FACTORS INFLUENCING UTILIZATION OF PREVENTION OF MOTHER TO CHILD TRANSMISSION(PMTCT) SERVICE AMONG PREGNANT WOMEN ATTENDING ANTI-NATAL CLINIC IN UNIVERSITY OF CALABAR TEACHING HOSPITAL(UCTH)

FACTORS INFLUENCING UTILIZATION OF PREVENTION OF MOTHER TO CHILD TRANSMISSION(PMTCT) SERVICE AMONG PREGNANT WOMEN ATTENDING ANTI-NATAL CLINIC IN UNIVERSITY OF CALABAR TEACHING HOSPITAL(UCTH)

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CHAPTER ONE

Introduction

Background to the Study

Everyday, approximately 5,000 women are newly infected with HIV (Human Immunodeficiency Virus), and more than 3,000 die from AIDS (Acquired Immune Deficiency Syndrome) – related illnesses (UNAIDS, 2000a). In most parts of the world, HIV infection is increasing faster among women than men. Nowhere is the trend more apparent than in sub – Saharan Africa where women comprise 58 per cent of existing HIV infection (UNAIDS, 2000b). These differences in infection rates are due to a combination of factors. Women and girls are commonly discriminated against in terms of access to education, employment and land inheritance. With increasing poverty levels, African women have found themselves in casual relationship with men as this can serve as a conduit for financial and social security. Women, therefore, find it difficult to demand for safe sex, as they become subordinates or dependents of mainly older men. Women are also biologically prone to infection and HIV is easily transmitted from men to women than the reverse.

This has led to the increase in women living with HIV. Results of initial early studies analyzing progression and survival in HIV syndrome suggested a difference based on gender. Most of these studies indicated that the prognosis for women was worse than for men. This reflected late access to limited care (Bastian, Bennet, Adams, Waskin, Divine & Edlin, 1993; Melnick, Sherer, Louise, Hillman, Rodriguez, Lackman, Capps, Brown, Caryln & Korvick 1994). Lack of access to care, minimal self – motivation, and attention to the health care of their children over that of themselves all contributed to decreased rates of early detection and intervention. HIV and AIDS for women, therefore, is an issue of access to health care (UNAIDS, 2003). Furthermore, at the end of 2004, UNAIDS reported that women made up almost half of the 37.2 million adults (aged 15 to

49)    living with HIV and AIDS worldwide. The hardest-hit regions are areas where heterosexual contact is the primary mode of transmission. This is most evident in sub-Saharan Africa, where close to 60 per cent of adults living with HIV and AIDS are women. Women and girls make up a growing proportion of those infected by HIV and AIDS (UNAIDS/WHO, 2005a).

AIDS is a disease of the immune system that makes the individual highly vulnerable to life-threatening infections such as tuberculosis (TB) and certain types of cancer. AIDS is caused by a retrovirus known as Human Immunodeficiency Virus (HIV)


which attacks and impairs the body’s natural defence system against diseases and infections (Piwoz & Preble, 2000). They further stated that HIV is a slow-acting virus that may take years to produce illness in a person. HIV is transmitted via three primary routes: having unprotected sex with a person already carrying the HIV virus; transfusions of contaminated blood and its by-products or use off non-sterilized instruments, such as shared needles, razor, and other surgical tools; and from an infected mother to her child (MTCT) during pregnancy, labour, childbirth or breastfeeding.

According to UNAIDS/WHO (2000), the principal mode of transmission of HIV in Africa is heterosexual. The second is mother – to – child transmission, which is the main mode of acquisition of HIV infection in children under 15 years. The number of children living with HIV infection is estimated at 2.5 million since the epidemic began. Each year, around half a million children aged under 15 become infected with HIV. Almost all of these infections occur in developing countries, and more than 90 per cent are the results of mother – to – child transmission during pregnancy, labour and delivery or breast – feeding. Without interventions, there is a 20 – 45 per cent chance that a baby born to an HIV – infected mother will become infected (De Cock, Fowler, Mercier, de Vincenzi, Saba & Hoff, 2000).

