Study in the prevention of mother to child transmission

Study JustificationFurther research into the role ofTraditional Birth Attendants in the provision of maternal and child healthservices and prevention of mother to child transmission at primary healthfacilities in Chegutu district is needed.

Given that TBAs attend to themajority of births in rural settings, it plausible that this study focuses ontheir role in PMTCT.1.3.1    TheRole of TBAs Prevention of infections remains one of thebiggest challenges especially during the current HIV/AIDS pandemic. Despitetheir roles in infection prevention, the TBAs also have several other roles toplay as the women-folk rush down to them on suspicions of witchcraft duringpregnancy, labour and delivery.

The roles of the TBAs are stipulated below: ·        They provide care tochildbearing women during pregnancy, labour, post-natal and family planningperiods ·        They identify and refertheir clients with obstetric emergencies to the next level of care. ·        They keep communityRegisters of all their deliveries and their postnatal attendancespost-delivery. ·        They give targetedhealth education to target groups on the importance of good personal hygienepractices and maintenance of proper environmental sanitation, the importance ofattending post natal care services and other safe motherhood practices. ·        They provide counselingto mothers on the Prevention of Mother to Child Transmission (PMTCT) services.

·        They are involved inthe distribution of Oral Rehydration Salts (ORS) and condoms in communities. ·        They keep communityrecords of immunization status of children of mothers they deliver. ·        They refer mothers toCommunity-based Distributors for counselling on family Planning. ·        They provide a linkbetween the communities they work in and the Health Centers1.4       Objectives ofthe Study1.4.

1    Overall Objective To investigate the role of Traditional Birth Attendants (TBAs) in the prevention of mother to child transmission through provision of maternal and child health services in Chegutu District, Mashonaland West Province, Zimbabwe. 1.4.2    Specific objectives ·        To assess knowledge ofrural women on ANC, HIV/AIDS, MTCT and PMTCT. ·        To determine theattitude of rural women towards ANC, HIV/AIDS and PMTCT services. ·        To determine thepractices of rural women in antenatal care. ·        To assess TraditionalBirth Attendants (TBAs) knowledge and practice in safe delivery practices andHIV/AIDS including PMTCT.

·        To identify healthfacility-related factors affecting access to ANC and PMTCT includingavailability of services, distance, nature of roads and transportation. 1.5       ResearchQuestions  Do rural women in in Chegutu District have knowledge of ANC, HIV and PMTCT? What is the attitude of rural women in Chegutu District towards ANC and HIV/ AIDS? Do rural women utilize ANC services? Do the Traditional birth attendants (TBAs) in rural areas have knowledge of safe delivery practices and HIV/ AIDS including PMTCT? Are there factors that affect access to ANC and PMTCT? If yes, what are these factors?    CHAPTER 2: LITERATURE REVIEW2.0       Sources of Literature Most of the literature regarding this studywas accessed via electronic means and multiple search engines were employed.These include Pubmed, HINARI, Google Scholar and African Journals on Line(AJOL).2.1       Introduction Zimbabwe adopted and isimplementing the Sustainable Development Goal 3 to ensure healthy lives andpromote healthy lives for all at all age groups.

Specific targets include reducingmaternal mortality rate to less than 70 deaths per 100000 live births, endingpreventable deaths of newborns and ending AIDS epidemics by 2030 (WHO, 2017).Achieving these goals could be a major challenge if efforts are not made tofight HIV and AIDS (Sachs & McArthur, 2005).HIV/AIDS is a leading cause of death where HIV-related mortality rates are high(Ronsmans, et al., 2003).

In the absence ofHIV, there could have been 281?500 (243?900–327?900) maternal deaths worldwidein 2008 (Hogan MC et al, 2010). However, with HIV related maternal mortalityincluded, an estimate of 342?900 (uncertainty interval 302?100–394?300) maternaldeaths occurred worldwide in 2008. Sub-Sahara Africa remains the most affectedregion where more than two-thirds (68%) of HIV-infected people live withfemales constituting 61% of those infected (UNAIDS,2007).

Thus; high levels of maternal mortality co-exist with high levelsof HIV prevalence among women of childbearing age (Graham & Hussein, 2003). There are importantdisparities with respect to access to health care for women. In the poorest 20%of households in most developing countries, more than 90% of deliveries takeplace at home (Gwatkin, 2004).Subsequently, each year more than 60 million women worldwide give birth withoutthe assistance of skilled care (Knippenberg, et al., 2013).With such high maternal mortality rates inresource-poor settings, priority interventions through the ‘Safe MotherhoodInitiative’ have been proposed and implemented.

