Research Articles (School of Public Health)
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Item Policy and programming towards addressing treatment gaps in adolescents living with HIV: A content analysis of policy and programme documents in Namibia(SAGE Publications Inc., 2024) Munyayi, Farai Kevin; van Wyk, Brian E.Adolescents living with HIV (ALHIV) face unique challenges resulting in persistent treatment gaps, particularly viral non-suppression. Country programs adopt policies, guidelines, and innovations, based on WHO recommendations and best practices from elsewhere. However, it is unclear to what extent these tools address the management of adolescents with viral non-suppression. We report on a review of guidelines for the provision of HIV services to ALHIV in Namibia. We conducted a systematic document review using Content Analysis and Thematic Analysis methodology, and the READ approach. We identified seven relevant policy documents, four of which somewhat addressed viral non-suppression (treatment gap) in ALHIV and outlined interventions to improve treatment outcomes in adolescents considering their lived experience and unique challenges. The persistent treatment gap may reflect policy implementation gaps in specifically addressing viral non-suppression. It may be worthwhile to leverage existing documents to develop specific operational guidance for ALHIV with unsuppressed viral loads.Item Disposable diaper usage, disposal practices and quantity estimation in rural areas(Elsevier, 2024) Nell, Charlotte M.; Schenck, Catherina J.; Chitaka, Takunda Y.This study aimed to describe the disposable diaper usage, disposal practices and quantity estimation in a specified rural setting within a developing, sub-Saharan country, South Africa. Quantitative and qualitative data collection methods were used to collect primary data, which included survey research, focus group discussions, participatory thematic mapping, illegal dumping mapping and member checking. Most diapers end up within the natural receiving environment due to a lack of formalised waste management service provision. Dumping hot spots are water courses and streams. On average, each infant generates 4.47 diapers per day, while an average of 158,154 and 34,493 total diapers are generated daily within Bushbuckridge and Maruleng, respectively. High unemployment and grant-dependency rates characterise the study area, and households often spend the majority of child support grants to purchase diapers. Residents were willing to use a diaper disposal point and are not opposed to incineration. This study forms a comprehensive baseline to determine the feasibility of disposable diaper beneficiation options in rural areas.Item Experiences of alcohol use during pregnancy: a qualitative study of pregnant women at risk of acquiring HIV in Cape Town, South Africa(Elsevier Ltd, 2024) Knight, Lucia; Miller, Amanda P.; Court, Lara; Schoetz, SarahIn South Africa, alcohol use during pregnancy is prevalent and associated with increased HIV risk. Developing locally sensitive and contextually appropriate evidence-based interventions to address alcohol use among pregnant and breastfeeding women in South Africa requires comprehensive understanding of the context of perinatal alcohol use and how relationships and lived environments may serve as barriers or supports for alcohol reduction. We conducted twenty in-depth qualitative interviews with isiXhosa speaking women who reported alcohol use during their recent pregnancy and/or recent intimate partner violence in Cape Town, South Africa between September and November 2022. We describe patterns and drivers of ongoing alcohol use during pregnancy and map them onto levels of the socioecological model. Data were analyzed utilizing the interpretivist paradigm and interpretive thematic analysis. Eight women reported alcohol use during pregnancy, sixteen reported experiencing recent IPV, and four women reported both alcohol use during pregnancy and recent IPV. In interviews, commonly cited reasons for continued alcohol use in pregnancy included stress (e.g., due to financial concerns), peer pressure, the central role of alcohol use in socialization and the persistence of misconceptions regarding the safety of alcohol use in pregnancy. Still, despite women reporting social norms that supported continued alcohol use in pregnancy, many altered who they drank with due to fear of judgement from close friends and family, leaving them isolated from their social support system. Interventions aimed at increasing interpersonal support, such as the use of peer mentors, could prove beneficial. Although the clinic provides messaging around the harms of alcohol use in pregnancy, these messages conflict with messaging received from their peers, limiting their impact on behavior. Locally sensitive tailored, relevant programming that intervenes on barriers to reducing alcohol use in pregnancy at multiple levels of the socioeconomic model are vital to effectively addressing this public health issue.Item Every loaf of bread is political – reflections on collective care responses to covid-19 in cape town(Elsevier Ltd, 2024) van Ryneveld, Manya; Schneider, Helen; Brady, LeanneFeminist perspectives on care have