CHAPTER of death where HIV-related mortality rates


2.0       Sources of Literature

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Most of the literature regarding this study
was accessed via electronic means and multiple search engines were employed.
These include Pubmed, HINARI, Google Scholar and African Journals on Line

2.1       Introduction


Zimbabwe adopted and is
implementing the Sustainable Development Goal 3 to ensure healthy lives and
promote healthy lives for all at all age groups. Specific targets include
reducing maternal mortality rate to less than 70 deaths per 100000 live births,
ending preventable deaths of newborns and ending AIDS epidemics by 2030 (WHO,
2017). Achieving these goals could be a major challenge if efforts are not made
to fight HIV and AIDS (Sachs & McArthur,
HIV/AIDS is a leading cause of death where HIV-related mortality rates are high
(Ronsmans, et al., 2003). In the absence of
HIV, there could have been 281?500 (243?900–327?900) maternal deaths worldwide
in 2008 (Hogan MC et al, 2010). However, with HIV related maternal mortality
included, an estimate of 342?900 (uncertainty interval 302?100–394?300)
maternal deaths occurred worldwide in 2008.

Sub-Sahara Africa remains the most affected
region where more than two-thirds (68%) of HIV-infected people live with
females constituting 61% of those infected (UNAIDS,
2007). Thus; high levels of maternal mortality co-exist with high levels
of HIV prevalence among women of childbearing age (Graham & Hussein, 2003). There are important
disparities with respect to access to health care for women. In the poorest 20%
of households in most developing countries, more than 90% of deliveries take
place at home (Gwatkin, 2004).
Subsequently, each year more than 60 million women worldwide give birth without
the assistance of skilled care (Knippenberg,
et al., 2013).

With such high maternal mortality rates in
resource-poor settings, priority interventions through the ‘Safe Motherhood
Initiative’ have been proposed and implemented. This public health strategy
emphasises safe delivery through the provision of skilled birth attendants,
improved basic obstetric services in health facilities, development of prenatal
care, and access to emergency obstetric care in hospitals, and family planning
as key interventions to reduce neonatal and maternal mortality (Graham &
Hussein, 2003).
It is now 20 years since the Safe Motherhood initiative was launched and little
progress has been reported (Smith & Rodriguez,


The regions of Sub-Saharan Africa, western
Asia and south Asia have shown little progress in terms of reduction of
maternal mortality (Hussein, et al., 2009). The stated reasons
for this have included: absence of a clear focus, strategic errors such as
focusing only on mother’s risk of complications through screening at antenatal
consultations, and an over reliance on traditional birth attendants (TBAs)  (Ronsmans,
et al., 2003).


Skilled attendance at birth is a key
indicator for measuring progress towards improved women’s health. Available
data from developing countries show an important increase in skilled attendance
at birth: from 45% to 54% between 1990 and 2000, except for the sub-Saharan
Africa region, where coverage has stagnated at approximately 40% (Perez, et al., 2008). Additionally, a
recent report confirms that world-wide, for the year 2007, an estimated 63% of
all births were attended by a skilled health-care worker with considerable
variations between developed regions (99%) as compared to developing countries
(59%)  .


Recent data shows that, in low-and
middle-income countries, the proportion of HIV-positive pregnant women
receiving antiretroviral prophylaxis for PMTCT in 2006 was 23% (UNAIDS/UNICEF/WHO, 2008). Globally, PMTCT
coverage is far below what is required to meet the United Nations target of
reducing the proportion of children infected with HIV by 50% in 2010  (UNAIDS, 2001).
The attainment of these figures will need that 80% of all pregnant women
accessing antenatal care receive services for PMTCT of HIV (du Plessis, et al.,
This will require strengthening of maternal and child health services as well
as the health systems and the development of new interventions to improve the
uptake of PMTCT services.


Antenatal care as well as deliveries in an
institutional setting with skilled health workers for all women remains a
distant reality. In resource-poor countries, between 60% and 90% of deliveries
in rural areas are assisted by TBAs (Choguya,
Preference for home births is associated with cultural norms and religious
beliefs. TBAs speak the local language, have the trust of community members and
can provide psychosocial support at birth.