This public health strategyemphasises safe delivery through the provision of skilled birth attendants,improved basic obstetric services in health facilities, development of prenatalcare, and access to emergency obstetric care in hospitals, and family planningas key interventions to reduce neonatal and maternal mortality (Graham & Hussein, 2003).It is now 20 years since the Safe Motherhood initiative was launched and littleprogress has been reported (Smith & Rodriguez, 2014). The regions of Sub-Saharan Africa, westernAsia and south Asia have shown little progress in terms of reduction ofmaternal mortality (Hussein, et al., 2009). The stated reasonsfor this have included: absence of a clear focus, strategic errors such asfocusing only on mother’s risk of complications through screening at antenatalconsultations, and an over reliance on traditional birth attendants (TBAs)  (Ronsmans, et al., 2003). Skilled attendance at birth is a keyindicator for measuring progress towards improved women’s health.

Availabledata from developing countries show an important increase in skilled attendanceat birth: from 45% to 54% between 1990 and 2000, except for the sub-SaharanAfrica region, where coverage has stagnated at approximately 40% (Perez, et al., 2008). Additionally, arecent report confirms that world-wide, for the year 2007, an estimated 63% ofall births were attended by a skilled health-care worker with considerablevariations between developed regions (99%) as compared to developing countries(59%)  . Recent data shows that, in low-andmiddle-income countries, the proportion of HIV-positive pregnant womenreceiving antiretroviral prophylaxis for PMTCT in 2006 was 23% (UNAIDS/UNICEF/WHO, 2008). Globally, PMTCTcoverage is far below what is required to meet the United Nations target ofreducing the proportion of children infected with HIV by 50% in 2010  (UNAIDS, 2001).The attainment of these figures will need that 80% of all pregnant womenaccessing antenatal care receive services for PMTCT of HIV (du Plessis, et al.

, 2014).This will require strengthening of maternal and child health services as wellas the health systems and the development of new interventions to improve theuptake of PMTCT services. Antenatal care as well as deliveries in aninstitutional setting with skilled health workers for all women remains adistant reality. In resource-poor countries, between 60% and 90% of deliveriesin rural areas are assisted by TBAs (Choguya, 2014).

Preference for home births is associated with cultural norms and religiousbeliefs. TBAs speak the local language, have the trust of community members andcan provide psychosocial support at birth. Public health programmes are seeking toenhance the role of TBAs by encouraging their participation in PMTCT programmes(Wanyu, et al., 2007). Given the potential coverage of the underserved population,participation of TBAs has been piloted to help improve the coverage and qualityof services offered to rural populations; their participation being defined bya package of activities that they are allowed to perform. Zimbabwe has one of the greatest HIV burdensin the world with an average antenatal HIV prevalence rate of 15.6% (Zimbabwe Ministry Of Health, 2014).

Prevention ofmother-to-child transmission of HIV (PMTCT) is among the key HIV preventionstrategies in the country’s national HIV/AIDS response. In spite of theimportant efforts and the rapid expansion of the national PMTCT programme,uptake of PMTCT remains suboptimal. Certain steps of the intervention cascadeneed to be substantially improved to increase the coverage of servicesparticularly in the later stages of the intervention.

 In 2006, 19 578 pregnant women wereidentified nationwide as HIV-infected, of whom 60% received some form ofantiretroviral (ARV) prophylaxis to prevent transmission of the virus to theirbabies. This translated to approximately 30% coverage of the total number ofHIV positive pregnant women in need (Zimbabwe Ministry Of Health, 2014). Limited ANCservices with an increase in home deliveries is not only reducing access to askilled practitioner through maternal services but also restricts theopportunities to provide PMTCT services in a context of an accelerated economiccrisis especially in rural areas.

 2.2       Definitions2.2.1    HumanImmunodeficiency Virus infection (HIV) This is infection with the virus(retrovirus) which causes AIDS leading to depression of the immune systemallowing life-threatening opportunistic infections and cancers to thrive.

2.2.2    AntenatalCare (ANC) ANC is the care a woman receives fromskilled attendants during pregnancy; it involves monitoring the woman and theunborn child. ANC requires essential interventions which include identifyingand managing potential obstetric complications such as pre-eclampsia, tetanustoxoid immunization, intermittent preventive treatment for malaria duringpregnancy (IPTp). It also entails prevention and management of infectionsincluding HIV, syphilis and other sexually transmitted infections (STIs) (WHO, 2006) 2.2.3    ANCStandard (adequate ANC) It is required that every pregnant woman hasat least 4 ANC assessments by a skilled attendant or under the supervision ofsuch an attendant.

