How Perceptions of HIV-Related Stigma Affect Decision-Making Regarding Childbirth in Rural Kenya

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Study Justification:
The study aims to investigate the relationship between perceptions of HIV-related stigma and attitudes towards facility-based childbirth among pregnant women in rural Kenya. This is important because HIV prevalence among pregnant women in Kenya is high, and there is a high risk of maternal mortality due to inadequate utilization of maternity services. Understanding the impact of HIV-related stigma on decision-making regarding childbirth can help inform interventions to improve skilled birth attendance and reduce maternal and infant mortality.
Highlights:
– The study included 1,777 pregnant women in rural Kenya.
– Women who anticipated HIV-related stigma from their male partners had lower odds of having positive attitudes towards facility-based childbirth.
– Negative attitudes towards facility-based childbirth were strongly related to the intention to give birth outside a health facility.
– Reducing HIV-related stigma may lead to more positive attitudes towards facility-based childbirth and increased skilled birth attendance.
Recommendations:
– Implement stigma reduction efforts to improve attitudes towards facility-based childbirth.
– Increase access to skilled healthcare providers during childbirth.
– Provide education and awareness programs to address misconceptions and fears related to HIV testing and disclosure.
Key Role Players:
– Healthcare providers: They play a crucial role in providing quality care and addressing the concerns and fears of pregnant women regarding HIV-related stigma.
– Community leaders and influencers: They can help promote positive attitudes towards facility-based childbirth and reduce stigma within the community.
– Policy makers: They can allocate resources and develop policies that support stigma reduction efforts and improve access to skilled birth attendance.
Cost Items:
– Training and capacity building for healthcare providers on stigma reduction and providing quality care during childbirth.
– Community education and awareness programs.
– Development and implementation of policies and guidelines to support stigma reduction and improve access to skilled birth attendance.
– Monitoring and evaluation of interventions to assess their effectiveness and make necessary adjustments.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a large sample size (1,777 pregnant women) and includes statistical analyses. The study received ethical approval and was conducted at sites supported by an established HIV prevention, care, and treatment program. The study also includes measures of stigma, attitudes, and intentions related to facility-based childbirth. However, to improve the evidence, the abstract could provide more details on the methodology, such as the specific statistical tests used and the results of the analyses. Additionally, it would be helpful to include information on the limitations of the study and suggestions for future research.

Introduction: HIV prevalence among pregnant women in Kenya is high. Furthermore, there is a high risk of maternal mortality, as many women do not give birth with a skilled healthcare provider. Previous research suggests that fears of HIV testing and unwanted disclosure of HIV status may be important barriers to utilizing maternity services. We explored relationships between women’s perceptions of HIV-related stigma and their attitudes and intentions regarding facility-based childbirth. Methods: 1,777 pregnant women were interviewed at their first antenatal care visit. We included socio-demographic characteristics, stigma scales, HIV knowledge measures, and an 11-item scale measuring health facility birth attitudes (HFBA). HFBA includes items on cost, transport, comfort, interpersonal relations, and services during delivery at a health facility versus at home. A higher mean HFBA score indicates a more positive attitude towards facility-based childbirth. The mean HFBA score was dichotomized at the median and analyses were conducted with this dichotomized HFBA score using mixed effects logit models. Results: Women who anticipated HIV-related stigma from their male partner had lower adjusted odds of having positive attitudes about giving birth at the health facility (adjusted OR =. 63, 95% CI 0.50-0.78) and less positive attitudes about health facility birth were strongly related to women’s intention to give birth outside a health facility (adjusted OR = 5.56, 95% CI 2.69-11.51). Conclusions: In this sample of pregnant women in rural Kenya, those who anticipated HIV-related stigma were less likely to have positive attitudes towards facility-based childbirth. Furthermore, negative attitudes about facility-based childbirth were associated with the intention to deliver outside a health facility. Thus, HIV-related stigma reduction efforts might result in more positive attitudes towards facility-based childbirth, and thereby lead to an increased level of skilled birth attendance, and reductions in maternal and infant mortality. © 2012 Medema-Wijnveen et al.

