Facility-based delivery in the context of Zimbabwe’s HIV epidemic – missed opportunities for improving engagement with care: A community-based serosurvey

BMC Pregnancy and Childbirth, Volume 15, No. 1, Year 2015

Interpretation

Background: In developing countries, facility-based delivery is recommended for maternal and neonatal health, and for prevention of mother-to-child HIV transmission (PMTCT). However, little is known about whether or not learning one’s HIV status affects one’s decision to deliver in a health facility. We examined this association in Zimbabwe. Methods: We analyzed data from a 2012 cross-sectional community-based serosurvey conducted to evaluate Zimbabwe’s accelerated national PMTCT program. Eligible women (≥16 years old and mothers of infants born 9-18 months before the survey) were randomly sampled from the catchment areas of 157 health facilities in five of ten provinces. Participants were interviewed about where they delivered and provided blood samples for HIV testing. Results: Overall 8796 (77 %) mothers reported facility-based delivery; uptake varied by community (30-100 %). The likelihood of facility-based delivery was not associated with maternal HIV status. Women who self-reported being HIV-positive before delivery were as likely to deliver in a health facility as women who were HIV-negative, irrespective of when they learned their status – before (adjusted prevalence ratio (PRa) = 1.04, 95 % confidence interval (CI) = 1.00-1.09) or during pregnancy (PRa = 1.05, 95 % CI = 1.01-1.09). Mothers who had not accessed antenatal care or tested for HIV were most likely to deliver outside a health facility (69 %). Overall, however 77 % of home deliveries occurred among women who had accessed antenatal care and were HIV-tested. Conclusions: Uptake of facility-based delivery was similar among HIV-infected and HIV-uninfected mothers, which was somewhat unexpected given the substantial technical and financial investment aimed at retaining HIV-positive women in care in Zimbabwe. We analyzed data from a 2012 baseline cross-sectional survey conducted to evaluate Zimbabwe’s accelerated national PMTCT program implemented in 2011. The objective of that evaluation was to assess the population-level impact of the PMTCT program on MTCT and HIV-free child survival at 9–18 months postpartum. [22] The methods have been published in detail elsewhere. [17, 23, 24] In brief, infants (alive or deceased) born 9–18 months prior (henceforth ‘index babies’) and their mothers or caregivers (≥16 years old) were eligible for the community-based baseline survey. The infants’ age range was chosen to meet the objectives of the impact evaluation. [17] For this analysis, we excluded data regarding caregivers (n = 349, 3.9 % of 9018 participants) and only analyzed data on living biological mothers who were present at the time of the survey (n = 8662), as data collected about deceased (n = 55) and unavailable mothers (n = 294) did not include information about their place of delivery. The survey was conducted in April-September 2012 in five of Zimbabwe’s ten provinces (Harare, Mashonaland West, Mashonaland Central, Manicaland, Matabeleland South). These regions include both major ethnic groups (i.e., Shona, Ndebele), some of the largest cities in Zimbabwe, and rural areas with higher and lower HIV prevalence. Study participants were identified using a two-stage stratified cluster design. Firstly, of the 699 health facilities offering PMTCT services in these five provinces, we randomly selected 157 facilities, proportionate to the number of facilities in each district. Secondly, we identified all eligible infants from the catchment areas of these 157 facilities and sampled a known fraction of them proportionate to the size of the target population in each catchment area. Eligible mother-infant pairs were identified based on information pooled from community health workers and immunization registers from selected and neighboring facilities (to identify women residing in sampled facilities who accessed services at facilities nearby). Further, those mothers identified using community health workers and immunization registers were asked to identify other infants in their neighborhood who were born in the previous two years. Trained interviewers visited the houses of potentially eligible mother-infant pairs (identified as explained above), verified their eligibility, administered the questionnaire in the participant’s preferred language (English, Shona or Ndebele) and collected dried blood spot samples for HIV antibody testing for infants and mothers. Specifically, participating mothers answered anonymous interviewer-administered questionnaires, capturing the mothers’ demographic characteristics, healthcare utilization and place of delivery for the index baby. Maternal samples were stored at room temperature and tested for HIV-1 antibody in batches, using AniLabsytems EIA kit (AniLabsystems Ltd, OyToilette 3, FIN-01720, Vantaa, Finland). Positive specimens were confirmed using Enzygnost Anti-HIV 1/2 Plus ELISA (Dade Behring, Marburg, Germany) and discrepant results were resolved by Western Blot. [25] To assess the place of delivery of the index baby, participating mothers were asked “where did you give birth to your baby?”