The visits should entail as a minimum all the interventionsoutlined in the WHO antenatal care model and this should commence as early aspossible in the first trimester (WHO, 2007). 2.2.4    Mother-to-ChildTransmission (MTCT) of HIV Is a situation where an HIV positive womancan transmit the virus to her child during pregnancy, labour and delivery, andduring breast-feeding. It has been found that the risk of an HIV positivemother transmitting the infection to her baby is 20-45% in the absence ofintervention, the rate during pregnancy may be 5-10%, at labour and delivery10-20% and 5-20 % during breast feeding (De Cock, et al., 2000) 2.2.

5    Riskfactors for Mother-to-child transmission There are several factors affecting the rateof mother-to-child transmission. These have been grouped as: viral factors,maternal factors, obstetric factors, foetal and breast feeding factors (MoH, Zimbabwe, 2010) Viral factorsinclude: high maternal viral load and viral characteristics; Maternal factorsinclude: advanced disease from HIV to AIDS, HIV infection acquired duringpregnancy or breast feeding, STIs; Obstetric factors include: Vaginal delivery,rupture of membranes for more than 4 hours and prolonged labour; Foetalfactors: pre-maturity; Breast feeding factors comprise of: mixed feeding,breast infections like mastitis, breast abscess, cracked nipples and prolongedbreast feeding (MoH, Zimbabwe, 2010).    2.2.

6    Preventionof Mother-to-Child Transmission (PMTCT) It has been recommended that to reduce therate of MTCT of HIV, several interventions which involve the use of ARVs eitheras prophylaxis to the pregnant mother or as therapy during pregnancy, labourand breast feeding should be in place. If the mother is not on ARVs during theperiod she is breast feeding, the baby should be given ARVs as prophylaxisthroughout this period until one week after weaning. If breast feeding is notpossible, infant formula is an alternative. Obstetric procedures such as earlyartificial rupturing of membranes, instrument aided deliveries, episiotomyshould be avoided, rather elective caesarian section should be considered. Theseare the strategies employed by the PMTCT program which is a global interventioninitiated by the United Nations (UN) (United Nations, June 2002).

 2.3       Conceptual Framework of Study Access to ANC and PMTCT (healthcare) Accessto healthcare in general including ANC has a number of dimensions which includebut are not limited to: accessibility (geographical access), acceptability,availability, affordability and adequacy. Access to healthcare is arelationship between community (user) factors and health facility factors, andhas been defined as the opportunity or freedom to make use of health serviceswhen the need for care is perceived. Access cab also be viewed as a determinantwhich allows people to take the steps that enable them to come in contact withand obtain health care. Information is very crucial to accessing healthcare (Thiede & McIntyre, 2008), thus the quality ofinformation and the manner in which this information is relayed to users is ofutmost importance in influencing access to services.

In order to achieve goodaccess, a fit should exist between demand and supply of services. Accessibility: This includes geographic accessibilitylike the physical distance between health facilities and those that require theservices, nature of transportation and the time it takes to get to the pointwhere services are rendered (Peters, et al., 2008)While, acceptability involves social andcultural factors that determine the possibility of people accepting services.However, acceptability does not directly result in utilization of services.Awareness of the availability of services is important and the decision toutilize is determined by the quality of information received from the healthproviders (Thiede & McIntyre, 2008).

Availability of health care encompasses allthe factors that relate to the actual existence of a particular service withinthe reach of the user, it also involves aspects of user friendliness which isclosely related to adequacy (the quality of services delivered). From a userpoint of view, if services are available, the next question that comes to mindis: are the services affordable?Affordability refers to the direct andindirect costs of healthcare in relation to the ability of the user to pay for services. CHAPTER 3: METHODOLOGY3.0       IntroductionMaterials and methods forconducting the study are highlighted in this chapter.

These include the studydesign, sampling techniques, data collection procedures and analysis.  3.1       Study designA descriptive cross sectional study wasconducted in Chegutu district.  3.2       Studypopulation In this study, the population were the TBAsboth trained and untrained in Chegutu Hospital- affiliated health centercatchment areas.

The research findings were generalised to this studypopulation. The study population comprised of all women in their reproductiveage with one woman as the study unit. 3.3       Study setting The study was conducted in communities andhealth facilities of Chegutu district.  3.4       Inclusion criteriaand exclusion criteria 3.

4.1    InclusionCriteria·        Any married woman whohas delivered another woman in labour either at the client’s home or in theirown homes within the last six months. ·        Any woman who has theirown biological children with good reputation, and has been selected to train asa TBA by her community and aged 18 years old or more.

·        Any trained TBA inChegutu district. ·        Any woman who has beenelected by the community members and has served the community. 3.4.

2    ExclusionCriteria·        Participants who werebe absent during the study period. ·        Any woman who wassingle and had no child of their own at the time of the survey.·        Any woman under the age18 years.