demonstrated how capitalism undervalues care work. The Covid-19 pandemic highlighted this further, as systems of production and social reproduction became destabilized globally. In many countries, the formal pandemic response fell short of attending to the daily, fundamental care needs of people living through the crisis, especially those compromised by the socio-economic effects of the pandemic. These needs were often attended to at the community level. This article explores a community-led network of care, known as CANs, that emerged in response to the pandemic in Cape Town. It makes three overarching observations. The first is that community-led responses were characterised by a push towards the collectivisation of care work. The second is that this enabled emergent strategies and relational practices of care, centring notions of solidarity, inter-dependence and horizontal exchange of resources and knowledge. Finally, we observed that, although the devaluation of care work limited the recognition and material support extended to CANs, opportunities to re-politicise care work as resistance work emerged. These represent a prefigurative moment in which alternative logics and strategies can transform the vision of our health and care systems, and the notion of community participation in and ownership of those systems.Item Food acquisition and consumption by NOVA food classification and lived poverty index among rural and urban households in South Africa and Ghana(Cambridge University Press, 2024) Agyapong, Nana Ama Frimpomaa; Kroll, Florian; Swart, Elizabeth Catherina; Swart, Elizabeth CatherinaObjective: This study aims to determine differences in food consumption by the NOVA food categories in South Africa and Ghana and how they relate to poverty and food supply systems. Design: This study used a cross-sectional design to assess household food acquisition and lived poverty index. Setting: The study was conducted in Khayelitsha and Mount Frere, urban and rural communities in South Africa, respectively, and Ahodwo and Ejuratia, urban and rural communities in Ghana, respectively. Participant: An adult in charge of or knowledgeable about household food acquisition and consumption was selected to participate in the study. Results: A total of 1299 households participated in the study. Supermarkets were a prominent source of ultra-processed foods for households in South Africa, while informal outlets were an important source of ultra-processed foods in Ghana. Consumption of unprocessed foods was higher among South African households (58.2%) than Ghanaian households (41.8%). In South Africa, deprivation was associated with increased odds of infrequent consumption of both unprocessed foods (OR 3.431 p<0.001) and ultra-processed foods (OR 2.656 p<0.001) compared to non-deprivation. In Ghana, no significant associations were observed between household deprivation and consumption of the NOVA food classes. Conclusion: Different food supply systems and poverty are associated with household acquisition of the different NOVA food classes. Policies should be geared towards formal shops in South Africa and informal shops in Ghana to reduce the consumption of key obesogenic foods.Item Relationship between psychosocial factors and physical activity among undergraduate students from a South African university(Multidisciplinary Digital Publishing Institute (MDPI), 2024) Johannes, Chanté; Roman, Nicolette V.; Onagbiye, Sunday O.; Titus, Simone; Leach, Lloyd L.Psychosocial factors such as mental health, motivation, and social support are key determinants of behavior that play a significant role in physical activity participation. Limited studies have investigated the relationship between psychosocial factors and physical activity among university students in Africa. The aim of this study was to determine the relationship between psychosocial factors and physical activity participation among undergraduate university students at a historically disadvantaged university (HDU) in South Africa. This was a cross-sectional study that used convenience sampling (n = 534, majority female, 53.6% with a mean age of 20.69). The study was conducted through an online, self-administered, and hard-copy, valid questionnaire in September 2022. Data on sociodemographic information were collected. Psychosocial factors were assessed using the Depression, Anxiety, and Stress-21 Scale for mental health, the Physical Activity and Leisure Motivation Scale for motivation, and the Perceived Social Support Scale for social support. Physical activity (calculated as MET-min/week) was assessed using the international physical activity questionnaire in short form. Results revealed that almost a third (29%) of undergraduate students were physically inactive, 31.1% were minimally active, and 39.9% were in the health-enhancing category. Physical activity was positively related to stress (r = 0.11, p < 0.05) and anxiety (r = 0.10, p < 0.05). Motivational factors were positively related to psychological condition and others’ expectations (r = 0.10, p < 0.05), and depression and others’ expectations (r = 0.11, p < 0.05). Results from this study highlighted that psychosocial factors were related to physical activity participation among