Role of traditional birth attendants in maternal care services -- a rural study

In India various programs have been launched to provide primary health care to women and children, particularly in the rural areas. However, the impact of these programs has not been significant. Though there is a provision of a trained dai (traditional birth attendant) in every village in the national program, most of the deliveries in rural areas are still conducted at home by untrained dais. This study was undertaken to find out about the decision of pregnant women in rural areas as regards the place of delivery and the nature of assistance received at delivery. Four villages in the Jawan Block, District of Aligarh, were randomly selected. All the villages were covered by the Integrated Child Development Services Scheme (ICDS). A total of 212 pregnant women were registered and each of them was contacted to inquire about the type of assistance received at delivery. 96.7% of the women were Hindus; 93.0% were illiterate and 68.5% were poor; 33.5% were high caste, 30.2% were low caste, and 30.2% were scheduled caste. Out of 212 deliveries, 205 (96.6%) were conducted at home. Assistance received at delivery (N = 212) was as follows: untrained dais (traditional birth attendants) 190 (89.6%); trained dais 0 (0.0%); prenatal care assistants 11 (5.2%); doctors 9 (4.2%); and relatives 2 (1.0%). The utilization of existing prenatal care services was meager, as the majority of pregnant women were illiterate and poor. As many as 205 (96.6%) deliveries were done at home. The finding that 89.6% deliveries were conducted by untrained dais assumes considerable significance in light of the fact that these villages of Jawan Block were among one of the first 3 ICDS blocks in Uttar Pradesh. This shows that there is still a wide gap between provision and utilization of maternal care services. Since most of the deliveries are conducted at home by untrained traditional birth attendants, the people must be educated to utilize the services of trained personnel.     

Competing knowledge claims in the provision of antenatal care: a qualitative study of traditional birth attendants in rural Zimbabwe

In this article we examine the role of traditional birth attendants (TBAs) in their care of women during pregnancy and childbirth, and highlight their views on the training they receive and the application of knowledge they gain. We also discuss the ways women and men reason around the practices of TBAs. Data were generated using focus group discussions and individual interviews with TBAs, women, and men. The accounts of the TBAs, women, and men indicate that the women combined traditional and professional care, reasoning that in this way they get the different forms of assurance that each offers for the proper pregnancy outcome. The accounts, moreover, suggest that little of the knowledge gained from the training, including the referral of women at high risk, was implemented. One reason for this appears to be the failure to reflect on local knowledge and realities in TBA training. We conclude that any efforts or plans to incorporate the two systems of care should acknowledge local knowledge and realities. Only then can the aim of reducing maternal and infant morbidity and mortality be achieved.     

Repositioning traditional birth attendants to provide improved maternal healthcare services in rural Ghana

Following the World Health Organization's recommendation for developing countries to discontinue the use of Traditional Birth Attendants (TBAs) in rural areas, the government of Ghana banned TBAs from offering maternal health care services. Since this ban, community‐level conflicts have intensified between TBAs, (who still see themselves as legitimate culturally mandated traditional midwives) and nurses. In this articles, we propose a partnership model for a sustainable resolution of these conflicts. This article emanates from the apparent ideological discontent between people from mainstream medical practice who advocate for the complete elimination of TBAs in the maternal health service space and individuals who argue for the inclusion of TBAs in the health sector given the shortage of skilled birth attendants and continued patronage of their services by rural women even in context where nurses are available. In the context of the longstanding manpower deficit in the health sector in Ghana, improving maternal healthcare in rural communities will require harnessing all locally available human resources. This cannot be achieved by “throwing out” a critical group of actors who have been involved in health‐care provision for many decades. We propose a win‐win approach that involve retraining of TBAs, partnership with health practitioners, and task shifting.     

Increasing the uptake of prevention of mother-to-child transmission of HIV services in a resource-limited setting

Background  

As in other resource limited settings, the Ministry of Health in Zambia is challenged to make affordable and acceptable PMTCT interventions accessible and available. With a 14.3% HIV prevalence, the MOH estimates over one million people are HIV positive in Zambia. Approximately 500,000 children are born annually in Zambia and 40,000 acquire the infection vertically each year if no intervention is offered. This study sought to review uptake of prevention of mother-to-child (PMTCT) services in a resource-limited setting following the introduction of context-specific interventions.     