·        Any woman who had neverdelivered another woman at home in the six months preceding the study. 3.5       Key informants  These included ChegutuDistrict Medical Officer and Community Health Nurse 3.6       Permission toproceed and Ethical considerations 3.6.1    Permission to proceed Permission to conduct thestudy was obtained from the District Medical Officer and Administrator.

  3.6.2   Ethical considerationsWritten informed consentwas sought from each study participant. The aim of the study was explained andthe participants were informed thatthey would be free to withdraw at any time during the interview. Confidentiality was assured by informing the participants that theresults of the study would not refer to individual study participants.

Noincentives were given to study participants for participating or as a way tomotivate them to participate.  Ethical approval was besought from the Research Ethics Committee of the University 0f Lusaka andMedical Research Council of Zimbabwe.  3.

7       Sample sizedeterminationFormula for cross-sectional studies (Lwanga & Lemeshow, 1991) n = Z?²pq           d²  Where q =1- p n = Minimum sample size desired Z = Standard normal deviate at 95%confidence levels 1.96 P = 89% (general ANC utilization in theZimbabwe Population) ( ZIMSTAT & ICF International 2012)d = desired absolute precision 5% (0.05)  Therefore 1.96 × 89% × (1? 89%) =                                     0.05² n =  Adjusting for 10% nr Where nr = non response rate 10 X (Minimum sample sizedesired)                                               100  Therefore (Minimum sample size desired +10%) = Purposive sampling was done for the TBAs,all identified TBAs consenting to participate in the study included.A minimum sample of 30 participants were selectedto participate in the study.  3.8       Sampling  Two questionnaireswere designed to collect qualitative and quantitative data: one for women(pregnant or who had delivered during the last year) and one for TBAs, both ofwhich were pre-tested in a nearby district (Kadoma district) to translate thetool from English to Shona and refine and validate the questionnaire.

For thequestionnaire on women, information was systematically collected onsocio-demographic variables, health seeking behaviours for the last pregnancy,knowledge on HIV/AIDS and perceptions concerning the participation of TBAs inPMTCT services. The questionnaire for TBAs included data on socio-demographicvariables, their background and the trainings they have received, their scopeof activities as a TBA, their knowledge, attitude and practice with regards toHIV/AIDS, and their willingness to participate in the PMTCT program. 3.8.1    Health Facilities Two health facilities were randomly selectedinto the study from the district of Chegutu. 3.

8.2    Primary participants Health workers and TBAs were be selectedthrough stratified random sampling.  3.8.3    Key informantsKey informants were purposively selected forthe study  3.9       Datacollection 3.9.

1    Primary participants Interviewer administered questionnaires wereused to collect data.  3.10     Pretesting ofdata collection toolsPretesting of the questionnaires was done toensure reliability and validity. The questionnaires were pretested in Kadomadistrict. 3.11     Key InformantsAn interview guide for key informants wasused to elicit information on the role of TBAs in PMTCT 3.

12     Data Collectionand AnalysisThe questionnaires wereadministered to the women and TBAs in the community using selected interviewerswho were student nurses in their final year of training. Four interviewers wererecruited and a one-day training session was conducted on interview andsampling techniques, selection criteria of the women and TBAs and content andapplication of the questionnaires. During this training session, the questionnaireswere also translated into vernacular language.The completedquestionnaires were verified by the supervisor and data was entered into aspecifically designed database throughout the survey.

Prior to analysis,missing data was checked against the survey forms.The questionnaire was created in Epi infoTMfor data analysis. Quantitative and categoricaldata was entered and analyzed in Epi InfoTM(3.5.

4), which was also used to generate frequencies, means and proportions.  3.13     Questionnaire 1 Structured questionnaires developed by theresearcher was administered by trained interviewers to respondents.

 3.13.1  Questionnaire will have 5 sections: Section 1: DemographicInformation Section 2: Reproductivehistory Section 3: Knowledge withregard to ANC, HIV/AIDS, MTCT and PMTCT services Section 4: Attitude towardsANC, HIV/AIDS Section 5: Practice withregard to ANC, HIV/AIDS and PMTCT3.13.2  Questionnaire 2 A semi-structured questionnaire (translatedinto Shona) was administered to TBAs who were patronized by the rural women togather information regarding their knowledge and practices with regards to safedelivery services, HIV/AIDS including PMTCT. 3.

14     Quantitativedata analysisThe data analysis was done using Epi –Infoversion 7. Univariate analysis for frequencies and proportions was done aswell. Odds ratios and p-values were determined to investigate the associationof identified factors and knowledge of HIV and ANC utilization.