undergraduate university students. Psychosocial factors should be considered a coping mechanism when implementing health-promoting strategies.Item How to evaluate a multi-country implementation-focused network: Reflections from the Quality of Care Network (QCN) evaluation(Plos, 2024) Seruwagi, Gloria; Kinney, Mary; English, MikeLearning about how to evaluate implementation-focused networks is important as they become more commonly used. This research evaluated the emergence, legitimacy and effectiveness of a multi-country Quality of Care Network (QCN) aiming to improve maternal, newborn and child health (MNCH) outcomes. We examined the QCN global level, national and local level interfaces in four case study countries. This paper presents the evaluation team’s reflections on this 3.5 year multi-country, multi-disciplinary project. Specifically, we examine our approach, methodological innovations, lessons learned and recommendations for conducting similar research. We used a reflective methodological approach to draw lessons on our practice while evaluating the QCN. A ‘reflections’ tool was developed to guide the process, which happened within a period of 2–4 weeks across the different countries. All country research teams held focused ‘reflection’ meetings to discuss questions in the tool before sharing responses with this paper’s lead author. Similarly, the different lead authors of all eight QCN papers convened their writing teams to reflect on the process and share key highlights. These data were thematically analysed and are presented across key themes around the implementation experience including what went well, facilitators and critical methodological adaptations, what can be done better and recommendations for undertaking similar work. Success drivers included the team’s global nature, spread across seven countries with members affiliated to nine institutions. It was multi-level in expertise and seniority and highly multidisciplinary including experts in medicine, policy and health systems, implementation research, behavioural sciences and MNCH. Country Advisory Boards provided technical oversight and support. Despite complexities, the team effectively implemented theItem Global financing facility investments for vulnerable populations: content analysis regarding maternal and newborn health and stillbirths in 11 African countries, 2015 to 2019(Taylor and Francis Ltd., 2024) Kinney, Mary; Kumar, Meghan Bruce; Kaboré, IssaThe Global Financing Facility (GFF) was launched in 2015 to catalyse increased domestic and external financing for reproductive, maternal, newborn, child, adolescent health, and nutrition. Half of the deaths along this continuum are neonatal deaths, stillbirths or maternal deaths; yet these topics receive the least aid financing across the continuum. To conduct a policy content analysis of maternal and newborn health (MNH), including stillbirths, in GFF country planning documents, and assess the mortality burden related to the investment. Content analysis was conducted on 24 GFF policy documents, investment cases and project appraisal documents (PADs), from 11 African countries. We used a systematic data extraction approach and applied a framework for analysis considering mindset, measures, and money for MNH interventions and mentions of mortality outcomes. We compared PAD investments to MNH-related deaths by country. For these 11 countries, USD$1,894 million of new funds were allocated through the PADs, including USD$303 million (16%) from GFF. All documents had strong content on MNH, with particular focus on pregnancy and childbirth interventions. The investment cases commonly included comprehensive results frameworks, and PADs generally had less technical content and fewer indicators. Mortality outcomes were mentioned, especially for maternal. Stillbirths were rarely included as targets. Countries had differing approaches to funding descriptions. PAD allocations are commensurate with the burden. The GFF country plans present a promising start in addressing MNH. Emphasising links between investments and burden, explicitly including stillbirth, and highlighting high-impact packages, as appropriate, could potentially increase impact.Item Policy analysis of the global financing facility in Uganda(Taylor and Francis Ltd., 2024) Wanduru, Phillip; Kinney, Mary; George, AshaBackground: In 2015, Uganda joined the Global Financing Facility (GFF), a Global Health Initiative for Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH). Similar initiatives have been found to be powerful entities influencing national policy and priorities in Uganda, but few independent studies have assessed the GFF. Objective: To understand the policy process and contextual factors in Uganda that influenced the content of the GFF policy documents (Investment Case and Project Appraisal). Methods: We conducted a qualitative policy analysis. The data collection included a document review of national RMNCAH policy documents and key informant interviews with national stakeholders involved in the development process of GFF policy documents (N = 16). Data were analyzed thematically using the health policy triangle. Results: The process of developing the GFF documents unfolded rapidly with a