Menu
Menu
Menu
Menu
Background: Childbirth at health facilities is an important strategy to reduce maternal morbidity and mortality, improve fetal outcomes, and reduce mother-to-child transmission of HIV. Although access to antenatal care in Kenya is high (>90%), less than half of births occur at health facilities. This analysis aims to assess correlates of facility delivery among recently pregnant HIV-infected women participating in a community-based survey, and to determine whether these correlates were unique when compared to HIV-uninfected women from the same region. Methods: Women residing in the Kenya Medical Research Institute/Centers for Disease Control and Prevention Health and Demographic Surveillance System, and who had delivered an infant in the previous year were visited at home in 2011. Consenting mothers answered a questionnaire assessing demographics, place of delivery, utilization of prevention of mother-to-child HIV transmission (PMTCT) services, and stigma indicators. Known HIV-positive women were purposively oversampled. Chi-square tests of proportions and multivariate logistic regression, stratified by HIV status, were performed to assess correlates of facility delivery. Results: Overall, 101 (46.8%) HIV-infected and 127 (39.9%) HIV-uninfected women delivered at health facilities. Among HIV-infected women, cost (42.8%), distance (18.8%) and fear of harsh treatment (15.2%) were primary disincentives for facility delivery; 2.9% noted fear of HIV testing was a disincentive. HIV-infected women who delivered at facilities had higher education (p = 0.04) and socioeconomic status (p < 0.005), initiated antenatal care (ANC) earlier (4.9 vs. 5.4 months, p = 0.016), were more likely to know partner's HIV status (p = 0.016), report satisfaction with delivery care (p = 0.001) and use antiretrovirals (87.1% vs. 77.4%, p = 0.063) compared to those with non-facility delivery. Stigma indicators were not associated with delivery location. Similar cofactors of facility delivery were noted among uninfected women. Conclusions: Utilization of facility delivery remains low in Kenya and poses a challenge to elimination of infant HIV and reduction of peripartum mortality. Cost, distance, and harsh treatment were cited as barriers and these need to be addressed programmatically. HIV-infected women with lower socioeconomic status and those who present late to ANC should be prioritized for interventions to increase facility delivery. Partner involvement may increase use of maternity services and could be enhanced by couples counseling.
This analysis utilized data obtained from a cross-sectional study of women residing in the Kenya Medical Research Institute/Centers for Disease Control and Prevention (KEMRI/CDC) Health and Demographic Surveillance System (HDSS) area who delivered an infant within a year prior to the survey. The KEMRI/CDC HDSS area is located northeast of Lake Victoria in the Nyanza Province of western Kenya [19]. The HDSS covers 385 villages with a population of approximately 220,000. The HDSS had implemented a program for home-based counseling and testing (HBCT) for HIV with high uptake of testing and linkage of HIV test result to HDSS dataset for all consenting participants. HIV-infected women were purposively oversampled to increase power of the study to detect associations related to uptake of PMTCT interventions. The methodology of the parent study has previously been described [20]. A list of women in the KEMRI-CDC HDSS area who had delivered in 2010 was generated. The sampling framework was designed to efficiently assess two populations relevant to PMTCT service delivery: a random sample of women in the general community to assess uptake of interventions targeting all pregnant women (ANC, HIV-testing), and a sample of known HIV positive women to assess uptake of interventions (antiretrovirals) targeting HIV-infected pregnant women. This included a comprehensive list of 275 women who had received their HIV status for at least 3 months before delivery and a second list of 523 randomly selected women from the areas where HBCT had not been conducted. Data generated from the HDSS included name, Global Positioning System location, and a randomly assigned identification code. Despite lead investigator knowledge of HIV status from the HDSS in HBCT areas for sampling purposes, field workers were blinded to HIV status and thus self-report of HIV status was used at interview. Outcomes of interest included self-report of place of delivery. Cofactors assessed for place of delivery included age, education level, marital status, utilization of antenatal care (ANC), use of maternal and infant ARVs, satisfaction with care provided during delivery and knowledge of partner HIV status. Socioeconomic status was assessed by using indicators such ownership of mobile phones, radio, bicycle, cattle and monthly family income. Standardized questions were used to quantitatively measure HIV-related stigma and discrimination [21]. We evaluated two domains of HIV stigma, namely: value- and morality-related attitudes of blame, judgment and shame for those living with HIV/AIDS; and enacted stigma or discrimination. To assess perceptions of community behavior, or perhaps reasons that women were unwilling to report themselves about reasons for non-facility delivery, all participants were also asked an open-ended question, “In your opinion, what are some of the reasons women in this area do not deliver their babies in a health facility?”. Analyses were restricted to women self-reporting HIV-positive status or HIV-negative status. Those who reported not knowing their status, and those who reported they were negative but who were known to be HIV-positive through prior HBCT, were excluded. STATA version 10 (STATA Corp, College Station, Texas, USA) was used to analyze data on rates and correlates of facility delivery and association of facility delivery with use of maternal and infant antiretrovirals. We used Pearson’s Chi square or Fisher’s exact tests to compare categorical variables, and t-tests were used for continuous variables. Multivariate logistic regression was conducted using covariates statistically associated (p < 0.05) with facility delivery in univariate analysis. Approval for the study was obtained from the Kenya Medical Research Institute (KEMRI) Ethical Review Committee (ERC), and from the Human Subjects Division at the University of Washington. Authorization was also obtained from Provincial Medical Officer, Nyanza and the District Medical Officers of Health. Study participants provided written informed consent to be interviewed and to have their survey data linked to their HDSS record.
N/A