Concerns and experiences of women participating in a short-term AZT intervention feasibility study for prevention of HIV transmission from mother-to-child

This paper describes the experiences and concerns of women participating in a short-term AZT intervention feasibility study to prevent mother-to-child HIV transmission at three sites in India. The study used qualitative methods to examine the experiences of 31 women during late pregnancy, delivery and at post-natal visits. It also elicited the perspectives of 19 healthcare providers. Frequent visits required during late-pregnancy and the post-natal period presented concerns for the women in the study. Women's understanding of the long-term implications of participating in the intervention study was poor, and living with uncertainty about the HIV status of the newborn was a major concern. The provision of psychosocial support is essential in future intervention studies and should be incorporated on an ongoing basis. Networking with women-centred support groups may be helpful in enabling women to gain the long-term benefits of this type of intervention.     

Non-adherence to the single dose nevirapine regimen for the prevention of mother-to-child transmission of HIV in Bindura town,Zimbabwe: a cross-sectional analytic study

Background  

The Prevention of Mother to Child Transmission of HIV (PMTCT) programme was introduced at Bindura Hospital in 2003. Seven additional satellite PMTCT clinics were set up in the district to increase service coverage but uptake of PMTCT interventions remained unsatisfactory. In this study we determined the prevalence of and factors associated with non-adherence to the single dose nevirapine (SD-NVP) regimen for PMTCT in Bindura town.     

Public sector services for the prevention of mother-to-child transmission of HIV infection: a micro-costing survey in Namibia and Rwanda

Objective

To assess the costs associated with the provision of services for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus in two African countries.

Methods

In 2009, the costs to health-care providers of providing comprehensive PMTCT services were assessed in 20 public health facilities in Namibia and Rwanda. Information on prices and on the total amount of each service provided was collected at the national level. The costs of maternal testing and counselling, male partner testing, CD4+ T-lymphocyte (CD4+ cell) counts, antiretroviral prophylaxis and treatment, community-based activities, contraception for 2 years postpartum and early infant diagnosis were estimated in United States dollars (US$).

Findings

The estimated costs to the providers of PMTCT, for each mother–infant pair, were US$ 202.75–1029.55 in Namibia and US$ 94.14–342.35 in Rwanda. These costs varied with the drug regimen employed. At 2009 coverage levels, the maximal estimates of the national costs of PMTCT were US$ 3.15 million in Namibia and US$ 7.04 million in Rwanda (or < US$ 0.75 per capita in both countries). Adult testing and counselling accounted for the highest proportions of the national costs (37% and 74% in Namibia and Rwanda, respectively), followed by management and supervision. Treatment and prophylaxis accounted for less than 20% of the costs of PMTCT in both study countries.

Conclusion

The costs involved in the PMTCT of HIV varied widely between study countries and in accordance with the protocols used. However, since per-capita costs were relatively low, the scaling up of PMTCT services in Namibia and Rwanda should be possible.     

HIV infection in children and the prevention of mother-to-child transmission

The introduction of highly active antiretroviral therapy (HAART) has led to a major improvement in the prognosis of paediatric HIV in the developed world. HIV infected children in the Netherlands exhibit a broad range of social-cultural backgrounds and many of them grow up in multiple-problem families. As well as the impact of HIV itself, these families struggle with social, economic and emotional disadvantages that interfere with an optimal treatment. The failure of HAART and the development of HIV resistant strains resulting from non-compliance are increasingly being observed. For an optimal support of these children and families, an integrated medical and psychosocial service is required. HAART during pregnancy and delivery as well as post-exposure prophylaxis to the neonate have significantly decreased the risk of HIV transmission from mother to child. Due to the implementation of national guidelines and the effort of HIV-internists, obstetricians, midwives and paediatricians, less transmission cases have occurred in the Netherlands in recent years, despite an increasing number of exposed infants. The goal is to detect and treat every pregnant HIV-infected woman and her baby.     

Universal combination antiretroviral regimens to prevent mother-to-child transmission of HIV in rural Zambia: a two-round cross-sectional study

Objective

To evaluate if a pilot programme to prevent mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV) was associated with changes in early childhood survival at the population level in rural Zambia.

