Factors Influencing The Utilization Of Prevention Of Mother–To-Child Transmission (PMCTC) Services Among Pregnant Women Attending Clinic

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Factors Influencing The Utilization Of Prevention Of Mother–To-Child Transmission (PMCTC) Services Among Pregnant Women Attending Clinic


Abstract


After years of implementing prevention of mother-to-child transmission of HIV (PMTCT) program in Nigeria, there are significant improvements especially in terms of service provision. However there are some challenges that prevent maximum utilization of PMTCT services by HIV positive pregnant women and postnatal mothers.
The aim of this study was to determine factors that influence utilization of PMTCT services among HIV positive women at Chiroma Ward in Lafia Local Government Area of Nasarawa State.

A cross sectional study was conducted between April and May 2014 among 126 HIV positive women who were attending antenatal clinic and postnatal clinic at Chiroma Ward in Lafia Local Government Area of Nasarawa State. Participants were recruited to participate in the study after obtaining their consent. The data on which this thesis is based was generated from structured interviews. The interviews focused on socio-demographic characteristics, retention of PMTCT clients into care, level of PMTCT knowledge, social support HIV positive women receive from different groups of people and women‟s satisfaction with the services.

Most of the participants had high knowledge about PMTCT services. About 87.3% knew that HIV positive women can infect her baby during pregnancy, delivery or breastfeeding. Almost all all participants (99.2%) knew that exclusive breastfeeding (EBF) is one of the ways to prevent their babies from being infected with HIV.
Many of the participants admitted to have received social support from health care workers (99.2%), husbands / partners (93.7%) and PLHIV within the health facility (67.5%). This motivated them to effectively utilize PMTCT services.

Women also reported that they were satisfied with the PMTCT services provided especially counseling on ARV use as well as counseling on disclosure of HIV status to the husbands/partners. Among 63 participants who were very satisfied with counseling on disclosure which was provided by health care workers, 63.2% had higher knowledge about PMTCT.


Chapter One


Introduction

1.1 Background to the Study

Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) has a devastating effects and is currently a complication of pregnancy worldwide with more than 700,000 children infected annually. Mother–To–Child Transmission (MTCT) of the virus is responsible for more than 90% of these cases in children under 15 years (United States AIDS, 2012).

Mother–To–Child Transmission (MTCT) of HIV can occur during pregnancy, labour and delivery, or breastfeeding. During pregnancy, about 5 – 8% of babies become infected through transmission across the placenta. Labour and delivery pose the greatest risk for transmission (10 – 20% of exposed infant). Breastfeeding also exposes the infant to HIV transmission particularly if prolonged (18-24 months). The additional risk of HIV infection when and infant is breast fed is around 15-25% World Health Organization (WHO, 2013) in collaboration with other non-governmental organization like global fund, president’s emergency plan for Aids relief (PEPFAR) etc.

Feasible and affordable interventions now exist to reduce the rate of MTCT by 50% (Population Reports, 2010). The Prevention of Mother–To–Child Transmission (PMTCT) protocol begins at pre-test counseling continues through the HIV test, result and enrolment for the intervention and at hospital delivery.

Hospital delivery ensures that both mother and baby receive the intervention (Nevira Pine) at the time. Maternal Nevirapine is administered at the beginning of labour, while the baby dose is given within 72 hours after delivery.

In 2012, around 400,000 children aged under 15 became infected with HIV (UNAIDS, 2013). Almost all of these infections occur in low and middle-countries, and more than 90% are the result of Mother-To-Child-Transmission during pregnancy and delivery or breastfeeding. Without interventions, there is a 20-45% chance that a baby born to a HIV- infected mother will become infected (De Cock et al; 2011).

In 2006, the proportion was 23% and by 2009 an estimated of 53% of pregnant women living with HIV in low and middle income countries received antiretroviral drugs to prevent HIV transmission to their infants World Health Organization/United Nations International Children Fund (WHO/UNICEF, 2011).

