Tuberculosis (TB) remains a major public health problem globally, with an estimated one third (1.86 billion) of the world’s population infected. TB kills more adults than malaria and is one of the leading causes of mortality among women of reproductive age worldwide . Kenya is ranked 13th among the 22 high burden countries that collectively contribute to about 80% of the world TB cases. The disease accounts for over 145,000 discounted life years lost in the country with the situation being worse for women in the reproductive age group . Tuberculosis is the most common HIV-1-related disease and the most frequent cause of mortality in young women in high prevalence regions. Tuberculosis and HIV-1 are independent risk factors for maternal mortality and adverse perinatal outcomes, and in combination have a greater impact on these parameters than their individual effects . Studies have demonstrated that active screening for TB within antenatal care (ANC) setting is beneficial to both the mother and the un born baby. In referral health centres in southern Africa, about one-sixth of all maternal deaths are due to tuberculosis/HIV-1 co-infection . In another study active screening TB was reported by 23. % of HIV-seropositive and 14% of HIV-seronegative women screened during pregnancy. Out of the 3937 women screened active pulmonary TB was diagnosed in 10/1,454 HIV-seropositve women (688 per 100,000) and 5/2,483 HIV-seronegative women (201 per 100,000) . In Kenya 43% of pregnant women attending ANC were screened for TB and 6 out 18911 pregnant women screened tested positive for TB. Further, the study showed that it is feasible and acceptable for providers to screen for TB during pregnancy . The Kenya study findings led to the introduction of TB screening in ANC services in the country. Although TB detection is encouraged among ANC clients within the Maternal and Child Health (MCH) clinics in Kenya, providers in these settings fail to appreciate the principle of continuum of care from pregnancy through to post-natal period.
Moreover, before the study, Kenya’s Ministry of Health (MOH) guidelines on postnatal care (PNC) did not focus on TB detection and its management for mothers and their babies. The recommended package of services only included three scheduled visits whose consultations emphasize the identification of danger signs or diseases that contribute directly to maternal and neonatal death. Counselling for HIV was recommended as part of the standard postnatal care package, but there was little effort to increase detection of TB among HIV-positive mothers and their babies, even though it has been established that at least one out of every eight (13%) HIV-positive patients is co-infected with TB . This lack of integration of TB in PNC implied a missed opportunity for screening for the disease among mothers and their babies, despite it being a public health concern even in the absence of HIV. Utilizing PNC services to screen for TB therefore provides a platform for early case detection and management of the disease.
In order to address this gap, an operations research study was conducted to determine if PNC providers, in addition to providing routine postnatal care services, could also screen and assess the client’s need for TB services and refer suspected cases for management. The study aimed to assess a tuberculosis screening and referral intervention in postnatal care settings with a focus on four key issues: (1) provider knowledge; (2) documenting the feasibility of integrating TB into postnatal care; (3) procedures /protocols in regard to referral mechanisms for PNC TB clients; and (4) evaluating the effect of TB screening, case detection and treatment on PNC clients.