strong country-led approach by the government. Work commenced in late 2015; the Investment Case was published in April 2016 and the Project Appraisal Document was completed and presented two months later. The process was steered by technocrats from government agencies, donor agencies, academics and selected civil society organisations, along with the involvement of political figures. The Ministry of Health was at the center of coordinating the process and navigating the contestations between technical priorities and political motivations. Although civil society organisations took part in the process, there were concerns that some were excluded. Conclusion: The learnings from this study provide insights into the translation of globally conceived health initiatives at country level, highlighting enablers and challenges. The study shows the challenges of trying to have a ‘country-led’ initiative, as such initiatives can still be heavily influenced by ‘elites’. Given the diversity of actors with varying interests, achieving representation of key actors, particularly those from underserved groups, can be difficult and may necessitate investing further time and resources in their engagement.Item Any better? a follow-up content analysis of adolescent sexual and reproductive health inclusion in global financing facility country planning documents(Taylor and Francis Group, 2024) Walmisley, Ulla; Kinney, Mary V.; Kiendrébéogo, Joël ArthurBackground: The global financing facility (GFF) supports national reproductive, maternal, newborn, child, adolescent health, and nutrition needs. Previous analysis examined how adolescent sexual and reproductive health was represented in GFF national planning documents for 11 GFF partner countries. Objectives: This paper furthers that analysis for 16 GFF partner countries as part of a Special Series. Methods: Content analysis was conducted on publicly available GFF planning documents for Afghanistan, Burkina Faso, Cambodia, CAR, Côte d’Ivoire, Guinea, Haiti, Indonesia, Madagascar, Malawi, Mali, Rwanda, Senegal, Sierra Leone, Tajikistan, Vietnam. Analysis considered adolescent health content (mindset), indicators (measure) and funding (money) relative to adolescent sexual and reproductive health needs, using a tracer indicator. Results: Countries with higher rates of adolescent pregnancy had more content relating to adolescent reproductive health, with exceptions in fragile contexts. Investment cases had more adolescent content than project appraisal documents. Content gradually weakened from mindset to measures to money. Related conditions, such as fistula, abortion, and mental health, were insufficiently addressed. Documents from Burkina Faso and Malawi demonstrated it is possible to include adolescent programming even within a context of shifting or selective priorities.Item Longitudinal trajectories of antiretroviral treatment adherence and associations with durable viral suppression among adolescents living with HIV in South Africa(Wolters Kluwer Health, Inc., 2024) Zhou, Siyanai; Cluver, Lucie; Knight, LuciaBackground: Compared with other age groups, adolescents living with HIV (ALHIV) are estimated to have lower levels of adherence to antiretroviral treatment. Despite this, we lack evidence on adolescents’ adherence patterns over time to inform the customization\of intervention strategies.Setting: Eastern Cape province, South Africa. Methods: We analyzed data from a cohort of ALHIV (N = 1046, aged 10–19 years at baseline) recruited from 53 public health facilities. The cohort comprised 3 waves of data collected between 2014 and 2018 and routine viral load data from the National Institute for Communicable Disease data warehouse (2014–2019). Durable viral suppression was defined as having suppressed viral load (,1000 copies/mL) at $2 consecutive study waves. Group-based multitrajectory model was used to identify adherence trajectories using 5 indicators of self-reported adherence. Logistic regression modeling evaluated the associations between adherence trajectories and durable viral suppression. Results: Overall, 933 ALHIV (89.2%) completed all 3 study waves (55.1% female, mean age: 13.6 years at baseline). Four adherence trajectories were identified, namely, “consistent adherence”(49.8%), “low start and increasing” (20.8%), “gradually decreasing” (23.5%), and “low and decreasing” (5.9%). Adolescents experiencing inconsistent adherence trajectories were more, likely to be older, live in rural areas, and have sexually acquired HIV. Compared with the consistent adherence trajectory, the odds of durable viral suppression were lower among adolescents in the low start and increasing (adjusted odds ratio [aOR]: 0.62, 95% CI: 0.41 to 0.95), gradually decreasing (aOR: 0.40, 95% CI: 0.27 to 0.59), and the low and decreasing adherence (aOR: 0.25, 95% CI: 0.10 to 0.62) trajectories. Conclusions: Adherence to antiretroviral treatment remains a challenge among ALHIV in South Africa. Identifying adolescents at risk of nonadherence, based on their adherence trajectories may inform the tailoring of adolescent-friendly support strategies.Item The relationship between food insecurity, the child support grant and childcare arrangements(University of Stellenbosch, 