Gaps in the prevention of mother-to-child transmission of syphilis: a review of reported cases, South Africa, January 2020-June 2022.

INTRODUCTION: Congenital syphilis (CS) is preventable through timely antenatal care (ANC), syphilis screening and treatment among pregnant women. Robust CS surveillance can identify gaps in this prevention cascade. We reviewed CS cases reported to the South African notifiable medical conditions surveillance system (NMCSS) from January 2020 to June 2022. METHODS: CS cases are reported using a case notification form (CNF) containing limited infant demographic and clinical characteristics. During January 2020-June 2022, healthcare workers supplemented CNFs with a case investigation form (CIF) containing maternal and infant testing and treatment information. We describe CS cases with/without a matching CIF and gaps in the CS prevention cascade among those with clinical information. FINDINGS: During January 2020-June 2022, 938 CS cases were reported to the NMCSS with a median age of 1 day (interquartile range: 0-5). Nine percent were diagnosed based on clinical signs and symptoms only. During January 2020-June 2022, 667 CIFs were reported with 51% (343) successfully matched to a CNF. Only 57% of mothers of infants with a matching CIF had an ANC booking visit (entry into ANC). Overall, 87% of mothers were tested for syphilis increasing to 98% among mothers with an ANC booking visit. Median time between first syphilis test and delivery was 16 days overall increasing to 82 days among mothers with an ANC booking visit. DISCUSSION: Only 37% of CS cases had accompanying clinical information to support evaluation of the prevention cascade. Mothers with an ANC booking visit had increased syphilis screening and time before delivery to allow for adequate treatment.

Untreated maternal syphilis has devastating consequences for the foetus. Congenital syphilis (CS) is preventable through timely maternal screening and treatment with robust surveillance. We evaluated CS surveillance data to identify gaps in CS surveillance and in the prevention cascade in South Africa.

Availability of medical abortion medicines in eight countries: a descriptive analysis of key findings and opportunities.

BACKGROUND: In recent years a growing number of manufacturers and medical abortion products have entered country markets and health systems, with varying degrees of quality and accessibility. An interplay of factors including pharmaceutical regulations, abortion laws, government policies and service delivery guidelines and provider's knowledge and practices influence the availability of medical abortion medicines. We assessed the availability of medical abortion in eight countries to increase understanding among policymakers of the need to improve availability and affordability of quality-assured medical abortion products at regional and national levels. METHODS: Using a national assessment protocol and an availability framework, we assessed the availability of medical abortion medicines in Bangladesh, Liberia, Malawi, Nepal, Nigeria, Rwanda, Sierra Leone and South Africa between September 2019 and January 2020. RESULTS: Registration of abortion medicines-misoprostol or a combination of mifepristone and misoprostol-was established in all countries assessed, except Rwanda. Mifepristone and misoprostol regimen for medical abortion was identified on the national essential medicines list/standard treatment guidelines for South Africa as well as in specific abortion care service and delivery guidelines for Bangladesh, Nepal, Nigeria, and Rwanda. In Liberia, Malawi, and Sierra Leone-countries with highly restrictive abortion laws and no abortion service delivery guidelines or training curricula-no government-supported training on medical abortion for public sector providers had occurred. Instead, training on medical abortion was either limited in scope to select private sector providers and pharmacists or prohibited. Community awareness activities on medical abortion have been limited in scope across the countries assessed and where abortion is broadly legal, most women do not know that it is an option. CONCLUSION: Understanding the factors that influence the availability of medical abortion medicines is important to support policymakers improve availability of these medicines. The landscape assessments documented that medical abortion commodities can be uniquely impacted by the laws, policies, values, and degree of restrictions placed on service delivery programs. Results of the assessments can guide actions to improve access.

Unsafe abortion is a leading cause of death and disability among women of reproductive age. Medical management of abortion with mifepristone and misoprostol pills, or just misoprostol, is a safe and effective way to end a pregnancy. Owing to an increase in the number of medical abortion products that have entered country health systems, we examined access to these medicines from supply to demand in selected countries. The overarching goal of the national landscape assessments was to produce evidence to support advocacy efforts and policymaking for improved access to quality medical abortion products that is appropriate to the needs of the country. This paper aims to describe key findings across eight country settings on the availability of medical abortion medicines and identify key opportunities to improve access to them across countries.