In Southern African where HIV is very widespread among pregnant women, Botswana leads the way. High quality PMTCT services are provided in all of the country’s public facilities through the maternal and child health/family planning system which serves over 95% of the pregnant women (US Global Aids, 2012).

Sub-Sahara African has continued to bear the greatest burden of the HIV/AIDS epidemic. Seventy percent of the estimated 37.8 million people living with HIV, 70 percent of the 4.8 million are new infections, 77 percent of the 2.9 million are HIV deaths and 90 percent of the 2.1 million children infected with HIV in 2003 were from sub-Saharan African. 630,000 children were infected with HIV, and out of these, 90 percent occurred is Sub-Saharan African.

The high prevalence of HIV in women of reproductive age group and the high fertility rates contribute to the comparatively high prevalence of transmission of HIV to infants. The high prevalence of MTCT of HIV is threatening to reverse the gains of the child survival strategy in the African continent (Federal Ministry of Health, (FMOH, 2010).

In Nigeria, the prevalence of HIV infection among pregnant mothers is estimated at 30% and is reversing the recent gains of child survival programmes, thereby increasing infant and child mortality rates at Chiroma Ward in Lafia Local Government Area of Nasarawa State (FMOH, 2013). This has necessitated the increment of prevention of Mother – To – Child – Transmission program sites from 11 in 2002 to 622 in 2013 (Chiroma Ward in Lafia Local Government Area of Nasarawa State, 2009). In March 2010 there was presidential directive to increase coverage of prevention of mother – to child – to 30% by the end of 2010 and 50% by 2013, based on 2011 WHO recommendations, Chiroma Ward in Lafia sentinel report have indicated highest HIV prevalence (10.6%). It is estimated that 7,620 pregnant women are infected with HIV Lafia Ministry of Health, 2013). About 2,000 babies are infected with HIV from their mothers annually in the study area.

A total of 438 HIV positive mothers enrolled for the PMTCT Ante-natal Clinic in 2012 at Chiroma Ward in Lafia Local Government Area of Nasarawa State and are beneficiaries of the PMTCT programme, out of the 438, only 337 continued attending the antenatal clinic to the end. Studies have indicated inadequate counseling and dropout at different service delivery points in implementing PMTCT protocol, posing the need for research to find reasons for such action (Madaki, 2015).

Combs (2013) found that MTCT knowledge was incomplete, as those interviewed stated that all mothers transmit HIV to their babies through breast feeding. Mothers lack information on the prevention of transmitting of HIV from an infected mother to her child, as well as measures that exist to reduce the risk of transmission. Combs (2013) concluded that health care workers needed additional MTCT training and support materials to enable them to provide counseling, appropriate information and advice to clients about HIV and breastfeeding options.

HIV in children is a major problem in developing or resources poor countries. About 277,000 children live with HIV representing 11% of the global pediatric HIV burden in Nigeria. Also over 65,000 to 117,000 of HIV infected children are delivered annually. About 8% of child mortality is related to HIV infection. This is a result of failed implementation Prevention of Mother to Child Transmission (PMTCT) (FMOH, 2013). In Chiroma Ward in Lafia Local Government Area of Nasarawa State, the prevalence of HIV infection in pregnant women is estimated at 24,620, up to 1868 (1.04% statistically insignificant) received antiretroviral for prophylaxis.

There were 3,328 (1.86%) HIV positive pregnant women receiving infant feeding counseling and support (Federal Ministry of Health, 2012). This reversing the recent gains of child survival programme thereby increasing infant and child mortality rates. Defaulting hospital appointments can be attributed to so many factors, such as: finance, unsatisfactory quality of service, transportation etc. Thus it is important to carry out this study so as to unveil the quality of services offered by PMTCT clinic as perceived by clients attending the services which will go along way to reducing the incidence of HIV/AIDS in Chiroma Ward in Lafia Local Government Area of Nasarawa State.

Understanding clients perspectives would also help to know whether the services are being delivered in accordance with their needs and if not then the need to improvement.


