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 2012Session: Challenges in Scaling Up PMTCT

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 transmissionZimbabwe• Adult HIV prevalence 15%; Women 15-49

18%• Increasing trend of home deliveries

Percentage national home delivery in Zimbabwe 1999-2010

Background: Home delivery limits maternal and newborn health and PMTCT programmes

1999 (ZDHS)

2005 -2006

(ZDHS)

2009 (MIMS)

2010 -2011

(ZDHS)

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

23%

31%

39%35%

1 in 3 women in Zimbabwe deliver at home

Objective: Describe the process of home delivery and services received by mothers ante, peri and postpartum

to identify gaps in the PMTCT Continuum of Care and generate recommendations for intervention.

MethodsMethods: Descriptive, retrospective study of mothers who delivered at home in the previous 12 months in Mashonaland

Central Province

• 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 Epi Info V3.5.1 and descriptive analysis conducted using SPSS for Windows V16.0

• 355 women who delivered at home from catchment of 12 health facilities

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

Results: ANC attendance rates improving but uptake is too late and # of visits not optimal

Antenatal Services Intrapartum Services

Postpartum /Postnatal Services

1 2 3

• 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

Results: There is more than meets the eye regarding the reasons why women deliver at

home.

41.1%

43.7%

7.9%7.3%Knowledge

All Other

Fees

Proximity

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

Antenatal Services Intrapartum Services

Postpartum /Postnatal Services

1 2 3

Results: High rates of postnatal care for babies, but uptake is not prompt.

Antenatal Services Intrapartum Services

Postpartum /Postnatal Services

• 88.2% babies taken for post-natal check-ups – only 37.5% within 72 hours after birth

321

within 24 hours

1-3 days 4-10 days 2-6 weeks 6 weeks + no post natal care

0%

5%

10%

15%

20%

25%

30%

11%

26% 25%

18%

9%11%

• 18/20 HIV+ mothers brought in babies within 72 hours

Time after birth post natal care for child accessed

63%

Results: The picture of postnatal care and services for mothers following home delivery is

poor.Antenatal Services Intrapartum

ServicesPostpartum /

Postnatal Services

321

• 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

Results: ‘Zero uptake’ group emerged that failed to access services at critical stages along the

continuum

Series1

4.2%

8.4%

13.2%

19.8%

100%

Increasin

gly invisib

le

Lost

Non Facility Birth

Zero UptakeHow do we find and support these increasingly invisible women?

No ANC

No ANC, HIV test

No ANC, HIV test, PNC Mother

Com

poun

ded

Zero

Upt

ake

Cascade of Zero Uptake of PMTCT Continuum of Care Services

Big jump from non facility birth to next level

Summary: There is good news and bad news about uptake along the PMTCT continuum of

care for mothers who deliver at home.

Antenatal Services Intrapartum Services

Postpartum /Postnatal Services

321

0 facility based delivery

ANC uptake and postnatal care for babies >80%

Zero Uptake group dropping off at each stage of continuum…

<20% before 14 weeks

24% 4+ ANC <38% babies received PPC

Low PNC and counselling for mothers

Discussion: What are we going to do about the chasm of skilled attendance at birth?

Antenatal Services20%

Postpartum /Postnatal Services

40%

Intrapartum Services

40%

Preventable infections and complications for mothers and babies – including vertical transmission

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

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

THANK YOU – TATENDA – SIYABONGA

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

Skilled Attendance or Skilled Attendants at Delivery?

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

Skilled birth attendant coverage least equitable MNCH intervention in 54 country retrospective review (Barros et al, 2012)

Home Delivery Study Sampling Methodology: Example of Process

Women who delivered at homePMTCT 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