Mother to child transmission (MTCT) also known as vertical transmission occurs when HIV positive woman passes the virus to her baby. This can occur during pregnancy, labour and delivery or breastfeeding, (Msellati, Leroy & Lepage, 1992). The most effective means of reducing mother – to – child transmission is to provide fully suppressive Antiretroviral therapy (ART) to the mother in long term, thereby not only reducing the risk of vertical transmission, but also sustaining the life and health of the mother while the child is growing up. In high income countries, MTCT has been virtually eliminated thanks to effective prevention programmes (Preble & Piwoz, 2002).

According to Hornby, (2001), prevention is the act of stopping something bad from happening. Prevention of mother to child transmission (PMTCT) of HIV and AIDS therefore, is the act of stopping a mother from passing or transmitting HIV and AIDS to her child during pregnancy, labour, delivery and breastfeeding. The member states of the United Nations set target for PMTCT in 2001, as part of a landmark agreement called the UNGASS (United Nations General Assembly) declaration. In this document, the world leaders made the following pledge: by 2005, reduce the proportion of infants infected with HIV by 20 per cent, and by 50 per cent by 2010, by: ensuring that 80 per cent of pregnant women accessing antenatal care have information, counseling and other HIV


prevention services available to them (UNGASS, 2001). The goals of PMTCT programme go beyond decreasing the MTCT risk to a minimum, and aim to achieve the strategic goal of virtual elimination of HIV infection in infants (Malyuta, Newell, Ostergren, Thorne & Zhilka, 2006).

Effective PMTCT, according to UNAIDS/WHO (2000), requires a three – fold strategy – (1) preventing HIV infection among prospective parents, (2) avoiding unwanted pregnancies among HIV positive women, and (3) preventing the transmission of HIV from HIV positive mothers to their infants during pregnancy, labour, delivery and breast feeding. UNAIDS (2000) added that PMTCT of HIV consists of a core package of interventions which includes, (1) voluntary counseling (VC), (2) HIV testing,

(3)  antiretroviral therapy (ART), (4) obstetric intervention or caesarean section (CS), and

(5)    safe infant feeding counseling. Zaman and Thorne-Lyman (2004) added ARV (antiretroviral vaccine) prophylaxis given to the baby within 72 hours of birth (a one time dose). But this study shall settle on the first five.

Voluntary counseling (VC) is the cornerstone of the PMTCT programme and provides critical information to pregnant women about HIV testing and prevention. Counseling is also necessary to help HIV- infected women to adjust to their diagnosis and reduce transmission to their children. Thus, counseling can enhance not only the possibility of reducing HIV vertical transmission but also the quality of antenatal care and other health services in addition to the prevention of HIV MTCT (Perez-Then, Peňa,

Tavarez-Rojas, Peňa, Quiňonez & Buttler, 2003).

HIV testing of pregnant women is to identify which women are infected so that increased precautions could be taken to reduce exposure of health care workers to HIV during deliveries (Stringer, Stringer & Phanuphak, 1999). For pregnant women, the benefit of HIV testing is to learn their HIV status so they could decide about pregnancy continuation, subsequent birth control, and prevention of HIV transmission to partners.

Women who have reached the advanced stages of HIV disease require a combination of antiretroviral drugs for their own health. This treatment, which must be taken every day for the rest of a woman’s life, is also highly effective at reducing the risk of mother to child transmission. Women who require treatment will usually be advised to take it, beginning either immediately or after the first trimester. Their newborn babies will usually be given a course of treatment for the first few days or weeks of life, to lower the risk even further (Kanabus & Nobel, 2006).


Caesarean section is an operation to deliver a baby through its mother abdominal wall. When a mother is HIV positive, a caesarean section may be done to protect the baby from direct contact with her blood and other fluids. However, there is a need to weigh the risk of HIV transmission against the risk of harm due to intervention (Kanabus & Nobel, 2006).