Methods

Combination antiretroviral regimens were offered to pregnant and breastfeeding, HIV-infected women, irrespective of immunological status, at four rural health facilities. Twenty-four-month HIV-free survival among children born to HIV-infected mothers was determined before and after PMTCT programme implementation using community surveys. Households were randomly selected and women who had given birth in the previous 24 months were asked to participate. Mothers were tested for HIV antibodies and children born to HIV-infected mothers were tested for viral deoxyribonucleic acid. Multivariable models were used to determine factors associated with child HIV infection or death.

Findings

In the first survey (2008–2009), 335 of 1778 women (18.8%) tested positive for HIV. In the second (2011), 390 of 2386 (16.3%) tested positive. The 24-month HIV-free survival in HIV-exposed children was 0.66 (95% confidence interval, CI: 0.63–0.76) in the first survey and 0.89 (95% CI: 0.83–0.94) in the second. Combination antiretroviral regimen use was associated with a lower risk of HIV infection or death in children (adjusted hazard ratio: 0.33, 95% CI: 0.15–0.73). Maternal knowledge of HIV status, use of HIV tests and use of combination regimens during pregnancy increased between the surveys.

Conclusion

The PMTCT programme was associated with an increased HIV-free survival in children born to HIV-infected mothers. Maternal utilization of HIV testing and treatment in the community also increased.     

Antenatal HIV testing in rural eastern Uganda in 2003: incomplete rollout of the prevention of mother-to-child transmission of HIV programme?

Background  

Uganda began to implement the prevention of mother-to-child transmission (PMTCT) of HIV programme in 2000, and by the end of 2003 it had expanded to cover 38 of the 56 districts including Mbale District. However, reports from Mbale Hospital showed that less than 10% of pregnant women accepted antenatal HIV testing. We therefore conducted a study to determine the proportion of pregnant women who tested for HIV and the gaps and barriers in PMTCT implementation.     

预防艾滋病母婴传播综合措施的费用效果分析

目的 对艾滋病高发地区4个预防艾滋病母婴传播项目县的预防艾滋病母婴传播综合措施进行经济学评价,探讨其费用效果及经济学效率.方法 运用项目全成本核算的方法,通过现场调查收集2003-2006年实施预防艾滋病母婴传播各项措施的费用和干预效果,计算每发现1例HIV感染孕产妇、避免1例儿奄新发感染HIV和挽救1个残疾调整寿命年(DALY)的费用.结果 孕产期每发现1例HIV感染孕产妇的费用平均为5512元(人民币),综合措施避免1例儿童HIV感染的费用为46 747元(人民币),挽同1个DALY的费用为1870元(人民币),折合231美元.结论 项目地区预防艾滋病母婴传播干预措施费用低,经济学效率较高.     

Promising outcomes of a national programme for the prevention of mother-to-child HIV transmission in Addis Ababa: a retrospective study

Background  

Prevention of Mother-to-Child HIV Transmission (PMTCT) is still the most effective intervention in combating new HIV infections. In 2008, revised national PMTCT guidelines that incorporated new policies on HIV counselling and testing, antiretroviral prophylaxis regimen and infant HIV diagnosis came into effect in Ethiopia. In the present study we have examined trends in PMTCT service utilization and assessed the rate of MTCT in relation to policy changes in the national PMTCT programme.     

妊娠前后获知HIV感染对预防母婴传播干预措施利用的影响

目的 探讨妇女妊娠前后获知HIV感染对预防母婴传播(PMTCT)干预措施利用的影响.方法 前瞻性调查了2005-2009年河南、广西、云南、新疆四省(自治区)确认HIV感染的孕产妇5552例,5894人次妊娠,了解其社会人口学特征(将调查对象分为15～、25～、35～49岁3个年龄段),以及确认感染的时期、妊娠结局、艾滋病抗病毒药物应用等PMTCT干预措施的实施.采用单因素和非条件logistic多因素回归模型对HIV感染孕产妇实施PMTCT干预措施的影响因素进行分析.结果 HIV感染孕产妇84.5%(4979/5894)年龄在35岁以下,56.0%(3108/5552)为汉族,85.1%(4727/5552)为农民或无业,86.8%(4815/5552)为初中或以下文化程度,31.2%(1836/5894)的感染孕产妇在妊娠前已知HIV感染.31.7%(1869/5894)的HIV感染孕产妇选择人工终止妊娠,妊娠前已知感染者终止妊娠的比例高达43.8%(805/1836).80.0%(3046/3808)分娩的HIV感染孕产妇应用抗病毒药物,92.3%(883/957)的妊娠前已知感染者应用抗病毒药物,远高于当次妊娠才明确感染者[75.9%(2163/2851);x2=120.39,P＜0.05].多变量分析结果显示,妊娠前已知感染较妊娠前未知感染(OR=3.91,95%CI:3.03～5.05)、15～岁年龄段较35～49岁年龄段(OR=0.75,95%CI:0.57～0.98)的HIV感染孕产妇抗病毒药物应用比例较高.结论 妊娠前已知HIV感染有利于感染孕产妇尽早接受抗病毒药物应用等预防母婴传播的干预措施.     