2024) Swart, Rina; Tyabashe-Phume, Babalwa Pearl; Zembe-Mkabile, WangaFood insecurity is endemic in South Africa because of high levels of poverty. Children in food-insecure households may be exposed to childcare instabilities. However, the role of social protection in mediating the relationship between food insecurity and childcare arrangements is not well understood. This study explored the relationship between food insecurity, childcare arrangements and the child support grant (CSG) in a township in Cape Town. The study design was mixed-methods; a hunger scale was administered to 120 participants and in-depth interviews conducted with 23 primary caregivers of children under 2 years of age. The findings indicated that despite being food insecure, many households had stable childcare arrangements, presumably because of the CSG and the age of the children at the time of the study. Further research is needed to unpack the relationship between food insecurity, childcare arrangements and the CSG.Item Global investments in pandemic preparedness and COVID-19: development assistance and domestic spending on health between 1990 and 2026(Elsevier Ltd, 2023) Okonji, Osaretin Christabel; Micah, Angela E; Bhangdia, Kayleigh; Cogswell, Ian E; Lasher, DylanBackground: The COVID-19 pandemic highlighted gaps in health surveillance systems, disease prevention, and treatment globally. Among the many factors that might have led to these gaps is the issue of the financing of national health systems, especially in low-income and middle-income countries (LMICs), as well as a robust global system for pandemic preparedness. We aimed to provide a comparative assessment of global health spending at the onset of the pandemic; characterise the amount of development assistance for pandemic preparedness and response disbursed in the first 2 years of the COVID-19 pandemic; and examine expectations for future health spending and put into context the expected need for investment in pandemic preparedness. Methods: In this analysis of global health spending between 1990 and 2021, and prediction from 2021 to 2026, we estimated four sources of health spending: development assistance for health (DAH), government spending, out-of-pocket spending, and prepaid private spending across 204 countries and territories. We used the Organisation for Economic Co-operation and Development (OECD)'s Creditor Reporting System (CRS) and the WHO Global Health Expenditure Database (GHED) to estimate spending.Item A call for social accountability within pharmacy education: concepts, relevance, and accreditation(Elsevier, 2023) Coetzee, Renier; Prisco, Jennifer L; Laudone, Thomas WIntroduction: Social accountability (SA) is a leap to excellence in health education. While pharmacists are ideally situated in the healthcare setting to practice SA through research, service, and practice, SA is underrepresented in pharmacy education. Commentary: Here the foundational concepts of SA, the relevance to pharmacy education, as well as the accreditation considerations for the implementation of SA are discussed. Implications: There is a need for SA to be implemented in pharmacy education to address health equity, quality, and improve patient health outcomes.Item The association between plant-based diets and dietary patterns with cardiometabolic risk in a sample of commercial taxi drivers in South Africa(MDPI Journal, 2023) Sekgala, Machoene Derrick; Lopes, Tatum; Zemlin, Annalise EdithThe consumption of unhealthy foods and a sedentary lifestyle predispose individuals to non-communicable diseases. This study investigated the distribution and the association of plant-based diets (PBDs) and dietary patterns in relation to the cardiometabolic risks in commercial taxi drivers. A cross-sectional analysis was conducted among males (19 years) who consumed street foods sold by vendors in the Cape Metropole. A validated questionnaire was administered, including a quantified 24 h dietary recall, and fasting blood samples were collected for biochemical analyses. Statistical analyses were performed to investigate the association between dietary habits and cardiometabolic risks, while adjusting for confounding variables. The analytic sample consisted of 189 males with a median age of 38 years. The taxi drivers who ranked in the top-third of the healthy plant-based diet index (hPDI) had a 1–4% lower likelihood of having raised triglycerides (TG). Furthermore, consumption patterns including refined grains and meat conferred a 33% lower likelihood of dysglycaemia (p = 0.049), while fish/seafood, potatoes, and vegetables conferred a 43% greater likelihood of low high-density lipoprotein cholesterol (HDL-C) (p = 0.026) and 44% greater probability of raised low-density lipoprotein cholesterol (LDL-C) (p = 0.027). Consumption patterns, including sugar-sweetened beverages and eggs, conferred a 37% greater probability of hypertension (p = 0.047) and 53% greater likelihood of subclinical inflammation (p = 0.017). These preliminary findings require larger and more elaborate studies to explore the associations between PBDs and dietary patterns in at-risk African populations, with or without sedentary lifestyles, and exposure to unhealthy food environments.Item Prevalence