Safe infant feeding counseling is the advice given to pregnant mothers especially those who are HIV positive on safer feeding option of their infant to avoid postpartum transmission of HIV. According to UNICEF, UNAIDS and WHO (2000), they are advice on the following different feeding methods during the first six months of postpartum: use of breast milk substitute exclusively, mixed feeding strategy (breast milk substitutes and breastfeeding) and exclusive breastfeeding.

According to UNICEF, UNAIDS and WHO (2000), many countries are implementing pilot programmes, which are aimed at demonstrating the feasibility and effectiveness of integrating activities to prevent mother – to – child transmission of HIV into routine Maternal and Child Health (MCH) services in developing countries. Preble and Piwoz (2002) also stated that low utilization of Antenatal Clinic (ANC) and other MCH services is a major problem in many resources – poor Asian countries. Advocacy for improved MCH services and use at all levels (community to national) is critical for PMTCT and has direct and indirect benefits for all mothers. For example: reducing the incidence and severity of malaria, tuberculosis, reproductive tract, and other infections will improve an HIV-infected women’s chances of avoiding or delaying conditions that will compromise her health and survival; improving antenatal care will improve birth outcomes, such as stillbirths, low birth weight, preterm births, and infant mortality, regardless of HIV status of the mother; and malnutrition and HIV infection are inextricably linked. Improving HIV-infected mother’s nutritional status may help to slow the progression of HIV disease and prolong survival.

PMTCT is an ongoing programme. The Federal Ministry of Health (Nigeria) developed a national PMTCT of HIV Programme in 2001. Since then, sites providing PMTCT services have increased, involving partners such as UNICEF, Centers for Disease Control (CDC), APIN (AIDS Prevention Initiative in Nigeria) and USAID (United States Agency for International Development). PMTCT services have also been expanded from the initial tertiary health facilities to secondary and primary health facilities (UNICEF, 2007). According to National Agency for the Control of AIDS –


NACA (2007), as at first of March, 2007, PMTCT  sites in Nigeria was 195, out of which 53 are in private hospitals and the remaining ones are in government hospitals.

Malyuta et al (2006) noted that the PMTCT programme has been integrated into existing maternal and child health care services supervised by the ANC Department of Health Care for mother and child, with collaboration from HIV and AIDS specific services. Nobel (2007) opined that to achieve wide coverage, PMTCT programme must be integrated into existing public health systems, with services provided by all antenatal and delivery clinics. More so, a health system is a blend of public and private sector in both service delivery and funding organization. Therefore, PMTCT programme should be provided by both government and private hospitals.

Every programme endeavor, including prevention of MTCT of HIV and AIDS aims at maintaining its relevance through monitoring and evaluation of its activities. Evaluation is essential to identify shortcomings in PMTCT of HIV programme and to conceptualize approaches to improve services (Reithinger, Megazzini, Durako, Harris & Vermund, 2007). This in turn, will improve a programme’s cost effectiveness and long term sustainability and save the most infant lives.

Evaluation as defined by Trochim (2006) is the systematic acquisition and assessment of information to provide useful feedback about some object. UNICEF, UNAIDS and WHO (2000) also stated that monitoring and evaluation activities support implementation of PMTCT program in that they are systematic ways of learning from experience and using the lessons learned to improve health activities and promote better planning. They can provide information support for local management and strategy, policy and program formulation and budgeting, and program delivery through various services and institutions.

Stufflebeam (1990) defined evaluation as the systematic investigation of the worth or merit of some objects and that the merits of an evaluation is what one is examining or studying in a programme. Olaitan (2003) submitted that evaluation is the process of obtaining information on what one is doing towards achieving objectives, how far one could go in achieving the objectives, what constraints hinder the achievement of the objective, and what to do in order to overcome the constraints of achieving the objectives. This position seems to lend credence to the felt need for obtaining such information on the programme for prevention of MTCT of HIV and AIDS services in hospitals in Umuahia, Abia State.


Evaluation helps to emphasize the importance of evaluation participants, especially the client or users of a programme and stakeholders. Agency for Health Care Research and Quality- AHRQ (2007) observed that potential audiences for quality measurement report for child health care services are the providers and the consumers. In this case, pregnant women and health care providers’ perception measures as well as several measures of the delivery of preventive care may be used to assess the quality of the health plan or programme for PMTCT of HIV and AIDS services in government and private hospitals in Umuahia. WHO (2004) observed that the main providers of health care and their role in child health includes two main categories of government and public sector players.

