Prevention of Mother-to-Child Transmission Coverage among HIV Positive Pregnant Women Accessing Antenatal Services in Ondo State, Nigeria

Introduction

Overtime, the health sector response to HIV/AIDS, prevention, treatment, care and support interventions have continued to expand guided by policies, strategic plans and guidelines [1]. Free HIV counselling and testing as well as Anti-retroviral therapy (ART) is also expanding with improved resource mobilisation and coordination [1]. Despite interventions, there is still a huge gap towards attaining the universal access [2]. This gap needs to be addressed because patients’ satisfaction with health care is an important health outcome which has implications for capacity utilisation. To enhance the utilization of the health services by people, it is most important that they should recognize the need for such services. This need will only be felt if they start to value health as a worthwhile asset [1].

Primary health care, which is supposed to be the bedrock of the country’s health care policy, is currently catering for less than 20% of the potential patients [3]. Although PHC was said to have made much progress in the 1980s, its goal of 90% coverage was probably excessively ambitious, especially in view of the economic strains of structural adjustment that permeated the Nigerian economy throughout the late 1980s [4].

ANC provides avenue to provide pregnant women with information, treat existing social and medical conditions and screen for risk factors. However it is not enough to receive ANC, since majority of the fatal complications occur during or shortly after delivery [5].

Pregnant women susceptibility to HIV and its consequent transmission to the foetus provide a unique opportunity for implementing preventive strategies against HIV infections of the new born babies. Most infant HIV infections could be averted if positive mothers have a high degree of awareness and knowledge about MTCT and the preventive strategies put in place to reduce the transmission during pregnancy and lactation [6].

PMTCT coverage is low in Nigeria despite being one of the countries with the highest burdens. Nigeria alone contributes 30% to the PMTCT gap - the difference between estimated number of HIV-positive pregnant women and those reached with antiretroviral prophylaxis for PMTCT [6]. The coverage of antenatal screening for HIV is 13% (UNICEF, 2010), a far cry from the UNGASS and national targets [7]. This low coverage is not unconnected with the concentration of services in secondary and tertiary level facilities which make up only 12.7% of health facilities offering maternity services in the country and provides access for a limited number of pregnant women [6, 7].

The target of c (PMTCT) is to stop children from being infected during pregnancy, labour or breastfeeding [8]. To achieve this, there is need for accessibility to take up a cascade of interventions like antenatal service, HIV counselling and testing (HCT) during pregnancy was positioned as a key strategy. In recognition of the lopsided distribution of PMTCT services and its resultant effect on coverage, the Government of Nigeria in 2010, started making plans to expand services to PHCs [4]. The commitment of the global community to accelerate the progression of preventing mother to child transmission of HIV virus further justifies the reason why no stone should be left unturned into research areas that will help to achieve such goals [9].

In Nigeria, effective PMTCT programmes is available free of charge and require by all HIV positive pregnant women to take up a cascade of interventions including antenatal services and HIV testing during pregnancy; use of antiretroviral treatment (ART) by pregnant women living with HIV; safe childbirth practices and appropriate infant feeding; uptake of infant HIV testing and other post-natal healthcare services [10].

Lack of adequate knowledge of mother to child transmission (MTCT) will continue to constitute a fundamental reason why mother to child transmission of HIV will be on the increase in our society [11, 12]. Utilization of health facilities are determined by many factors; maternal age, parity, income, standard of living of household, ANC user’s fees, and travel distance to antenatal care provider are common economic factors that have been cited by previous researchers [13].

According to study carried out in the Oromia region of Ethiopia, showed that challenges of the PMTCT program included human resource limitations, inadequate coordination between regional and local health services concerning new policies and guidelines, irregular supplies of laboratory test kits, stigmatization, inadequate counselling, Cultural barriers and ARVs [14, 15].

However despite concerted efforts to scale-up PMTCT services in Nigeria, the coverage and utilization of the service by pregnant women remain low and unevenly distributed. In spite of this, only a limited number of pregnant women actually use these services. The researcher is curious to find out why there was low PMTCT Utilisation despite government’s effort to increase access, factors influencing utilisation and possible interventions to increase access. This study was therefore designed to explore the factors affecting utilization of PMTCT intervention among HIV positive pregnant women attending ANCs at Comprehensive Health centres.