. We categorized women into two groups: i) mothers who delivered in healthcare facilities e.g., clinic, health center, hospital (henceforth ‘facility-based delivery’) and ii) mothers who delivered at home or elsewhere e.g., someone else’s home (henceforth ‘home-based delivery’). For this paper, we measured maternal HIV status in two ways. Firstly, our analyses used the mothers’ self-reported HIV status before delivery, based on the assumption that women’s healthcare behavior could only have been influenced by their known HIV status at the time of delivery (rather than unknown and laboratory-assessed status). Self-reported HIV status distinguished between mothers who did not know their status before delivery, those who reported they were HIV-negative before delivery, those who reported they were HIV-infected before the pregnancy, and those who learned they were HIV-infected while pregnant with the index baby. Secondly, we examined the association between the uptake of facility-based delivery and the mother’s laboratory-assessed HIV status at the time of the survey. We examined utilization of health services during the pregnancy (i.e., ANC, HIV testing) as these are key services preceding labor and delivery and thus represent possible opportunities to inform women of the benefits of facility-based delivery. We examined several covariates for inclusion in the multivariate models as potential confounders: province of residence, urban/rural status, age, highest educational level, religion, marital status, parity, the decision-maker regarding the place of delivery (i.e., mother, father, other), the sex of the person who makes important household decisions (i.e., female, male, both), the number of sellable assets present in the household (i.e., livestock, bicycle, motorcycle, car/truck, scotch cart, wheel barrow, phone, radio, television) and household-level food security as another indicator for household economic status. Household food security was assessed based on questions from the Household Food Insecurity Access Scale on anxiety and uncertainty about household food supply, insufficient food quality and insufficient food intake; we distinguished between three categories: food security, moderate food insecurity and severe food insecurity. These variables have been selected as covariates for inclusion in the multivariate models because previous studies have shown these factors to be associated with uptake of facility-based delivery in sub-Saharan Africa. [26] First, we described the uptake of facility-based delivery in Zimbabwe at the individual and community levels. At the individual level, we estimated the uptake of facility-based delivery in our sample and by province. We also assessed the aggregate-level uptake of facility-based delivery within each catchment area, the proxy for community. Community-level analyses include data from 156 catchment areas; we excluded one catchment area where only 4 mother-infant pairs were recruited in the study. Second, we examined the association between maternal HIV status and the uptake of facility-based delivery through univariate, bivariate and multivariate analyses. We constructed unadjusted and adjusted Poisson regression models with uptake of facility-based delivery (i.e., yes, no) as the outcome and self-reported HIV status before delivery as the exposure. In Poisson models with cross-sectional data, the exponentiated parameter estimates represent prevalence ratios, a conservative and more interpretable measure of association (compared to odds ratio) if the outcome is common, [27–30] as is the case for facility-based delivery (77 %). In building the adjusted model we checked for statistical interactions between each covariate and the uptake of facility-based delivery, as well as multicollinearity between the variables included in the models. Third, we explored healthcare utilization in our sample of recent mothers. Specifically, we distinguished between six categories of women, corresponding to the six possible combinations of the following two variables: receipt of ANC during the pregnancy (i.e., yes, no) and self-reported HIV status before delivery (i.e., not tested, HIV-negative, HIV-positive). For each of these six groups we computed the absolute and relative frequency of home-based deliveries. All analyses were conducted in STATA 12; we used the STATA svy commands, which allowed us to weight the data to account for the two-stage stratified cluster design and the survey non-response, and to adjust for catchment area-level clustering. The Medical Research Council of Zimbabwe and the ethics committees of the University of California, Berkeley and University College London approved the study protocol. Written informed consent was obtained from all participants prior to their participation. All participants received a gift (i.e., laundry soap and petroleum jelly) worth approximately $5USD. Women were able to receive their HIV test results at the local health facility up to 3 months after the survey, using a card with their unique identifier barcoded.