Programme evaluation, according to Worthen (1990), consists of those activities undertaken to judge the worth or utility of a programme. Therefore, in the context of this study, evaluation of the PMTCT of HIV and AIDS services involve:

1.      input, that is an aspect of evaluation which according to Robinson (2002) represents a phase in which the evaluator determine the resourses and materials needed to meet the goals and objectives of the programme,

2.      process, an aspect of the programme evaluation that in the views of Robinson (2002) and Voelker-Morris (2004) is concerned with determination of the effectiveness of the delivery systems employed in the programme during implementation, and

3.      product, an aspect of evaluation, described by Robinson (2002) as focusing on measuring the outcomes of the inputs and process in a programme. The end product of these aspects of evaluation demonstrates the worth or utility of the

prevention of mother to child transmission of HIV and AIDS services in hospitals in Umuahia.

These three models can be involved in two forms of evaluation. They are goal evaluation and goal free evaluation. In the opinion of McNamara (1999), goal evaluation is also known as Goal based evaluation because the goals of the programme are often described in the original programme plan. Goal free evaluation in the opinion of Steecher (1991) is an approach to evaluation in which merit is determined from an examination of programme effects without reference to goals or objectives of the programme. Results which the programme effected are of focus rather than intentions of the programme. Goal evaluation is therefore, adopted in this study.


According to UNICEF, UNAIDS and WHO (2000), in each health facility offering the PMTCT intervention, local managers (e.g. Nurses and Physicians) and other stake holders (e.g. including representatives of People Living with AIDS – (PLWAS), local leaders, mother support groups) will analyze the information they collect routinely for clinical and administrative management in order to get an idea on whether the conditions for routine implementation are in place. Furthermore, whether the implementation of intervention is progressing, what are the key problems in the implementation to trigger corrective management action? UNICEF, UNAIDS and WHO (2000) went further to state that local monitoring indicators are mainly process indicators such as use of pre-testing counseling, use of HIV test, use of HIV pos-test counseling, infant feeding counseling, availability of ARV, initial use of ARV, receipt of ARV during labour and continuity of ARV. However, when aggregated and analyzed as a whole, they should provide a valid picture of the progress toward effectiveness.

Effectiveness is a measure of the ability of a program, project or task to produce a specific desired effect or result that can be qualitatively measured. Effectiveness is also a measure of the quality of attainment in meeting objectives (resource effectiveness or team effectiveness) (hptt://www.visitask.com/effectiveness-gasp). According to Windsor and Thomas (1984), effectiveness is a measure of the extent to which the programme achieves its pre-established, measurable objectives. The effectiveness of PMTCT is typically measured in terms of the estimated percentage change (a reduction in the percentage) of HIV infected infants who are born to HIV infected mothers (Reithinger et al, 2007). They further stated that effective prevention relies on a cascade of steps. A pregnant woman must receive antenatal care at a centre offering HIV testing. If she consents to testing she must receive her HIV test result and, if infected, receive appropriate prophylaxis. She must then take the prophylaxis during labour and her infant must receive prophylaxis after delivery. Finally, the mother and infant must receive follow-up care to ensure that they have any necessary treatment and that the infant is tested for HIV, typically in the second year of life when HIV antibody testing is reliable.