Discussion

There are nearly 1.72 million women and girls living with HIV in Nigeria and the prevalence continues to increase despite efforts by the Nigerian Ministry of Health [19]. Furthermore, 60,000 new HIV infections occurred among children, making Nigeria the country with the largest number of children acquiring HIV through mother-to- child transmission of HIV (MTCT) [20]. Although PMTCT interventions can be highly successful in reducing the risk of HIV transmission, access to and utilization of PMTCT services is still limited in many parts of sub-Saharan Africa owing to a variety of factors that facilitate or hinder PMTCT service uptake in Nigeria by extension in Ondo State.

If the national targets of ensuring that at least 90% of all pregnant women have access to voluntary counselling and testing, 80% of all HIV-exposed infants have access to early infant diagnosis services, 80% of all HIV-positive pregnant women and HIV-exposed infants have access to efficacious ARV’s and 80% of HIV-positive pregnant women have access to infant feeding counselling are to be met by 2015 [21].

The study was designed to investigate why pregnant women do not use PHCs for PMTCT services in some urban parts of Ondo State in Southern Nigeria. We based the study on the premise that PHCs offer the best opportunity for women in Nigeria to enter the health care system to receive the most optimal evidence-based access to skilled delivery care [22, 23].

The socio-demographic profile of the women showed that majority of the respondents were under 34 years old with the highest age range being 21-40 (79.3%; n=305); this is in line with the finding by Nnamdi Okagbue (2009) in a different study conducted in Anambra State of Nigeria where the highest age range were 25-29 years old accounted for 36.3% of the respondents [24]. This shows that less than 34 years is still a high risk age group according to this study and it means that this age group should be the target for campaigns against unsafe sex, the most common source of contracting HIV in Nigeria. Early marriage is predominant especially in the rural setting where they do not have the opportunity to attend higher education. Thus it is important that HIV/AIDS awareness should be directed to higher institutions (universities and polytechnics) where these age groups are found.

Of all the respondents, 85.2% (n=328) were married, this signifies that marriage is a factor especially where pre- marital HCT is not considered a priority. This is in keeping with Olanrewaju AM, et al. [25] where they find marital status (>80%) significantly associated with HIV status. This result is not out of place in an environment where pregnancy outside marriage is not acceptable. Still HIV testing before marriage should be encouraged so that those willing not to get pregnant upon knowing there status can have access to family planning method of their choice.

Of the respondents, 83.9% (n=323) had achieved secondary and tertiary education, this collaborates with the 2010 ANC sentinel survey (FMOH 2010) where 34% of the women had secondary education, closely followed by primary education (22.4%) with only 19% having higher education [26]. Katushabe J [27] reveals that majority of the respondents were within the range of higher primary and ordinary Level. Some 43.4% (n=167) were self-employed, 22.9% (n=88), house wife 15.1% (n=58) and trader, 12.2% (n=47).Though majority of the respondents had secondary and tertiary education, only few (43.4%) are in one form of employment or another. This supports Nnamdi Okagbue where 31.4% were housewives, while 19.6% were either students or unemployed 25% were traders, and 23.5% were in permanent employment Shangula MN [28] in his study reveals that majority of the mothers are unemployed (80%) with only 20% employed.

In the study 84.7% among pregnant women screened for HIV were aware MTCT was possible through breastfeeding by lactating mothers, during delivery and pregnancy while 77.4% were aware that the risk of MTCT can be reduced through the use of readily available drug(anti-retroviral), this in keeping with Asefa A, et al. [29] reveals that only 60.7% of all interviewed pregnant women who were aware of HIV/AIDS transmission knew about the risk of MTCT [29]. The possibility of MTCT during pregnancy, delivery and breastfeeding was known by 48.4%, 58.6% and 40.7% of the respondents, respectively.

Third-fifths of the respondents heard about HIV/AIDS from either the health workers or the radio, with others source of information less than 10% about HIV/AIDS. The two most important sources of information about HIV/ AIDS in this research were through health workers and radio. This is related to the outcome of a 2006 study which reported electronic media as the main source of information on HIV/AIDS [30]. This is lesser than the study conducted by Artwinne et al in Uganda where information regarding HIV and PMTCT was 69.66% from health workers, 32.58% from the mass media and 9% from schools [31]. Exposure to mass media was generated with frequency of listening to radio, watching television and health care workers were identified as key sources of information regarding HIV and PMTCT.