广东地区预防HIV母婴传播服务需求与能力分析

目的  分析广东省各地预防艾滋病母婴传播（mother-to-chlid transmission,MTCT）的服务需求与能力,了解工作的薄弱地区和环节。 方法  收集2014年-2017年广东省感染人类免疫缺陷病毒（human acquired immunodeficiency virus,HIV）的孕产妇及暴露婴儿的服务需求及干预情况,使用SPSS 21.0软件分析各地服务需求与能力差异,以及各地助产机构和母婴保健人员数量与HIV的MTCT之间相关性。 结果  感染HIV孕产妇文化程度不高,以初中为主（54.49%）;各地感染HIV的孕产妇服务需求不同,珠三角区外来少数民族（12.96%）、山区非本地居住（43.75%）、东翼感染途径不详（77.78%）孕产妇占比高;各地服务能力不同,山区和东翼孕产妇多产时/产后确诊（占比41.67%和44.44%）、治疗晚（山区和东翼超过36周治疗或未治疗占比43.75%和55.56%）、孕产妇和婴儿未治疗比例高（山区和东翼为2.08%和33.33%）,且东翼母乳喂养比例高（11.11%）;东翼助产服务机构和母婴保健服务人员数量少,覆盖面小;各地助产机构和母婴保健人员数量与MTCT均无相关性（均有P>0.05）。 结论  山区和东翼是广东省预防HIV的MTCT工作薄弱地区,检测晚、干预不规范、信息质量低是薄弱环节。有针对地消除服务能力的地区差异,是实现广东省消除HIV的MTCT目标的关键。     

艾滋病病毒母乳传播的研究进展

艾滋病病毒母乳传播是艾滋病病毒母婴传播的一种方式,其传播率为5%～20%,占艾滋病病毒母婴传播的1/3～1/2.婴儿摄入艾滋病病毒感染母亲的母乳后,其消化道粘膜是最可能发生艾滋病病毒母乳传播的部位.艾滋病病毒母乳传播可能发生在哺乳期的任何时间,但目前研究还不能确定母乳喂养持续时间与艾滋病病毒传播时间之间的精确关系.影响艾滋病病毒母乳传播的因素主要包括母亲和婴儿这两方面的因素,因此预防艾滋病病毒母乳传播也应从这两个方面着手,主要包括预防育龄妇女艾滋病病毒感染、艾滋病病毒感染母亲和/或婴儿预防性抗病毒治疗,以及其它与婴儿喂养行为相关措施.     

Factors associated with the utilization of antenatal care and prevention of mother-to-child HIV transmission services in Ethiopia: applying a count regression model

Background

Prevention of Mother-to-Child HIV Transmission (PMTCT) coverage has been low in Ethiopia and the service has been implemented in a fragmented manner. Solutions to this problem have mainly been sought on the supply-side in the form of improved management and allocation of limited resources. However, this approach largely ignores the demand-side factors associated with low PMTCT coverage in the country. The study assesses the factors associated with the utilization of PMTCT services taking into consideration counts of visits to antenatal care (ANC) services in urban high-HIV prevalence and rural low-HIV prevalence settings in Ethiopia.

Methods

A multivariate regression model was employed to identify significant factors associated with PMTCT service utilization. Poisson and negative binomial regression models were applied, considering the number of ANC visits as a dependent variable. The explanatory variables were age; educational status; type of occupation; decision-making power in the household; living in proximity to educated people; a neighborhood with good welfare services; location (urban high-HIV prevalence and rural low-HIV prevalence); transportation accessibility; walking distance (in minutes); and household income status. The alpha dispersion test (a) was performed to measure the goodness-of-fit of the model. Significant results were reported at p-values of <?0.05 and?<?0.001.