This study received ethical approval from the Kenya Medical Research Institute (KEMRI) Ethical Review Committee and the Committee on Human Research of the University of California, San Francisco. The Maternity in Migori and AIDS Stigma (MAMAS) Study was conducted at sites supported by Family AIDS Care and Education Services (FACES), an HIV prevention, care, and treatment program operating in Nyanza Province Kenya. HIV prevalence among women of reproductive age in Nyanza Province is estimated at 16% [3]. Women at least 18 years old in their first seven months of pregnancy, who were visiting the antenatal care clinic (ANC) for the first time in their pregnancy and did not know their current HIV status (never tested or tested negative more than 3 months ago) were recruited at nine governmental health facilities. After obtaining signed informed consent, participants were interviewed in their preferred language (Dholuo, Kiswahili, or English) by a trained interviewer. Subsequently all women were offered voluntary HIV counselling and testing during the ANC visit, followed by post-test counseling and antiretroviral drugs for PMTCT for those who tested HIV-positive, as per Kenyan national guidelines [25]. Information on their acceptance of HIV testing and their test result were subsequently obtained from the women’s medical charts. Recruitment, baseline interviews and HIV testing took place between November 2007 and April 2009. To measure perceptions of HIV-related stigma at baseline, two stigma scales developed in sub-Saharan Africa were included in the survey. Anticipated stigma is the anticipation that one will personally experience specific types of stigma or discrimination if one is found to be HIV-positive and others learn of one’s HIV status. This type of stigma was measured by a nine-item scale originally developed in Botswana that also captures from whom they expected this stigma: male partner (break-up of relationship, physical abuse), family members (neglect, denial of care), or others (treatment as outcast, bad treatment at school or work, bad treatment by health workers, loss of friends, loss of job) [26]. Researchers in Botswana found this scale to have high internal reliability consistency (Cronbach’s alpha = 0.77) [26]. In the current study, a total anticipated stigma score was calculated by taking the mean of all responses for women who provided responses to at least 6 of the 9 scale items, and women who provided 5 or fewer responses were coded as missing. We furthermore created dichotomous measures of anticipated stigma for the different ‘sources’ of stigma. Given our previous analyses showing the importance of male partner stigma, as compared to other dimensions of stigma, as a predictor of HIV test refusal in this population [27], we chose this as our primary anticipated stigma variable. Analyses were conducted using all of the different anticipated stigma measures, but we chose to construct a more parsimonious model including the anticipated male stigma variable, which had the strongest relationship with the outcome. To measure general attitudes and perceptions about persons living with HIV (PLWH) and how they are treated in their community, referred to as perceived community stigma in this paper [27], [28], we used a 22-item scale developed by Genberg et al. [29], [30] with items like ‘People living with HIV/AIDS deserve to be punished’ and ‘People living with HIV/AIDS in this community face rejection from their peers’. This scale was found to have high internal consistency validity and good divergent validity in both Thailand and Zimbabwe [30]. As reported elsewhere [27], internal-consistency reliability of these scales in our sample of pregnant women in Kenya was high (Cronbach’s alpha.86 for the anticipated stigma scale and.85 for the perceived community stigma scale). To measure women’s perceived quality of care and attitudes towards giving birth at the health facility, we developed an 11-item scale derived from our previous qualitative research in Nyanza Province. In that study, we identified common beliefs and attitudes towards giving birth at the health facility assisted by a skilled healthcare provider versus giving birth at home assisted by a TBA, based on in-depth interviews with postpartum women, male partners, TBAs, and health workers [31]. This resulted in 11 statements with which women were asked to agree or disagree (coded 1 or 0). A total HFBA score was calculated by taking the mean score for women who provided responses to 8 or more scale items, and women who provided 7 or fewer responses were coded as missing, with a higher mean score indicating a more positive attitude towards giving birth at a health facility. The internal-consistency reliability of this score in this sample was found to be moderate (Cronbach’s α = .60), but acceptable for research in the early stages [32]. The survey also included questions on socio-demographic characteristics. Questions that assessed knowledge regarding HIV transmission and prevention (for example, can a person get HIV by sharing a meal with someone who is infected?) were included and were used to construct a HIV knowledge index based on the number of items that were answered correctly. The primary outcome variables for our analyses of women’s intentions regarding childbirth were based on questions in which participants were asked where they intended to give birth and with what type of assistance. Participants were also asked about expected costs related to their delivery (transportation, supplies, medicines, fees). We considered giving birth in a health facility to be equivalent to giving birth with a skilled health care provider (although recognizing that the quality of birth attendance provided in health facilities may not be optimal) [33]. Initial analyses were conducted using SPSS 16.0. [34]. With HFBA as the dependent variable, initial tests of bivariable associations were conducted using the Pearson’s Chi-square for nominal or ordinal variables, student T-test and ANOVA for continuous variables, and Kruskal-Wallis-test or the Mann-Whitney U-test for continuous variables with non-normal distributions. Following these initial analyses, HFBA was dichotomized into high and low, with the median (.73) chosen as a cut-off point. After conducting unadjusted logistic regression analyses to identify significant associations, we ran a mixed-effects logit model [35] using Stata 11 [36]. This multivariable model accounted for clustering by site and included variables that were significantly associated with the HFBA score in bivariable analyses (p<.05), as well as other variables that have been shown to be important for childbirth decision-making in the literature. Specifically, we included socio-economic factors including age, educational level, and occupation, as these factors related to women’s empowerment have been shown to be important factors in decision-making regarding childbirth in Kenya and similar countries [3], [37]. These analyses were repeated with a continuous version of the HFBA variable (normally transformed) to examine the potential impact of dichotomization on our results. Similar analytic methods were used to examine the predictors of intended type of assistance during delivery, in that variables found to have statistically significant relationships with the outcome in bivariable analyses (p<.05) were included in the multivariable model (education, occupation, being in a polygamous relationship, HFBA, expectations to pay for transport or supplies, and anticipated stigma), as well as household television ownership as a measure of wealth and access to mass media [38]. Binomial regression was used to obtain estimates of risk ratios for the multivariable analyses, with adjustment for clustering by site. Finally, we conducted exploratory mediation analyses to examine if the effects of anticipated male partner HIV-related stigma on intended type of delivery might potentially operate through effects on HFBA. The conditions for mediation were met [39] as: 1) anticipated male partner stigma is significantly associated with HFBA, 2) HFBA independently predicts intended type of delivery assistance, and 3) the association of anticipated male partner stigma with intended type of birth assistance is reduced after adjustment for HFBA.