After scoring of outcome variables for knowledge about HIV/AIDS/MTCT, PMTCT and PMTCT utilization, more than half of respondents, 72.2%, 67.5% and 60.3% respectively had good comprehensive knowledge about HIV/AIDS/MTCT, PMTCT and PMTCT utilization. This is much higher than the reported regional (South-west) and national values of 26.5% and 23.4% respectively for women of reproductive age [32]. The present study, therefore, lends credence to previous evidence showing better ANC/PMTCT utilization in South- West region in the country [33, 34]. Also, the percentage average score of 72.2%, which translated to average knowledge about HIV/AIDS, varies from the 2012 Indian research that reported 63.2% having good knowledge score [35]. This may not be unconnected with the high literacy level of the respondents with about 83.9% of mothers in our study having post primary school education. Thus, Education is the key to mother’s survival and enables a woman to know what to do in determining illness, health condition and making child bearing safer.

Concerning taking permission from spouse before doing HCT, 27.3% (n=105) of the respondent stated that they need permission while 72.7% (n = 280) responded they do not. This contradicts Okonkwo KC, et al. [35] where 82.9% responded they did not need permission to undergo testing while 17.1% answered they did needed permission.35 Our result is consistent with Nnamdi-Okagbue findings that showed only 33% of respondents’ needed husband permission while 65% does not need husband’s permission.24 Culture can influence access through inherent inequalities in the social system. Gender also affects access, pushing women into gender specific roles that negatively influence their health or force to seek permission to obtain healthcare. This shows the dominance of men over their spouses. This is where couple counselling plays a vital role in uniting the family.

On the issue of disclosure, 43.4% (n = 167) disclosed their result while 56.6% (n = 218) did not. Many were of afraid of abandonment or divorced and some were afraid of being separated from their children and thrown out of home. This can be related to the previous question on permission. The situation can degenerate to physically violated or abused in the family especially for discordant couples where accusations and counter-accusations will manifest. Also 74.8% of women that practise Christian religion disclosed their results to their spouse. This contradicts Okonkwo KC, et al. [35] where 69.2% of their respondents responded that they would be discriminated against socially and/or culturally if they tested HIV positive. According to Talam NC, et al. [36], they identified stigma (28.9%) as one of the factors affecting adherence to treatment with ARVs [36]. According to health service utilisation, stigma, fear and disclosure are some of the identified socio-economic factors influencing PMTCT utilisation.

The socio-demographic variables found to be significantly associated with utilization of PMTCT services were the practiced religions of the women for spouse permission to uptake HCT (OR 3.7, 95% CI: 2.3-6.1, P=0.00) and for disclosure of result to their partners (OR 1.5, 95% CI: 0.9-2.3, P=0.01) which is different from the study of Okonofua NL, et al. [37] in Nigeria.

Also Dairo MD, et al. [38] conducted a study in Ibadan Nigeria to determine the factors affecting the utilization of ANC/PMTCT services in Ibadan, Nigeria. Women who were Muslims or other religions were more than 2 times likely to attend ANC clinic than women who were Christians [(OR=2.398, 95%CI, 1.264-4.557) [38]. The variations might be due to the difference in methodologies. Effort towards ensuring the utilization of PMTCT should be targeted towards ANC, the importance of maternal care should be emphasized even in the religious settings among reproductive age.

Conclusion

Evidence from this study suggests two significant findings. First is that infants to be born to HIV-positive mothers are more likely to become HIV-positive if they have a mother who has failed to disclose her HIV-positive status, and second is that the socio-demographic profile of the study suggests an important relationship between women taking permission from the spouse to uptake HCT and disclosure of HCT results to their spouse. It was revealed that religion is the predictor of accessing and utilizing PMTCT intervention in this study. Women who practice Islamic as a religion recorded lower chances of utilizing the services. The positive influence on utilization of health service acceptability may be responsible for higher utilization of PMTCT intervention among those who practice Christianity as a religion. Given the important role played by socio-economic factors in PMTCT, stakeholders need to re-examine policies on disclosure and male partner involvement with a view to addressing behavioural contributors to MTCT. The success of PMTCT of HIV depends on identifying and integrating effective methods through ANC to address safe disclosure, closing gaps in geographical coverage, accessing and utilization of the services. Efforts devoted toward addressing these factors can be achieved using innovative approaches like increasing pregnancy care services and PMTCT utilization in PHCs to reduce child transmission and maternal mortality.