Health System Quality of Prevention of Mother-to-Child Transmission Services in Ethiopia: A Structured Narrative Review Using Donabedian and WHO Quality Frameworks

Abstract

Background: Despite substantial expansion of prevention of mother-to-child transmission (PMTCT) services in Ethiopia through Option B+ and integration within maternal and child health services, vertical HIV transmission remains above the World Health Organization (WHO) elimination target. Evidence on the quality of PMTCT services and their determinants remains fragmented. Objective: To synthesize evidence on PMTCT service quality across WHO quality domains and identify multi-level determinants. Methods: A structured narrative review (SANRA-guided) searched PubMed, Embase, AJOL, HINARI and grey literature (2015–2026). Evidence was synthesized using the Donabedian, WHO Quality of Care, and Socio-ecological frameworks. Results: Quality gaps spanned all domains: suboptimal retention and 9–10% transmission (effectiveness); stock-outs and weak laboratory systems (safety); poor communication and privacy (people-centeredness); delayed ART initiation (timeliness); fragmented care and workforce shortages (efficiency); marked regional and rural–urban inequities; and inconsistent service integration. Determinants included individual stigma and fear of disclosure, provider burnout and inadequate training, facility infrastructure gaps, health system supply chain and digital health weaknesses, and community gender norms with limited male partner involvement. Conclusion: Ethiopia has achieved coverage expansion but implementation quality, equity, and continuity remain major challenges. Progress toward Triple Elimination requires comprehensive health system strengthening, reliable supply chains, workforce development, digital health, continuous quality improvement, and people-centred care to ensure uninterrupted, high-quality services.