AI Digest

Study Justification:

– The study aimed to evaluate the association between knowing one’s HIV status and the decision to deliver in a health facility in Zimbabwe.
– This information is important for understanding the impact of HIV on facility-based delivery and maternal and neonatal health.

Study Highlights:

– Overall, 77% of mothers reported facility-based delivery, but uptake varied by community.
– The likelihood of facility-based delivery was not associated with maternal HIV status.
– Women who self-reported being HIV-positive before delivery were as likely to deliver in a health facility as women who were HIV-negative, regardless of when they learned their status.
– Mothers who had not accessed antenatal care or tested for HIV were most likely to deliver outside a health facility.
– 77% of home deliveries occurred among women who had accessed antenatal care and were HIV-tested.

Study Recommendations:

– The findings suggest that HIV status does not significantly influence the decision to deliver in a health facility in Zimbabwe.
– Efforts should focus on improving access to antenatal care and HIV testing to increase facility-based delivery rates.
– Strategies should be implemented to ensure that all pregnant women have the opportunity to learn their HIV status and receive appropriate care.

Key Role Players:

– Ministry of Health: Responsible for implementing policies and programs related to maternal and neonatal health and HIV prevention.
– Healthcare providers: Involved in delivering antenatal care, HIV testing, and facility-based delivery services.
– Community health workers: Play a crucial role in identifying and referring eligible mother-infant pairs for the study and promoting healthcare utilization.
– Non-governmental organizations: Provide support and resources for maternal and neonatal health programs, including HIV prevention and facility-based delivery.

Cost Items for Planning Recommendations:

– Antenatal care services: Includes staffing, training, equipment, and supplies for providing comprehensive antenatal care to pregnant women.
– HIV testing services: Covers the cost of HIV testing kits, laboratory equipment, and personnel for conducting HIV tests during pregnancy.
– Facility-based delivery services: Includes staffing, equipment, supplies, and infrastructure for ensuring safe and quality delivery in health facilities.
– Community outreach and education: Covers the cost of training community health workers, developing educational materials, and conducting awareness campaigns to promote facility-based delivery and HIV testing.
– Monitoring and evaluation: Includes the cost of data collection, analysis, and reporting to assess the impact of interventions and track progress towards improving facility-based delivery rates.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a cross-sectional community-based serosurvey conducted in Zimbabwe. The study analyzed data from a 2012 baseline survey to evaluate the country’s PMTCT program. The survey used a two-stage stratified cluster design and included a large sample size of 8,796 mothers. The study found that the uptake of facility-based delivery was similar among HIV-infected and HIV-uninfected mothers. However, the abstract does not provide information on the representativeness of the sample or the generalizability of the findings. To improve the strength of the evidence, future studies could consider using a longitudinal design to assess the impact of the PMTCT program over time and include a more diverse sample of participants from different regions of Zimbabwe.