An exploration of pregnant women and mothers' attitudes, perceptions and experiences of formula feeding and formula marketing, and the factors that influence decision-making about infant feeding in South Africa.

BACKGROUND: Despite strong evidence showing the lifelong benefits of breastfeeding for mothers and children, global breastfeeding practices remain poor. The International Code of Marketing of Breastmilk Substitutes is an internationally agreed code of practice, adopted by the World Health Assembly in 1981, to regulate promotion of commercial formula, and is supported by legislation in many countries. However, marketing of formula remains widespread and contributes to mother's decisions to formula feed. We present South African data from a multi-country, mixed-methods study exploring women's decision-making about infant feeding and how this was influenced by exposure to formula marketing. METHODS: Using a consumer-based marketing approach, focus group discussions (FGDs) were conducted with pregnant women and mothers of children aged between 0 and 18 months in two urban sites in South Africa. Participants were purposively selected according to their child's age, infant feeding practices and socioeconomic status. Ten FGDs were conducted during February 2020 with a total of 69 participants. Thematic analysis was used to analyse the data with NVivo v.12 software. RESULTS: Despite being encouraged by health professionals to breastfeed and intending to do so, many mothers chose to give formula in the early weeks and months of their child's life. Mothers reported breastfeeding challenges as the most frequent reason for initiating infant formula, stating that family members and health professionals recommended formula to solve these challenges. Although participants described few advertisements for infant formula, advertisements for 'growing-up' formulas for older children were widespread and promoted brand recognition. Mothers experienced other marketing approaches including attractive packaging and shop displays of infant formula, and obtained information from social media and online mothers' groups, which influenced their choice of formula brand. Mothers reported strong brand loyalty derived from previous experiences and recommendations. Health professionals frequently recommended formula, including recommending specific formula brands and specialist formulas. CONCLUSION: Global formula companies use multifaceted marketing methods to promote a strong narrative portraying formula feeding as a positive lifestyle choice. Positive, coordinated efforts are required to counter pro-formula messaging and change the narrative to support breastfeeding as an aspirational choice. In particular, health professionals must stop supporting the formula industry.

Limited resources restrict the provision of adequate neonatal respiratory care in the countries of Africa.

AIM: Over two thirds of newborn deaths occur in Africa and South Asia, and respiratory failure is a major contributor of these deaths. The exact availability of continuous positive airway pressure (CPAP) and surfactant in Africa is unknown. The aim of this study was to describe the availability of newborn respiratory care treatments in the countries of Africa. METHODS: Surveys, in English, French and Portuguese, were sent to neonatal leaders in all 48 continental countries and the two islands with populations over 1 million. RESULTS: Forty-nine (98%) countries responded. Twenty-one countries reported less than 50 paediatricians, and 12 countries had no neonatologists. Speciality neonatal nursing was recognised in 57% of countries. Most units were able to provide supplemental oxygen. CPAP was available in 63% and 67% of the most well-equipped government and private hospitals. Surfactant was available in 33% and 39% of the most well-equipped public and private hospitals, respectively. Availability of CPAP and surfactant was greatly reduced in smaller cities. Continuous oxygen saturation monitoring was only available in 33% of countries. CONCLUSION: The availability of proven life-saving interventions in Africa is inadequate. There is a need to sustainably improve availability and use of these interventions.

Expansion of HIV testing in Eswatini: stakeholder perspectives on reaching the first 90.