Public health programmes are seeking to
enhance the role of TBAs by encouraging their participation in PMTCT programmes
(Wanyu, et al., 2007). Given the potential
 coverage of the underserved population,
participation of TBAs has been piloted to help improve the coverage and quality
of services offered to rural populations; their participation being defined by
a package of activities that they are allowed to perform.


Zimbabwe has one of the greatest HIV burdens
in the world with an average antenatal HIV prevalence rate of 15.6% (Zimbabwe Ministry Of Health, 2014). Prevention of
mother-to-child transmission of HIV (PMTCT) is among the key HIV prevention
strategies in the country’s national HIV/AIDS response. In spite of the
important efforts and the rapid expansion of the national PMTCT programme,
uptake of PMTCT remains suboptimal. Certain steps of the intervention cascade
need to be substantially improved to increase the coverage of services
particularly in the later stages of the intervention.


In 2006, 19 578 pregnant women were
identified nationwide as HIV-infected, of whom 60% received some form of
antiretroviral (ARV) prophylaxis to prevent transmission of the virus to their
babies. This translated to approximately 30% coverage of the total number of
HIV positive pregnant women in need (Zimbabwe Ministry Of Health, 2014). Limited ANC
services with an increase in home deliveries is not only reducing access to a
skilled practitioner through maternal services but also restricts the
opportunities to provide PMTCT services in a context of an accelerated economic
crisis especially in rural areas.


2.2       Definitions

2.2.1    Human
Immunodeficiency Virus infection (HIV)

This is infection with the virus
(retrovirus) which causes AIDS leading to depression of the immune system
allowing life-threatening opportunistic infections and cancers to thrive.

2.2.2    Antenatal
Care (ANC)

ANC is the care a woman receives from
skilled attendants during pregnancy; it involves monitoring the woman and the
unborn child. ANC requires essential interventions which include identifying
and managing potential obstetric complications such as pre-eclampsia, tetanus
toxoid immunization, intermittent preventive treatment for malaria during
pregnancy (IPTp). It also entails prevention and management of infections
including HIV, syphilis and other sexually transmitted infections (STIs) (WHO, 2006)


2.2.3    ANC
Standard (adequate ANC)


It is required that every pregnant woman has
at least 4 ANC assessments by a skilled attendant or under the supervision of such
an attendant. The visits should entail as a minimum all the interventions
outlined in the WHO antenatal care model and this should commence as early as
possible in the first trimester (WHO, 2007).


2.2.4    Mother-to-Child
Transmission (MTCT) of HIV

Is a situation where an HIV positive woman
can transmit the virus to her child during pregnancy, labour and delivery, and
during breast-feeding. It has been found that the risk of an HIV positive
mother transmitting the infection to her baby is 20-45% in the absence of
intervention, the rate during pregnancy may be 5-10%, at labour and delivery
10-20% and 5-20 % during breast feeding (De Cock, et al., 2000)


2.2.5    Risk
factors for Mother-to-child transmission


There are several factors affecting the rate
of mother-to-child transmission. These have been grouped as: viral factors,
maternal factors, obstetric factors, foetal and breast feeding factors (MoH, Zimbabwe, 2010) Viral factors
include: high maternal viral load and viral characteristics; Maternal factors
include: advanced disease from HIV to AIDS, HIV infection acquired during
pregnancy or breast feeding, STIs; Obstetric factors include: Vaginal delivery,
rupture of membranes for more than 4 hours and prolonged labour; Foetal
factors: pre-maturity; Breast feeding factors comprise of: mixed feeding,
breast infections like mastitis, breast abscess, cracked nipples and prolonged
breast feeding (MoH, Zimbabwe, 2010).  



2.2.6    Prevention
of Mother-to-Child Transmission (PMTCT)

It has been recommended that to reduce the
rate of MTCT of HIV, several interventions which involve the use of ARVs either
as prophylaxis to the pregnant mother or as therapy during pregnancy, labour
and breast feeding should be in place. If the mother is not on ARVs during the
period she is breast feeding, the baby should be given ARVs as prophylaxis
throughout this period until one week after weaning. If breast feeding is not
possible, infant formula is an alternative. Obstetric procedures such as early
artificial rupturing of membranes, instrument aided deliveries, episiotomy
should be avoided, rather elective caesarian section should be considered. These
are the strategies employed by the PMTCT program which is a global intervention
initiated by the United Nations (UN) (United Nations, June 2002).