The recommendation to improve access to maternal health based on the study “How Perceptions of HIV-Related Stigma Affect Decision-Making Regarding Childbirth in Rural Kenya” is to implement HIV-related stigma reduction efforts. This can be achieved through innovative strategies such as community education and awareness campaigns, sensitization of healthcare providers, peer support groups, integration of HIV and maternal health services, engaging male partners, and addressing structural barriers.

These strategies aim to increase knowledge and understanding of HIV, promote acceptance and support for pregnant women living with HIV, ensure non-judgmental and supportive care from healthcare providers, provide emotional support and guidance through peer support groups, make HIV and maternal health services more accessible by integrating them, involve male partners in antenatal care and childbirth education programs, and address structural barriers that hinder facility-based childbirth.

By implementing these innovative strategies, it is expected that HIV-related stigma will be reduced, leading to more positive attitudes towards facility-based childbirth, increased skilled birth attendance, and reductions in maternal and infant mortality.
AI Innovations Description
The recommendation that can be developed into an innovation to improve access to maternal health based on the study “How Perceptions of HIV-Related Stigma Affect Decision-Making Regarding Childbirth in Rural Kenya” is to implement HIV-related stigma reduction efforts. The study found that pregnant women in rural Kenya who anticipated HIV-related stigma were less likely to have positive attitudes towards facility-based childbirth. Negative attitudes about facility-based childbirth were also associated with the intention to deliver outside a health facility. Therefore, reducing HIV-related stigma could lead to more positive attitudes towards facility-based childbirth, increased skilled birth attendance, and reductions in maternal and infant mortality.