Achieving the United Nations' 90-90-90 goals has proven challenging in most settings and the ambitious 95-95-95 goals seem even more elusive. However, in Eswatini - a lower-middle-income country in sub-Saharan Africa with the highest HIV prevalence in the world - an estimated 92% of people living with HIV know their status. We conducted 26 in-depth interviews with stakeholders from policy, implementation, donor, local advocacy and academic sectors to elicit the facilitators and inhibitors to HIV testing uptake in Eswatini. Background data and related reports and policy documents (n = 57) were also reviewed. Essential facilitators included good governance via institutional and national budgetary commitments, which often led to swift adoption of globally recommended programs and standards. The integration of HIV testing into all points of care fostered a sense that testing was part of routine care, which reduced stigma. Challenges, however, centred on social norms that disadvantage certain groups with high ongoing HIV risk (such as key populations, adolescent girls and young women), a heavy reliance on external donor funding, and stigma that had subsided but nevertheless persisted. Amid concerns about whether the 90-90-90 targets could be achieved by 2020, the experience of Eswatini provides tangible insights into factors that have successfully influenced HIV testing uptake and may thus prove informative for other countries.

Revival of the mother-baby friendly initiative (MBFI) in South Africa: towards a quality improvement project.

BACKGROUND: The discontinuation of "Mother-Baby Friendly" accreditation, coupled with the impact of the COVID-19 pandemic, has contributed to reduced breastfeeding rates observed in parts of South Africa. Consequently, the Child, Youth and School Health cluster of the National Department of Health, with support from the World Health Organization and United Nations Children's Fund, organised a Mother-Baby Friendly initiative revitalisation workshop. METHODS: Held in Johannesburg, South Africa, on June 29-30, 2022, the workshop brought together local and international breastfeeding promotion experts to engage on issues related to the revitalisation of the Mother-Baby Friendly Initiative. The workshop included presentations and group sessions aimed at setting expectations, evaluating the Ten Steps to Successful Breastfeeding, and developing actionable revitalisation strategies. RESULTS: Inadequate monitoring of the Mother-Baby Friendly Initiative implementation and adherence to the Ten Steps was identified as a major implementation bottleneck. Participants identified steps ten (coordinating discharge so that parents and their infants have timely access to ongoing support and care), five (supporting mothers to initiate and maintain breastfeeding and manage common difficulties), and two (ensuring that staff have sufficient knowledge, competence, and skills to support breastfeeding) of the Baby-Friendly Hospital Initiative as the most difficult to implement. Step seven (enabling mothers and their infants to remain together and to practise rooming-in 24 h a day) was the least difficult to implement. Workshop participants identified the following proposed solutions to revitalise breastfeeding promotion: strengthening capacity building and mentorship, improving monitoring and accountability measures, and certification of facilities meeting the initiative's standards. CONCLUSION: Current breastfeeding policies and practices must be evaluated by the National Department of Health in collaboration with provincial and private representatives of the initiative to effectively revitalise the Mother-Baby Friendly Initiative. Moreover, an integrative monitoring framework must be developed through stakeholder engagement, role clarification, and ownership. While collaboration between the private and public sectors is required to promote training and communication within healthcare facilities and communities.

They push their products through me: health professionals' perspectives on and exposure to marketing of commercial milk formula in Cape Town and Johannesburg, South Africa - a qualitative study.

OBJECTIVE: To understand the views of public and private sector health professionals on commercial milk formula, to describe their exposure to companies that market commercial milk formula within their workplaces and to describe their awareness of South African (SA) regulations. DESIGN: A qualitative study consisting of semistructured interviews. SETTING: The study was conducted in Cape Town and Johannesburg, SA. PARTICIPANTS: Forty health professionals who had regular contact with pregnant or postnatal women were interviewed between February 2020 and February 2021. RESULTS: Analysis of the interviews revealed six themes. Health professionals in the private sector reported frequent contact with industry representatives with over two-thirds reporting exposure to industry representatives to present products, provide training or sponsor educational activities. Participants held strong opinions regarding the equivalency of breastfeeding to commercial milk formula citing information from industry representatives and product packaging. Health professionals were very knowledgeable on so-called formulas for special medical purposes and these were valued as solutions to infant feeding challenges. Of the 40 health professionals interviewed, less than half (19) had ever heard of the SA regulation related to marketing of breast milk substitutes (R991). CONCLUSIONS: This study demonstrates clearly that health professionals, particularly in the private sector, are exposed to and promote the use of commercial milk formula among SA women. The findings of this study should be used to catalyse policy responses, social movements, consumer and professional association action to strengthen monitoring and enforcement of the Code regulations in order to protect breastfeeding and support the optimal health and well-being of the population.