The effective implementation of PMTCT programme requires the introduction of health care providers as with the introduction of health service providers into any new health service. At the same time, facilities would have to create an enabling and supportive environment that motivates health care providers to effectively apply their learning and provide PMTCT services to HIV- positive women and mothers (Tint, Doherty, Nkonki, Witten & Chopra, 2003). According to Magoni, Okong, Bassani,


Kituka, Onyango Namaganda and Giuliano (2007), the successful implementation of PMTCT programme for larger number of women is feasible if the health system has adequate resources and personnel. PMTCT service providers include doctors, nurses, midwives, laboratory technicians, pharmacists, social workers, outreach workers, counselors and programme manager who contribute to effective PMTCT programme in their health facilities and communities (http://www.etharc.org/pmtct/PMTCTres.htm). Material resources for effective PMTCT implementation include HIV test kit, CD4 count machine, drugs, reagents, microscope, needles or lancets, laboratory tubes, centrifuges, incubators, washers and spectrophotometers, constant source of electricity, laboratory infrastructure and gloves use for the phlebotomy (drawing blood samples). Furthermore, compliance with universal infection control procedures and provision of appropriate decontamination and antiseptic solutions, gloves, syringes, and other sterile equipment can help minimize risk of delivery- related HIV transmission, as well as the risk of occupational exposure- that is, health providers becoming HIV infected through contact with HIV- infected clients’ blood (Preble & Piwoz, 2002).

Challenges involved in PMTCT are now greater than envisaged and progress has not been made as expected (Arulogun, Adewole, Olayinka-Alli & Adesina, 2007). They further stated that this has a great implication on the future of any society, as there will be nobody to take care of the future if nothing is done to reverse this trend. Furthermore, women face a lot of discrimination as well as obstacles in making decisions pertaining to their health as well as in health seeking behaviour. Furthermore, where drugs are available to prevent this mode of transmission during pregnancy, a lot of people cannot afford it due to the cost. Nuwagaba – Biribonwoha, Mayon – White, Okong and Carpenter (2007) further observed that the main challenges lay in the reluctance of women to be tested for HIV, incomplete follow – up of participants, non – disclosure of HIV status and difficulties with infant feeding for HIV – positive mothers. Dadian Siwale, Kankasa, Nduati, Ngacha, Oyieke et al (2003) suggested that counselors and laboratory staff should receive special training to build skills and knowledge needed to implement PMTCT services. More so, Skinner et al (2003) discovered that some clinics are poorly staffed and are often missing facilities required for general clinic services and PMTCT, such as telephones, separate counseling rooms, and own access to medication. These limitations can influence the successful implementation of PMTCT.

Skinner et al (2003) observed that the generally low level of education and skill in an area would also limit the capacity for development. In this case, low level of


education among pregnant women may limit their use of PMTCT programme. Bajunirwe and Muzoora (2005) found that women with at least a post-primary education are more likely to choose HIV testing compared to those with lower education.

The focus on the implementation of PMTCT in rural community is important since research often tends to be focused on urban areas (Skinner et al 2003). They further observed that people that stay in rural areas are often neglected and isolated from the benefits that accrue from research. Furthermore, people who stay in the more inaccessible rural areas have difficulties in reaching the clinics. Bajunirwe and Muzoora (2005) suggested that it is crucial that any differences between rural and urban areas are addressed since the significant proportion of people in developing countries live in the rural areas.

Magoni et al (2007) discovered that the mean age of women who attended ANC for PMTCT programme was 25.3 years. That women over thirty years of age enrolled in the programme more than women less than twenty years.

Statement of the Problem

Worldwide, approximately 2.2 million women and 600,000 infants are infected with HIV each year (UNAIDS, 2000c). Since the first pediatric AIDS case was documented in 1985, the number of infected children has increased markedly, and the health care for these children is becoming an increasing burden on the public health system (Perez- Then et al, 2003). As a result, PMTCT programme was initiated.

PMTCT exist in different parts of the world including Nigeria. The services which include VC, HIV testing, ART, obstetric intervention (cesarean section) and safer infant feeding (Ioannidis, Abrams, & Ammann, 2001) are available in different parts of the world. Magoni et al (2007) maintained that successful implementation of PMTCT programme for a larger number of women is feasible if the health system has adequate resources and personnel. This implies that availability and adequate utilization of the services will reduce or eliminate the risk of MTCT of HIV.

Unfortunately, literature has shown that several factors impede the availability and utilization of PMTCT. By implication, one may be tempted to doubt the availability and adequacy of PMTCT resources and the level of utilization of these services by pregnant women. Skinner et al (2005) found out that several clinics that provide the services to the local


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