be rendered at each visit. The nurse fills in the paediatric stationery in the baby’s folder at each visit, but she only writes in the mother’s folder at the mother’s clinical visits or if she receives family planning. For all other visits, the mother’s information is recorded in the club register.

• City of Cape Town Paediatric Stationery (July 2017)
• ART register Club Register (August 2016)

Data clerks should ensure that all the latest blood results of the mothers are filed in the folder.

Facility clerks regularly capture the PNC visits into an electronic data system, using a combination of the club register and the mothers’ and babies’ folders for other services rendered. The mothers’ and babies’ folders are kept together in crates, per PNC number, at the reception, where all folders are kept. This is clearly identified on the mothers’ and babies’ cards so that their folders are easily retrievable in case they come for a clinical visit outside the PNC.

Once the data capturing is completed, the clerk has to sign off each page that has been captured. When all patients’ information has been transferred into the electronic system, the cover page of the club register will be signed off.

A summary of who is filling in and capturing what is provided in the table below.

From June 2016 to 31^st December 2018, we recruited 433 mothers (27 high-risk) and 439 infants (6 sets of twins). 

Uptake of infant HIV testing was high at age 9 months (99.1%) and 18 months (98.4%). No seroconversions of infants were observed (See Figure 12).

Of those reaching their 18-months visit, 70.5% of pairs were still in care (see Figure 13).

Of the 141 mothers who were eligible for a pap smear, 53.2% received a pap smear by 18 months.

Of all the women who had a mental health screening, 17.5% screened positive for depression on at least one occasion.

Maternal viral load testing and suppression remained above 90% throughout PNC (see Figure 14).

Out of a total of 187 confirmed infants’ vaccination coverage at 12 months, 88.9% were fully immunised.

** Protocol was approved by Foundation Professional Development-Ethics Research Board and by MSF-ERB

Challenge: length of club visit

The peer support group session is lengthy at 30 to 45 minutes, and a dedicated counsellor or peer mentor is required to facilitate the session. In addition, the PNC nurse and clinic management initially felt that the clinical visit was very lengthy and that too many services were being rendered at the PNC. They suggested that some interventions (i.e. Pap smear) should be shifted back to other clinic staff.

An informal “time and motion study” challenged this perception, showing that the time taken to provide all PNC services in a non-integrated way differed little from the duration of an integrated PNC clinical visit. Following further discussions, staff unanimously agreed that no services should be removed from the PNC model.

Challenge: meeting headcount targets

In the City of Cape Town health system, nurses have a target number of patients to see per day (“headcount”). Initially, there was concern that the PNC nurse was not seeing enough patients.

This headcount does not take into consideration that multiple services are being offered. Such targets should be changed to the number of services rendered to more accurately reflect the workload. It is also important to note that an integrated clinical visit provides an improved quality of care, as seen in an audit of the City of Cape Town PMTCT –PNC indicators.

We conducted a qualitative study in September 2017 to look at “Knowledge transmission, peer support, health-seeking behaviour and satisfaction in Postnatal Clubs in Khayelitsha, South Africa”. 10 IDIs (individual interviews), 3 FGDs (focused group discussion) and 2 POs (observations) were conducted with PNC participants, staff and key informants in isiXhosa and English until reaching saturation. Findings of the study are below and were published **** 

*** Protocol was approved by University of Cape Town Ethics Board, ITM IRB, UZA/UA and MSF ERB

****Knowledge transmission, peer support, behaviour change and satisfaction in Post-Natal clubs in Khayelitsha, South Africa: a qualitative study

• PNC Scheduler

• PNC session guide

• ROTF worksheet

• Club Register

• Standard operating Procedure on Postnatal clubs

• Road to Health Booklet 

• City of Cape Town Paediatric Stationery

• Post Natal Clubs Review of model

• PMHP maternal Risk Screening Tool

• Job Description Club Facilitator

• Job Description Checklist Data Clerk

• Job Description Checklist PNC Nurse

• Job responsibility Checklist Pharmacy Assistance

Facilitators attend 3 days of training, nurses attend the last 2 days of training, facility managers/OPM/Clerk/pharmacy assistant/doctor attend the last day of training.

• Health Care Worker training - HCW content

• Health Care Worker training - Day 1

• Health Care Worker training - Day 2

• Health Care Worker training - Day 3

• Health Care Worker training - HCW content

PNC in national South African PMTCT guidelines

MSF scientific day presentation

PNC presentation for USAID

PNC in Child gauge

AIDS 2020 poster

PNC on IAS website

Through the PNC model, we were able to improve maternal retention in HIV care and postpartum Viral Load completion and suppression. We were also able to realize a higher uptake of infant HIV testing until 18 months of age, and experienced no infant seroconversions.

A qualitative study also showed high levels of satisfaction among participating mothers. The PNC model allows for the comprehensive integration of a number of healthcare services for the mother-infant pair. Given the high uptake of several services and favourable outcomes through the PNC model, PNCs are being scaled up in other clinics in South Africa. This model can also be adapted with relative ease to be implemented in or other resource-limited settings with substantial burdens of HIV.

Shariefa Abrahams, Kornelia Flami, Leila Stein, Orli Setton and Shaun Brassell.

All of existing and previous MSF team members (Tabitha Mutseyekwa, Leticia Mdani, Nompumulelo Mantangana, Aurelie Nelson, Leigh Snyman, Damian Hacking, Tali Cassidy, Keitu Lebelo, Nikiwe Malabi, Laura Trivino Duran, Rodd Gerstenhaber, Kate Buchanan, Julia Hill, Catherine Wedderburn, Marianna Garcia, Rinako Uenishi, Esther Casas, Sean Christie, Suhair Solomon, Simone Honickman, Lynne Wilkinson, Paola Lopez, Vinayak Bhardwaj and Bulelwa Rorwana).

Mothers2mothers staff and their support team provided astounding care and listening skills to all the mothers.

COCT and Town 2 staff were instrumental in supporting the intervention from the start and help remodel it as we piloted it.

All photos by Leila Stein and Sean Christie/MSF

ART - Antiretroviral therapy

ARV - Antiretroviral

CDU - Central dispensing unit

CF - Club facilitator

CN - Club nurse

ECD - Early childhood development

FM - Facility manager

FP - Family planning

HR - Human resource

IMCI - Integrated management of childhood illness

IUCD - Intrauterine contraceptive device

M2m - Mother 2 mothers

MIP - Mother-infant pair

MSF - Médecins Sans Frontières

MTCT - Mother to child transmission

PCR - Polymerase chain reaction

PMHP - Perinatal Mental Health Project

PMTCT - Prevention of mother to child transmission

SOP - Standard operating procedure

RIC - Retention in care

ROTF - Risk of treatment failure

VL - Viral load

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