1.2 Statement of the Problem

The burden of HIV infection has now become a burning issue word wide divide. An estimated million people are now living with the virus on planet earth with 2,000 babies getting infected daily. Majority of all new infections in diverse setting have helped reduce the HIV infections rate. The national HIV zero prevalence has proven that the infection does yield to determined and connected intervention.

Worldwide, approximately 2.2 million women and 600,000 infants are infected with HIV each year (UNAIDS, 2012). 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 (Philips, 2013). 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 (Abrams, 2014) are available in different parts of the world.

Johnson (2014) maintained that successful implementation of PMTCT programme for a larger number of women are 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 (2015) found out that several clinics that provide the services to the local population were already unstaffed and over-pressured. But it is an accepted fact that availability and adequacy of resources are important in the utilization of PMTCT services.

Nigeria’s 2005 HIV zero-prevalence rate of 4.4% through an improvement over the 2003 rate us still too high and unacceptable. During the year 2004 in Nigeria alone about 100,000 babies were likely to contract HIV from their mothers (UNAIDS, 2011).

The PMTCT intervention remains the only sure and feasible hope in the problems of early infant HIV diagnosis. Therefore, to lay much emphasis on prevention rather than care and treatment, in a nutshell the greatest unmet need remains the PMTCT of HIV (UNAID, 2011).


1.3 Purpose of the Study

The purpose of the study is to assess the Factors influencing the Utilization of Prevention of Mother–To-Child Transmission (PMCTC) Services among Pregnant Women attending Clinic at Chiroma Ward in Lafia Local Government Area of Nasarawa State. Specifically, it seeks to:

  1. Determine the progressive level or implementation of PMTCT at Chiroma Ward in Lafia Local Government Area of Nasarawa State.
  2. Identify the number of available skilled manpower for the implementation of PMTCT.
  3. Identify the number of clients patronage at the PMTCT services at Chiroma Ward in Lafia Local Government Area of Nasarawa State.
  4. Determine the Factors affecting PMTCT of HIV and AIDS services.

1.4 Significance of the Study

Health workers and parents may find the information on the factors influencing the Utilization of Prevention of Mother–To-Child Transmission (PMTCT) services useful to check whether their local hospitals provide full PMTCT programme and to press for improvement in line with the recommendations that will be made for the benefits of mothers of child bearing age and their infants.

The information may also be helpful to hospital administrators to reorganize and train their staff for full PMTCT programme implementation in their hospitals in realizing their responsibilities in health care provision for pregnant women especially those that are seropositive and their children who vertically acquired the HIV.

The findings generated on the availability of PMTCT services may help pregnant women to know the hospitals that provide the services. This will help to increase the level of utilization of the services by the target group and there will be improvement on quality of life.

The information will also help service providers to intensify public enlightenment programme on the need for HIV positive pregnant mothers to make use of the services. The data generated may help to see the need to establish more PMTCT sites.

The findings obtained from the availability of qualified of PMTCT service providers will help hospital administrators in planning and using multiple approaches to training and retraining the service providers to improve on their skills. The data may also provide basis to recruit qualified staff for rendering PMTCT services in their hospitals.

The findings will help hospital administrators to facilitate procurement of more materials for PMTCT. Donor agencies may also be motivated to procure these materials for the hospitals. The data may also help the hospitals management to solicit for material help from World Health Organization.

The information on the adequacy of qualified PMTCT service providers will help hospital management to train more PMTCT service providers. The information may also help the government to restrict service providers from migrating to other countries for job .This will invariably place a check on brain drain in the county.

By providing information on the adequacy of PMTCT materials, service providers will be motivated and encouraged to create awareness to pregnant women for maximum utilization of the services. The government will accelerate action to achieve the goal of eliminating HIV infection in infants and young children.

The information generated will help the service providers to be motivated to create awareness in rural areas to provide bases for pregnant women to attend antenatal care. This may also help hospitals management to know the capability of workers in their hospitals which may encourage training and retraining of their staff for that purpose.

