The Road to Elimination of Mother-to-Child Transmission of Syphilis in Malawi: A Mixed-Methods Analysis of Health System Readiness

BACKGROUND: This study evaluated health system readiness in Malawi for elimination of mother-to-child transmission (EMTCT) of syphilis against World Health Organization (WHO) validation criteria by identifying key health system bottlenecks. It also developed a replicable toolkit to assess bottlenecks to syphilis EMTCT in other countries. METHODS: A mixed-methods design integrated quantitative and qualitative data. A National Clinic Readiness Survey assessed coverage indicators for prevention of maternal and congenital syphilis at 58 health centers. Exit surveys included 9513 mothers at antenatal care (ANC) and 4724 at delivery across 7 sites, with additional data from 131 syphilis-positive mothers. Exit-survey data informed two modified Tanahashi bottleneck analyses assessing EMTCT process outcomes at ANC and delivery. Semistructured in-depth interviews were conducted with 29 facility staff. RESULTS: The readiness survey identified inefficiencies and gaps in the procurement of tests and treatment. During frequent stock-outs, most sites required mothers to purchase treatment at personal cost. Variation existed in identifying potential congenital syphilis cases and recording surveillance data across centers. Tanahashi analyses showed limited coverage of maternal testing at ANC and variable coverage of maternal treatment at ANC and delivery. Interviews indicated that syphilis treatment is deprioritized relative to Human Immunodeficiency Virus (HIV) and other conditions requiring intramuscular benzathine penicillin G (IM BPG). CONCLUSIONS: Despite strong political commitment to integrated EMTCT of syphilis, HIV, and hepatitis B, persistent health system bottlenecks may delay WHO validation. This toolkit may support monitoring and strengthening EMTCT programs in Malawi and other settings.