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Where do women who deliver at home fall through the cracks in the PMTCT Continuum of Care?

Where do women who deliver at home fall through the cracks in the PMTCT Continuum of Care? Descriptive evidence from Zimbabwe. Karen A Webb 1 , D Patel 1 , G Mujaranji 1 , B Engelsmann 1 1 Organisation for Public Health Interventions and Development (OPHID) Trust, Harare, Zimbabwe

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Where do women who deliver at home fall through the cracks in the PMTCT Continuum of Care?

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  1. Where do women who deliver at home fall through the cracks in the PMTCT Continuum of Care? Descriptive evidence from Zimbabwe Karen A Webb1, D Patel1, G Mujaranji1, B Engelsmann1 1Organisation for Public Health Interventions and Development (OPHID) Trust, Harare, Zimbabwe International AIDS Conference 2012 Session: Challenges in Scaling Up PMTCT

  2. Background: Home delivery limits maternal and newborn health and PMTCT programmes Internationally • 60 million non-facility births each year worldwide • Results in preventable maternal and infant morbidity and mortality • Limits PMTCT programme coverage • Non-adherence to ARVs to prevent vertical transmission Zimbabwe • Adult HIV prevalence 15%; Women 15-49 18% • Increasing trend of home deliveries Percentage national home delivery in Zimbabwe 1999-2010 1 in 3 women in Zimbabwe deliver at home

  3. Objective: Describe the process of home delivery and services received by mothers ante, periand postpartum to identify gaps in the PMTCT Continuum of Care and generate recommendations for intervention.

  4. Methods: Descriptive, retrospective study of mothers who delivered at home in the previous 12 months in Mashonaland Central Province Methods 355 womenwho delivered at home from catchment of 12 health facilities Mixed-method sampling: Systematic selection: facility registers of home births Purposive sampling: community level chain-referral Household-level interviews using pilot-tested, structured questionnaire Data entered using EpiInfo V3.5.1 and descriptive analysis conducted using SPSS for Windows V16.0

  5. Results: Women who delivered at home shared characteristics with the most vulnerable and isolated Rural - 81% Young - mean age 26 Limited education - Primary highest for 60% Apostolic (60.5%) or Traditional Religious Beliefs (18.9%) Resource constrained - 10.4% women, 28.4% partners formally employed Trend between increased parity and home delivery - even though 89% said home delivery unplanned Limited social support - 96% children in the household, few stay with partners

  6. Results: ANC attendance rates improving but uptake is too late and # of visits not optimal 2 3 1 80.2% booked for ANC 78% HIV tested in pregnancy, 89.8% of whom booked for ANC However… ANC uptake late - 20+ weeks for 57.2% of women Only 24.2% attended 4+ ANC appointments

  7. Results: There is more than meets the eye regarding the reasons why women deliver at home. 1 2 3 Percentage grouped number one reasons for home delivery • Fees still greatest barrier in areas with free maternity services • Unskilled Birth Attendant costs approximate or exceed clinic fees • High ANC uptake –with adequate planning, transport for service uptake possible

  8. Results: High rates of postnatal care for babies, but uptake is not prompt. 2 1 3 Time after birth post natal care for child accessed 88.2% babies taken for post-natal check-ups – only 37.5% within 72 hours after birth 63% 18/20 HIV+ mothers brought in babies within 72 hours

  9. Results: The picture of postnatal care and services for mothers following home delivery is poor. 2 1 3 Significantly fewer mothers accessed postnatal care for themselves (64%) than for their babies (p< 0.0001 Pearson’s Chi-square) Only 30% reported receiving post-natal counselling

  10. Results: ‘Zero uptake’ group emerged that failed to access services at critical stages along the continuum Cascade of Zero Uptake of PMTCT Continuum of Care Services No ANC Big jump from non facility birth to next level Compounded Zero Uptake No ANC, HIV test No ANC, HIV test, PNC Mother How do we find and support these increasingly invisible women?

  11. Summary: There is good news and bad news about uptake along the PMTCT continuum of care for mothers who deliver at home. ANC uptake and postnatal care for babies >80% 1 2 3 Low PNC and counselling for mothers 0 facility based delivery <38% babies received PPC <20% before 14 weeks 24% 4+ ANC Zero Uptake group dropping off at each stage of continuum…

  12. Antenatal Services • 20% Discussion: What are we going to do about the chasm of skilled attendance at birth? • Postpartum / • Postnatal Services • 40% • Intrapartum Services • 40% Late Uptake Reduced PMTCT programme coverage Non adherence to ARVs Postnatal care not Prompt Low postnatal counselling = knowledge and feeding practices Non adherence to ARVs Preventable infections and complications for mothers and babies – including vertical transmission

  13. Conclusion Identify and fill the cracks in the continuum: Early uptake, retention Reduce home delivery rates: priority area for unlocking coverage/adherence required for achieving virtual elimination of new paediatric infections Know Your Zero Uptakes for targeted and evidence-based outreach and intervention Health systems interventions: fees, distance Community-based interventions: demand generation, MNCH gatekeepers, supportive community environment for uptake and retention across the continuum

  14. THANK YOU – TATENDA – SIYABONGA

  15. Strengths and Limitations No conflicts of interest Mixed method sampling provided access to ‘unregistered’ home births and identification of zero uptakes Recall bias Friendship/proximity biases Possible social desirability bias to explain discrepancies in data Generalizability

  16. Skilled Attendance or Skilled Attendants at Delivery? Skilled birth attendant coverage least equitable MNCH intervention in 54 country retrospective review (Barros et al, 2012) Best Case: “Skilled Attendance” Delivery with skilled attendant at facility Quality maternity services – ensure facility birth = skilled attendance EmONC Preventable infections and complications beyond HIV Supervised/supported PMTCT program adherence *Multi-level action and infrastructural health system and community-based support. Skilled Attendant: Striking balance between optimal public health and reality Working with TBAs Strengthening community-facility linkages Birth-packs for HIV positive women, including prophylaxis for home use Innovations: packaging (ARV pouch) and engagement strategies. *Targeted interventions building on existing capacities

  17. Home Delivery Study Sampling Methodology: Example of Process

  18. Women who delivered at home PMTCT programme progression 78% tested for HIV (n=277) 7% of those tested self-reported being HIV positive (n=20) Of positives, 15/17 (83%) enrolled in PMTCT programme 100% reported receiving ARVs to prevent vertical transmission Regimens reportedly received regimens behind current recommendations for both mothers and children

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