The data obtained from the level of utilization of HIV testing service may be an eye opener to service providers to be propelled to intensify strategies for pregnant mothers to willingly accept HIV testing. This may also help to motivate the various hospital administrators to make available all the equipment and materials necessary for HIV testing service in their hospitals. More so, their laboratory scientist may be retrained for HIV testing.

The findings generated may also help health care providers to support for community mobilization efforts to increase acceptance of ART for PMTCT. It will also help to bring about effort to support global efforts to negotiate reduced costs of the drugs and foster partnerships among organizations to purchase drugs collectively at low cost.

The information may also help health care providers to provide community education about the importance of antenatal care and deliveries assisted by MTCT- trained attendants.

The information on the level of utilization of safer infant feeding options will help service providers to counsel HIV positive pregnant mothers to make an informed decision concerning safer feeding option for their babies. Informed and safer choice may promote and increase quality of life of infants born to HIV positive mothers.

The information will help PMTCT service providers to continually improve their services and the way they work and to improve the coordination of PMTCT programme which will lead to changes in the process of preventive service delivery in practice. They will use the information in decision making and in carrying out their responsibilities in multiple practice organization for HIV patients.

It will also provide an opportunity for improvement of the services provided and increase the knowledge of the community on the availability of PMTCT services. Its package and intervention strategies will help to dispel some erroneous beliefs and practices on the use of antiretroviral drugs (ARVS) that encourage or promote HIV/AIDS transmission.


1.5 Research Questions

  1. What is the participants‟ knowledge about PMTCT at Chiroma Ward in Lafia Local Government Area of Nasarawa State
  2. What are the retention rates of PMTCT clients from enrolment up to 12 months after enrollment at PMTCT clinic at Chiroma Ward in Lafia Local Government Area of Nasarawa State.
  3.  What type of support and from whom do PMTCT clients at Chiroma Ward in Lafia Local Government Area of Nasarawa State receive.
  4. To what extent HIV positive women are satisfied with the provided PMTCT services at Chiroma Ward in Lafia Local Government Area of Nasarawa State.

1.6 Scope of the Study

The study is delimited to pregnant women that attended antenatal clinic in Chiroma Ward in Lafia Local Government Area of Nasarawa State.


1.7 Limitations

Major limitation was encountered during this study because the Teaching Hospital was on strike and many patients were not (accessed) reached. Also some respondents refused to divulge their information for confidential purposes.


1.8 Operational Definition of Terms

Factors:

Are variables that influence utilization of PMTCT services

Utilization:

Refers to the process of using PMTCT services

PMTCT services:

Are services that aims at offering preventive measures towards mother to child transmission.

Ante natal:

Refers a period from conception to the onset of labour


Chapter Five


Discussion, Conclusion and Recommendations

5.1 Discussion

It was observed that there was a strong commitment from health care workers who were providing various PMTCT services to HIV positive pregnant and postnatal women who went for care at Chiroma Ward in Lafia Local Government Area of Nasarawa State. PMTCT knowledge was observed to be a contributing factor for utilization of the services by study participants. Husbands/partners support their wives to utilize PMTCT services but they were not participated in the services.

From this study, it was observed that all women who were attending PMTCT clinic at Chiroma Ward in Lafia Local Government Area of Nasarawa State had a fairly high level of knowledge about PMTCT which is very important factor for women to access and utilize the services. The main source of PMTCT information for the study participants were health care workers. The finding suggests that frequency use of PMTCT services leads to high level of knowledge about PMTCT not only to the participants but also to their families and community. As a result many women will be informed about PMTCT which will lead to the increase of number of women who utilize the services. Similar results have been reported by Komunami et al (2007), that spreading information on HIV especially mother to child transmission – MTCT are significant factors of HIV test acceptance among women which is the entry point of PMTCT services.

Interestingly the level of PMTCT knowledge was negatively related to the level of education of the study participants. This finding may suggest that PMTCT clients with high level of education do not want to mix together with other clients during health education sessions at the PMTCT clinic. These women developed relationships with some of health care workers who assisted them to get ARV whenever they came at the hospital. It is possible this was among the reasons these women missed an opportunities to learn about important PMTCT information which are provided during health education sessions.