Abstract

We analyzed data from a 2012 baseline cross-sectional survey conducted to evaluate Zimbabwe’s accelerated national PMTCT program implemented in 2011. The objective of that evaluation was to assess the population-level impact of the PMTCT program on MTCT and HIV-free child survival at 9–18 months postpartum. [22] The methods have been published in detail elsewhere. [17, 23, 24] In brief, infants (alive or deceased) born 9–18 months prior (henceforth ‘index babies’) and their mothers or caregivers (≥16 years old) were eligible for the community-based baseline survey. The infants’ age range was chosen to meet the objectives of the impact evaluation. [17] For this analysis, we excluded data regarding caregivers (n = 349, 3.9 % of 9018 participants) and only analyzed data on living biological mothers who were present at the time of the survey (n = 8662), as data collected about deceased (n = 55) and unavailable mothers (n = 294) did not include information about their place of delivery. The survey was conducted in April-September 2012 in five of Zimbabwe’s ten provinces (Harare, Mashonaland West, Mashonaland Central, Manicaland, Matabeleland South). These regions include both major ethnic groups (i.e., Shona, Ndebele), some of the largest cities in Zimbabwe, and rural areas with higher and lower HIV prevalence. Study participants were identified using a two-stage stratified cluster design. Firstly, of the 699 health facilities offering PMTCT services in these five provinces, we randomly selected 157 facilities, proportionate to the number of facilities in each district. Secondly, we identified all eligible infants from the catchment areas of these 157 facilities and sampled a known fraction of them proportionate to the size of the target population in each catchment area. Eligible mother-infant pairs were identified based on information pooled from community health workers and immunization registers from selected and neighboring facilities (to identify women residing in sampled facilities who accessed services at facilities nearby). Further, those mothers identified using community health workers and immunization registers were asked to identify other infants in their neighborhood who were born in the previous two years. Trained interviewers visited the houses of potentially eligible mother-infant pairs (identified as explained above), verified their eligibility, administered the questionnaire in the participant’s preferred language (English, Shona or Ndebele) and collected dried blood spot samples for HIV antibody testing for infants and mothers. Specifically, participating mothers answered anonymous interviewer-administered questionnaires, capturing the mothers’ demographic characteristics, healthcare utilization and place of delivery for the index baby. Maternal samples were stored at room temperature and tested for HIV-1 antibody in batches, using AniLabsytems EIA kit (AniLabsystems Ltd, OyToilette 3, FIN-01720, Vantaa, Finland). Positive specimens were confirmed using Enzygnost Anti-HIV 1/2 Plus ELISA (Dade Behring, Marburg, Germany) and discrepant results were resolved by Western Blot. [25] To assess the place of delivery of the index baby, participating mothers were asked “where did you give birth to your baby?”. We categorized women into two groups: i) mothers who delivered in healthcare facilities e.g., clinic, health center, hospital (henceforth ‘facility-based delivery’) and ii) mothers who delivered at home or elsewhere e.g., someone else’s home (henceforth ‘home-based delivery’). For this paper, we measured maternal HIV status in two ways. Firstly, our analyses used the mothers’ self-reported HIV status before delivery, based on the assumption that women’s healthcare behavior could only have been influenced by their known HIV status at the time of delivery (rather than unknown and laboratory-assessed status). Self-reported HIV status distinguished between mothers who did not know their status before delivery, those who reported they were HIV-negative before delivery, those who reported they were HIV-infected before the pregnancy, and those who learned they were HIV-infected while pregnant with the index baby. Secondly, we examined the association between the uptake of facility-based delivery and the mother’s laboratory-assessed HIV status at the time of the survey. We examined utilization of health services during the pregnancy (i.e., ANC, HIV testing) as these are key services preceding labor and delivery and thus represent possible opportunities to inform women of the benefits of facility-based delivery. We examined several covariates for inclusion in the multivariate models as potential confounders: province of residence, urban/rural status, age, highest educational level, religion, marital status, parity, the decision-maker regarding the place of delivery (i.e., mother, father, other), the sex of the person who makes important household decisions (i.e., female, male, both), the number of sellable assets present in the household (i.e., livestock, bicycle, motorcycle, car/truck, scotch cart, wheel barrow, phone, radio, television) and household-level food security as another indicator for household economic status. Household food security was assessed based on questions from the Household Food Insecurity Access Scale on anxiety and uncertainty about household food supply, insufficient food quality and insufficient food intake; we distinguished between three categories: food security, moderate food insecurity and severe food insecurity. These variables have been selected as covariates for inclusion in the multivariate models because previous studies have shown these factors to be associated with uptake of facility-based delivery in sub-Saharan Africa. [26] First, we described the uptake of facility-based delivery in Zimbabwe at the individual and community levels. At the individual level, we estimated the uptake of facility-based delivery in our sample and by province. We also assessed the aggregate-level uptake of facility-based delivery within each catchment area, the proxy for community. Community-level analyses include data from 156 catchment areas; we excluded one catchment area where only 4 mother-infant pairs were recruited in the study. Second, we examined the association between maternal HIV status and the uptake of facility-based delivery through univariate, bivariate and multivariate analyses. We constructed unadjusted and adjusted Poisson regression models with uptake of facility-based delivery (i.e., yes, no) as the outcome and self-reported HIV status before delivery as the exposure. In Poisson models with cross-sectional data, the exponentiated parameter estimates represent prevalence ratios, a conservative and more interpretable measure of association (compared to odds ratio) if the outcome is common, [27–30] as is the case for facility-based delivery (77 %). In building the adjusted model we checked for statistical interactions between each covariate and the uptake of facility-based delivery, as well as multicollinearity between the variables included in the models. Third, we explored healthcare utilization in our sample of recent mothers. Specifically, we distinguished between six categories of women, corresponding to the six possible combinations of the following two variables: receipt of ANC during the pregnancy (i.e., yes, no) and self-reported HIV status before delivery (i.e., not tested, HIV-negative, HIV-positive). For each of these six groups we computed the absolute and relative frequency of home-based deliveries. All analyses were conducted in STATA 12; we used the STATA svy commands, which allowed us to weight the data to account for the two-stage stratified cluster design and the survey non-response, and to adjust for catchment area-level clustering. The Medical Research Council of Zimbabwe and the ethics committees of the University of California, Berkeley and University College London approved the study protocol. Written informed consent was obtained from all participants prior to their participation. All participants received a gift (i.e., laundry soap and petroleum jelly) worth approximately $5USD. Women were able to receive their HIV test results at the local health facility up to 3 months after the survey, using a card with their unique identifier barcoded.

