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Evaluation database

Evaluation report

2014 Lesotho: Assessment of MBP in Lesotho

Author: Elizabeth Glaser Pediatric AIDS Foundation

Executive summary


With the adoption of the 2010 WHO prevention of mother-to-child (PMTCT) guidelines and expansion of the PMTCT program in Lesotho, a mechanism for delivering prepackaged PMTCT and safe motherhood medicines, known as the Mother Baby Pack (MBP), was developed. The PMTCT regimen provided in the MBP was part of “Option A”, which included infant Nevirapine (NVP) prophylaxis for prevention of breastfeeding transmission. In April 2013, the Lesotho PMTCT guidelines were revised to provide universal ART to all pregnant women regardless of CD4 cell count, known as Option B+ as per new WHO PMTCT guidelines. The MBP for distribution of antenatal and antiretroviral drugs was modifications based on new guidelines.

The MBP were implemented to address operational challenges such as late and infrequent ANC attendance, stock-outs, poor adherence and retention, and particularly to decrease the risk of MTCT for HIV-positive women with limited access to healthcare. To minimize potential stigmatization associated with the pack, three types of Mother Baby Packs were developed: MBP1 for HIV-negative women, MBP2 for HIV-positive women eligible for PMTCT prophylaxis, and MBP3 for HIV-positive women on ART. Each pack contained smaller packages inside representing the antenatal, intrapartum, and postpartum periods of pregnancy. With variations based on the type of pack, MBP was generally administered beginning at 14 weeks gestation/ earlier, and contained drugs through six weeks postpartum. HIV-positive women and their infants were continuously monitored after this time and collection of additional infant NVP for women on prophylaxis and ARV for women on ART

MBP was initiated in the first three districts in January 2011, and by August 2011 was rolled out in all the 10 districts nationwide.   After the introduction of Option B+ the packs for ARV prophylaxis were discontinued in April 2013, and what remained was MBP1 for HIV-negative women and MBP3 for all HIV-positive women on ART.


The three primary research objectives addressed by the evaluation of MBP were as follows:

To assess the acceptability of the MBP implementation (all three packs) among women, healthcare workers and community representatives.
To assess the feasibility of the MBP implementation at individual, site, and program levels.
To determine the uptake of selected MCH/PMTCT services by women receiving MBP compared with women who do not receive MBP.

The two secondary research objectives were:

To determine adherence to the drugs in the MBP among pregnant and early postpartum women and infants.
To document the occurrence of severe anemia in women who receive the MBP


The study adopted mixed methods covering, retrospective and prospective cohort and cross-sectional. The  retrospective include review of cohort data from facility registers. Given that the MBP was rolled out nationwide in Lesotho by the time of the evaluation, differences in the delivery and uptake of services using the MBP compared with provision of the Option A regimen without the MBP could only be investigated retrospectively using routinely data. Data on MCH and PMTCT variables were extracted from registers, and facilities in three districts that initiated MBP in January 2011 (Cohort 1) were compared with facilities in three similar districts that implemented the Lesotho guidelines using Option A without MBP (Cohort 2). In facilities with option A, data from pre-MBP periods were compared to data collected in the same facilities  after introduction of MBP (Cohort 3).
The prospective data collection included structured and semi-structured interviews with pregnant and postpartum women at follow-up antenatal visits and 6- and 14-week postnatal visits; semi-structured interviews with health care workers (HCW) delivering MCH services and pharmacy personnel; and FGD with communities to capture critical issues of acceptability and feasibility.
Six study sites out of ten districts were included. The 31 sites were from the three districts who initiated MBP-  and three comparable districts with later MBP initiation. The comparison districts were purposively selected to match the three geographical settings of Lesotho (Lowlands, Foothills, and Highlands) covered by initial districts. Sites were stratified by district and randomly selected using the probability proportional to size, for both groups.

All quantitative data were entered, imported and converted into SAS datasets, and qualitative data were entered into Microsoft Word as data files and analyzed using MAXqda.

Findings and Conclusions:


With regard to acceptability it is found out that a large proportion has high ratings for MBP acceptability. This is more evident among HIV-positive women than  HIV-negative pregnant women. A range of benefits from the MBP include;
- MBP is a good way of receiving drugs, and all women on ART agreed,
- more women found the MBP helped them to understand the medicine, and was convenient and easy to store,
- allow women to attend ANC, and
- disclosure.
The majority of health care workers stated that the MBP is a good way of dispensing pills
The issue of the package being big was indicated by both pregnant women and health care workers


The primary endpoint for this objective was the proportion of women with high ratings for MBP feasibility using a Likert scale as assessed from the exit interviews. Almost 90% of women expressed agreement on nearly all statements. The HIV-positive women on ART generally agreed the most when compared to the other two groups, but all three groups responded similarly.

HCW agreed that the MBP was a feasible way of dispensing pills.  Similar to the women, about half of the HCW felt that the pack caused delays in the clinic, but most felt it did not interfere with other MCH service delivery.

Uptake of PMTCT/MCH services:

Introduction of MBP increased uptake of PMTCT and MCH services for both HIV- positive and HIV-negative pregnant women, and this brought positive responses such as;
- earlier attendance of ANC visits
- increased number of ANC visits
- increase in number of deliveries in the facilities


The study found out that there is a high rate of adherence among pregnant women exposed to MBP, and the rate is even higher among pregnant women on ART.

The study found out that there are few pregnant women who were reported to have experience pregnancy complication during ANC and this is indicated by small proportion of women with anemia.


Improve the written instructions on MBP contents. This includes supplement pill bags, AZT bottles and the pink (for infant) and yellow (for labor) inner boxes.

Pharmacists should dispense packs to women instead of nurses, in order to conduct more objective adherence counseling and monitoring.

Develop an SOP for nurses on how to provide the NVP to infants using pack. Currently this is only provided on the instruction sheet contained in the pack.

Provide additional components in the pack to assist women with taking their medicine. This includes snacks that can be taken with drugs and an alarm in the packs to help remind women to take their drugs.

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