Results of this study show that out of 176 women who were enrolled into PMTCT services, only 71.6% were retained after twelve months. Out of 83 Pre-ART clients 63.9% were retained after 12 months and out of 93 ART clients 78.5% were retained after 12 months. This finding shows that PMTCT clients who are using ARV are more likely to retain into services that those who have not started to use ARV. The finding may suggests that early initiation of ARV to HIV positive women at PMTCT is not only efficiency in preventing mother to child transmission of HIV but also an important factor to retain women into PMTCT services. Same results were reported by Toit et al (2011) that many clients on ART (94%) were retained in ART services compared to less than half (43%) of those who on Pre-ART.

The study participants mainly received support from Health care workers, partners and fellow PLHIV at the hospital. This indicates that these three groups of people are very important to support women to utilize PMTCT services. Partners seem to be very supportive although they do not want to attend clinic with their wives/partners. There is a need to develop strategies which can effectively involve them in PMTCT program in order to have good results. A study which was conducted by Carter (2002) suggests that active involvement of male partners in PMTCT services is crucial to the effectiveness of programs.

PLHIV/Peers at the health facility are important to encourage women to utilize PMTCT services. Findings from this study showed that 66% of women receive support from their fellow PLHIV. This is probably due to that fact that women feel free to discuss about HIV issues with their fellow PLHIV whom they share the same experience. They tend to believe in PMTCT services through testimonies provided by PLHIV who have graduated from PMTCT and who have benefited from the services. The same was reported by Annelie te al (2011) that peer educators are recognized for being close to clients, they provide clients with an opportunity to individually talk to someone who was also living with HIV, who had a positive attitude about their situation and are willing to share personal stories of hope when educating and counseling clients.

Another finding showed that many participants were satisfied with provided PMTCT services. Participants with higher knowledge were very satisfied with PMTCT services provide by health care workers. This finding suggests that satisfaction with the services is determined by women‟s knowledge of PMTCT services. The higher level of PMTCT knowledge among clients leads to their satisfaction with the PMTCT services and hence increases utilization of services. Similar resulta were reported by Kalembo et al (2012) that the knowledge level of HIV positive women on ART and PMTCT are important factors in adherence to ART.


5.2 Conclusion

Basing on the results made from this study the following conclusion can be made. Knowledge about PMTCT was relatively high among the study participants and the main source was the health care workers. Most of the participants knew about exclusive breast feeding for an HIV exposed infant.

Retention of women into PMTCT services was 76.1% and the remaining were either transferred out, dead or defaulters. Women who were using ARV were more likely to retain in PMTCT services (78.5%) compared to women who had not yet started to use ARV (63.9%).

Study participants received support mainly from health care workers, husbands/partners and their fellow PLHIV in the hospital. Very few women receive support from relatives, neighbors and friends.
Most participants were satisfied with the PMTCT services provided by health care workers. Most of them were very satisfied with the way counseling on ARV use and disclosure of HIV status to partners was provided.


5.3 Recommendation

  1. Since the knowledge of PMTCT was relatively high among the study participants, which was related to the effective utilization of PMTCT services, there is a need to educate all women of childbearing age about PMTCT so as to reduce the risk of HIV transmission from mother to child.
  2. As retention into PMTCT services was observed to be higher among those women who were using ARV that those who were not using ARV, there should be strategies for ensuring that all pregnant women be initiated on ARV as soon as they are diagnosed as HIV infected.
  3. From the study it was observed that husbands/partners were very supportive to their wives who are HIV positive. Health care worker should put strategies to involve them in PMTCT program so as to increase utilization of services by HIV positive pregnant and postnatal women.
  4. Participants mentioned that good assistance from HCWs and availability of PMTCT services as main factors influencing them to come for the services. Therefore there should be strategies to ensure that health care workers are equipped with the up to date information and PMTCT commodities should be available at the hospital.

Factors Influencing The Utilization Of Prevention Of Mother–To-Child Transmission (PMCTC) Services Among Pregnant Women Attending Clinic


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