Results

Household income, socio-economic setting (urban high-HIV prevalence and rural low-HIV prevalence) and walking distance (in minutes) had a statistically significant relationship with the number of ANC visits by pregnant women (p?<?0.05). A pregnant woman from an urban high-HIV prevalence setting would be expected to make 34% more ANC visits (counts) than her rural low-HIV prevalence counterparts (p?<?0.05). Holding other variables constant, a unit increase in household income would increase the expected ANC visits by 0.004%. An increase in walking distance by a unit (a minute) would decrease the number of ANC visits by 0.001(p?<?0.001).

Conclusion

Long walking distance, low household income and living in a rural setting are the significant factors associated with low PMTCT service utilization. The primary strategies for a holistic policy to improve ANC/PMTCT utilization should thus include improving the geographical accessibility of ANC/PMTCT services, expanding household welfare and paying more attention to remote rural areas.

     

Investing in HIV services while building Kenya's health system: PEPFAR's support to prevent mother-to-child HIV transmission

Trade-offs may exist between investments to promote health system strengthening, such as investments in facilities and training, and the rapid scale-up of HIV/AIDS services. We analyzed trends in expenditures to support the prevention of mother-to-child transmission of HIV in Kenya under the President's Emergency Plan for AIDS Relief (PEPFAR) from 2005 to 2010. We examined how expenditures changed over time, considering health system strengthening alongside direct treatment of patients. We focused on two organizations carrying out contracts under PEPFAR: the Elizabeth Glaser Pediatric AIDS Foundation and FHI360 (formerly Family Health International), a nonprofit health and development organization. We found that the average unit expenditure, or the spending on goods and services per mother living with HIV who was provided with antiretroviral drugs, declined by 52 percent, from $567 to $271, during this time period. The unit expenditure per mother-to-infant transmission averted declined by 66 percent, from $7,117 to $2,440. Meanwhile, the health system strengthening proportion of unit expenditure increased from 12 percent to 33 percent during the same time period. The analysis suggests that PEPFAR investments in prevention of mother-to-child transmission of HIV in Kenya became more efficient over time, and that there was no strong evidence of a trade-off between scaling up services and investing in health systems.     

预防艾滋病母婴传播医务人员心理压力分析

目的 了解云南省艾滋病高流行地区从事预防艾滋病母婴传播工作医务人员的心理状况,并分析影响因素.方法 对云南省13个县/市的255名从事预防艾滋病母婴传播工作的医务人员进行自填式问卷调查.结果 从事预防艾滋病母婴传播工作医务人员的症状自评评定量表评分除人际关系敏感因子分外,其余8项因子分及总分均高于全国成人常模;心理问题检出率为48.0%;非条件Logistic回归分析结果显示,30～40岁年龄段、直接接触患者体液、血液机会较大的岗位、对报酬不满意、非主动意愿从事本项工作、自己不能缓解工作压力、认为发生职业暴露后无充分的医疗保障及担心患者态度不友好是使医务人员产生心理问题的危险因素,接受过艾滋病相关培训是保护因素.结论 从事预防艾滋病母婴传播工作医务人员的心理压力大,心理问题检出率高,心理问题受多种因素影响,有必要对医务人员进行综合性心理干预.     

Factors influencing teen mothers' enrollment and participation in prevention of mother-to-child HIV transmission services in Limpopo Province, South Africa

In this article, we examine barriers to HIV testing uptake and participation in prevention of mother-to-child HIV transmission (PMTCT) services among adolescent mothers aged 15 to 19 years in rural and urban Limpopo Province, South Africa. We used the narrative research method involving key informants constructing typical case studies of adolescent experiences with HIV testing and entry into PMTCT. Case studies formed the basis of a community-based questionnaire and focus group discussions with adolescent mothers. Client-counselor dynamics during pretest counseling were pivotal in determining uptake and participation, and counselor profile strongly influenced the nature of the interaction. Other factors found to influence adherence to PMTCT recommendations included HIV and early premarital pregnancy stigma, fear of a positive test result, and concerns over confidentiality and poor treatment by health care providers. Adolescents described elaborate strategies to avoid HIV disclosure to labor and delivery staff, despite knowing this would mean no antiretroviral therapy for their newborn infants. Theoretical, methodological, and programmatic implications of study findings are also discussed.