of depression, syndemic factors and their impact on viral suppression among female sex workers living with HIV in eThekwini, South Africa(BMC women's health, 2023) Phetlhu, Rene; Bhardwaj, Anvita; Comins, Carly A.; Guddera, VijayIntroduction Over half of female sex workers (FSW) in South Africa are living with HIV and clinical depression has been frequently documented among FSW. Data characterizing structural determinants of depression and the role of syndemic theory, synergistically interacting disease states, on viral suppression among FSW in South Africa are limited. Methods: Between July 2018-March 2020, non-pregnant, cisgender women (≥ 18 years), reporting sex work as their primary income source, and diagnosed with HIV for ≥ 6 months were enrolled into the Siyaphambili trial in eThekwini, South Africa. Using baseline data, robust Poisson regression models were used to assess correlates of depression and associations between depression and syndemic factors on viral suppression.Item Human capabilities of South African parents who have children with developmental disabilities(Aosis, 2023) Magidigidi, Lumka; Roman, Nicolette V; Sonn, Inge KBackground: Parenting a child with a developmental disability (DD) has a substantial influence on the lives of the parents or caregivers, as well as on how the family operates. This is frequently because of the adjustments in some daily practices that are crucial for parents’ or caregivers’ human capabilities to provide for childcare. There is not enough research done on human capabilities of parents or children with DD in South Africa. Objectives: This study investigated the available support in improving the human capabilities of parents or caregivers with children with DD and the bodily health and bodily integrity human capabilities of parents or caregivers with children with DD. Method: Qualitative interviews were conducted with 11 parents or caregivers of children aged between 1 and 8 years old with DD. This study used snowball sampling. Thematic data analysis was chosen to analyse the data collected. Results: The results of the study indicate that participants have difficulties bringing up their children because of the emotional strain that goes along with parenting a child with DD. In addition, participants were not able to afford decent and satisfactory shelter and had limited access to good quality food because they could not afford it.Item Reasons why insured consumers co-pay for medicines at retail pharmacies in Pretoria, South Africa(AOSIS, 2019) Mpanza, Ntobeko M.; Bradley, Hazel; Laing, RichardCostly prescription medicines with existing cheaper alternatives tend to be purchased by medically insured consumers of healthcare. In South Africa medical scheme members pay higher out-of-pocket payments for medicines than those without insurance.This study explored reasons for co-payments among insured Pretoria medical scheme members purchasing prescription medicines at private retail pharmacies, despite being insured and protected against such payments.Item Women’s perceptions and reflections of male partners and couple dynamics in family planning adoption in selected urban slums in Nigeria: A qualitative exploration(BMC, 2014) Aransiola, Joshua Oyeniyi; Akinyemi, Akanni Ibukun; Fatusi, Adesegun OlayiwolaNigeria is one of the countries where significant progress has not been recorded in contraceptive uptake despite decades of family planning programs while there are indications that slum dwellers may differ significantly from other urban dwellers in their sexual and reproductive behavior, including family planning uptake. This study therefore examined local notions regarding male partners’ involvement in family planning (FP) adoption by women in two selected urban slums areas in Nigeria – Ibadan (Southwest region) and Kaduna (Northwest region). Specifically, the study investigated women’s narratives about FP, perceived barriers from male partners regarding FP adoption by the women and how women negotiate male partners' cooperation for FP use.Item Intervention in mothers and newborns to reduce maternal and perinatal mortality in 3 provinces in South Africa using a quality improvement approach: Protocol for a mixed method type 2 hybrid evaluation(JMIR Publications, 2023) Chetty, Terusha; Singh, Yages; Mianda, SolangeThe COVID-19 pandemic undermined gains in reducing maternal and perinatal mortality in South Africa. The Mphatlalatsane Initiative is a health system intervention to reduce mortality and morbidity in women and newborns to desired levels. Our evaluation aims to determine the effect of various exposures, including the COVID-19 pandemic, and a system-level, complex, patient-centered quality improvement (QI) intervention (the Mphatlalatsane Initiative) on maternal and neonatal health services at 21 selected South African facilities. The objectives are to determine whether Mphatlalatsane reduces the institutional maternal mortality ratio, neonatal mortality rate, and stillbirth rate (objective 1) and improves patients’ experiences (objective 2) and quality of care (objective 3). Objective 4 assesses the contextual and implementation process factors, including the COVID-19 pandemic, that shape Mphatlalatsane uptake and variation.