To implement this recommendation, innovative strategies can be developed to address HIV-related stigma in the context of maternal health. These strategies may include:

1. Community education and awareness campaigns: Conducting educational programs to increase knowledge and understanding of HIV, debunking myths and misconceptions, and promoting acceptance and support for pregnant women living with HIV.

2. Sensitization of healthcare providers: Providing training and sensitization programs for healthcare providers to ensure they provide non-judgmental and supportive care to pregnant women living with HIV, reducing stigma within healthcare settings.

3. Peer support groups: Establishing peer support groups for pregnant women living with HIV, where they can share experiences, provide emotional support, and receive information and guidance on accessing maternal health services.

4. Integration of HIV and maternal health services: Ensuring that HIV testing, counseling, and treatment services are integrated into routine antenatal care, making it easier for pregnant women to access both HIV and maternal health services in one location.

5. Engaging male partners: Involving male partners in antenatal care and childbirth education programs, addressing their fears and concerns about HIV, and promoting their support for facility-based childbirth.

6. Addressing structural barriers: Identifying and addressing structural barriers such as transportation costs, availability of skilled healthcare providers, and facility infrastructure to make facility-based childbirth more accessible and acceptable for pregnant women.

By implementing these innovative strategies to reduce HIV-related stigma, access to maternal health services can be improved, leading to better health outcomes for pregnant women and their infants.
AI Innovations Methodology
To simulate the impact of the main recommendations of this abstract on improving access to maternal health, a methodology could be developed as follows:

1. Define the target population: Identify the specific population of pregnant women in rural Kenya who are at risk of experiencing HIV-related stigma and have negative attitudes towards facility-based childbirth.

2. Baseline data collection: Collect data on the current levels of HIV-related stigma, attitudes towards facility-based childbirth, and intentions to deliver outside a health facility among the target population. This can be done through surveys and interviews similar to the methods used in the original study.

3. Develop intervention strategies: Based on the recommendations outlined in the abstract, design and implement innovative strategies to reduce HIV-related stigma and improve access to maternal health services. These strategies should include community education and awareness campaigns, sensitization of healthcare providers, peer support groups, integration of HIV and maternal health services, engaging male partners, and addressing structural barriers.

4. Implement the interventions: Roll out the intervention strategies in the target population. This may involve training healthcare providers, conducting community education programs, establishing peer support groups, and integrating HIV and maternal health services.

5. Post-intervention data collection: After implementing the interventions, collect data on the changes in HIV-related stigma, attitudes towards facility-based childbirth, and intentions to deliver outside a health facility among the target population. This can be done through follow-up surveys and interviews.

6. Data analysis: Analyze the pre- and post-intervention data to assess the impact of the interventions on improving access to maternal health. Compare the baseline data with the post-intervention data to determine if there have been significant changes in HIV-related stigma, attitudes towards facility-based childbirth, and intentions to deliver outside a health facility.

7. Evaluate outcomes: Evaluate the outcomes of the interventions, including changes in attitudes towards facility-based childbirth, skilled birth attendance rates, and maternal and infant mortality rates. Assess the effectiveness of the interventions in achieving the desired improvements in access to maternal health.

8. Refine and scale-up: Based on the findings from the evaluation, refine the intervention strategies as needed and develop plans for scaling up the interventions to reach a larger population of pregnant women in rural Kenya.

By following this methodology, it would be possible to simulate the impact of the main recommendations outlined in the abstract on improving access to maternal health in rural Kenya. The data collected and analyzed would provide valuable insights into the effectiveness of the interventions and inform future efforts to reduce HIV-related stigma and improve maternal health outcomes.

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