Materials

N/A

Innovations

Based on the provided information, it is difficult to identify specific innovations for improving access to maternal health. The description provided is a detailed account of the methods and procedures used in a study conducted in Zimbabwe to evaluate the country’s PMTCT program. It does not explicitly mention any innovations or recommendations for improving access to maternal health. To provide recommendations, it would be helpful to have information on the current challenges or gaps in maternal health access in Zimbabwe or any specific goals or objectives for improvement.

AI Innovations Description

The recommendation that can be developed into an innovation to improve access to maternal health based on the provided description is to strengthen antenatal care and HIV testing services. This can be done by implementing the following strategies:

1. Increase awareness: Develop and implement targeted awareness campaigns to educate pregnant women about the importance of facility-based delivery for maternal and neonatal health, as well as for prevention of mother-to-child HIV transmission (PMTCT). These campaigns should emphasize the benefits of accessing antenatal care and getting tested for HIV during pregnancy.

2. Improve accessibility: Ensure that antenatal care and HIV testing services are easily accessible to all pregnant women, especially those in rural areas. This can be achieved by increasing the number of health facilities offering these services and by providing transportation options for women who live far from healthcare facilities.

3. Enhance quality of care: Train healthcare providers to deliver high-quality antenatal care and HIV testing services. This includes ensuring that providers have the necessary knowledge and skills to provide comprehensive care, as well as creating a supportive and non-judgmental environment for pregnant women.

4. Strengthen referral systems: Establish effective referral systems between antenatal care clinics and delivery facilities to ensure a smooth transition for pregnant women. This includes providing clear guidelines for healthcare providers on when and how to refer women to delivery facilities, as well as ensuring that referral information is communicated accurately and efficiently.

5. Address barriers to facility-based delivery: Identify and address the barriers that prevent pregnant women from delivering in health facilities. This may include addressing cultural beliefs and practices, improving the availability of skilled birth attendants, and addressing financial barriers by providing financial incentives or subsidies for facility-based delivery.

By implementing these strategies, it is expected that more pregnant women will choose to deliver in health facilities, leading to improved access to maternal health services and better health outcomes for both mothers and newborns.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Strengthening Antenatal Care (ANC) Services: Enhance ANC services by ensuring that all pregnant women have access to comprehensive care, including HIV testing, counseling, and education on the benefits of facility-based delivery.

2. Community Outreach Programs: Implement community-based programs to raise awareness about the importance of facility-based delivery and provide information on available maternal health services. This can include health education sessions, mobile clinics, and community health workers.

3. Transportation Support: Address transportation barriers by providing transportation vouchers or subsidies for pregnant women to access health facilities for delivery. This can help overcome geographical challenges and increase the likelihood of facility-based delivery.

4. Quality Improvement Initiatives: Implement quality improvement initiatives in health facilities to ensure that they provide safe, respectful, and culturally sensitive care to pregnant women. This can include training healthcare providers, improving infrastructure, and enhancing the overall patient experience.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the Outcome Measure: Determine the primary outcome measure to assess the impact of the recommendations, such as the percentage of facility-based deliveries or the reduction in maternal mortality rates.

2. Data Collection: Collect baseline data on the current status of access to maternal health services, including the percentage of facility-based deliveries, maternal mortality rates, and other relevant indicators. This can be done through surveys, interviews, or analysis of existing data sources.

3. Intervention Implementation: Implement the recommended interventions in selected communities or health facilities. Ensure that the interventions are implemented consistently and monitor their implementation fidelity.

4. Data Analysis: Collect post-intervention data on the outcome measure(s) identified in step 1. Compare the post-intervention data with the baseline data to assess the impact of the recommendations on improving access to maternal health.

5. Statistical Analysis: Analyze the data using appropriate statistical methods to determine the statistical significance of the observed changes. This can include conducting regression analyses, calculating confidence intervals, and performing hypothesis testing.

6. Interpretation of Results: Interpret the results of the analysis to understand the impact of the recommendations on improving access to maternal health. Identify any limitations or challenges encountered during the implementation and analysis process.

7. Recommendations and Next Steps: Based on the findings, make recommendations for scaling up successful interventions, addressing any identified gaps, and further improving access to maternal health services. Develop a plan for ongoing monitoring and evaluation to ensure continuous improvement.

It is important to note that the methodology described above is a general framework and may need to be adapted based on the specific context and resources available for the evaluation.

Author

Dima Health

Statistics:

Citations: 9

Identifiers:

DOI: 10.1186/s12884-015-0782-y

Research Areas:

Community Interventions, Disparities, Food Security, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Mental Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

Zimbabwe

Study Design:

Case-Control Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Male & Female