2.3       Conceptual Framework of Study

Access to ANC and PMTCT (healthcare) Access
to healthcare in general including ANC has a number of dimensions which include
but are not limited to: accessibility (geographical access), acceptability,
availability, affordability and adequacy. Access to healthcare is a
relationship between community (user) factors and health facility factors, and
has been defined as the opportunity or freedom to make use of health services
when the need for care is perceived. Access cab also be viewed as a determinant
which allows people to take the steps that enable them to come in contact with
and obtain health care. Information is very crucial to accessing healthcare (Thiede & McIntyre, 2008), thus the quality of
information and the manner in which this information is relayed to users is of
utmost importance in influencing access to services. In order to achieve good
access, a fit should exist between demand and supply of services.

Accessibility: This includes geographic accessibility
like the physical distance between health facilities and those that require the
services, nature of transportation and the time it takes to get to the point
where services are rendered (Peters, et al., 2008)

While, acceptability involves social and
cultural factors that determine the possibility of people accepting services.
However, acceptability does not directly result in utilization of services.
Awareness of the availability of services is important and the decision to
utilize is determined by the quality of information received from the health
providers (Thiede & McIntyre, 2008).

Availability of health care encompasses all
the factors that relate to the actual existence of a particular service within
the reach of the user, it also involves aspects of user friendliness which is
closely related to adequacy (the quality of services delivered). From a user
point of view, if services are available, the next question that comes to mind
is: are the services affordable?

Affordability refers to the direct and
indirect costs of healthcare in relation to the ability of the user to pay for services.



3.0       Introduction

Materials and methods for
conducting the study are highlighted in this chapter. These include the study
design, sampling techniques, data collection procedures and analysis.


3.1       Study design

A descriptive cross sectional study was
conducted in Chegutu district.


3.2       Study

In this study, the population were the TBAs
both trained and untrained in Chegutu Hospital- affiliated health center
catchment areas. The research findings were generalised to this study
population. The study population comprised of all women in their reproductive
age with one woman as the study unit.


3.3       Study setting

The study was conducted in communities and
health facilities of Chegutu district.


3.4       Inclusion
criteria and exclusion criteria


3.4.1    Inclusion

Any married woman who
has delivered another woman in labour either at the client’s home or in their
own homes within the last six months.

Any woman who has their
own biological children with good reputation, and has been selected to train as
a TBA by her community and aged 18 years old or more.

Any trained TBA in
Chegutu district.

Any woman who has been
elected by the community members and has served the community.


3.4.2    Exclusion

Participants who were
be absent during the study period.

Any woman who was
single and had no child of their own at the time of the survey.

Any woman under the age
18 years.

Any woman who had never
delivered another woman at home in the six months preceding the study.

3.5       Key informants


These included Chegutu
District Medical Officer and Community Health Nurse


3.6       Permission to
proceed and Ethical considerations


3.6.1    Permission to proceed


Permission to conduct the
study was obtained from the District Medical Officer and Administrator.


 3.6.2   Ethical considerations

Written informed consent
was sought from each study participant. The aim of the study was explained and
the participants were informed that
they would be free to withdraw at any time during the interview.

Confidentiality was assured by informing the participants that the
results of the study would not refer to individual study participants. No
incentives were given to study participants for participating or as a way to
motivate them to participate.


Ethical approval was be
sought from the Research Ethics Committee of the University 0f Lusaka and
Medical Research Council of Zimbabwe.


3.7       Sample size

Formula for cross-sectional studies (Lwanga & Lemeshow, 1991)


n = Z?²pq



Where q =1- p

n = Minimum sample size desired

Z = Standard normal deviate at 95%
confidence levels 1.96

P = 89% (general ANC utilization in the
Zimbabwe Population) ( ZIMSTAT & ICF International 2012)

d = desired absolute precision 5% (0.05)


Therefore 1.96 × 89% × (1? 89%) =  


n =  

Adjusting for 10% nr

Where nr = non response rate 10 X (Minimum sample size



Therefore (Minimum sample size desired +
10%) =

Purposive sampling was done for the TBAs,
all identified TBAs consenting to participate in the study included.

A minimum sample of 30 participants were selected
to participate in the study.


3.8       Sampling


Two questionnaires
were designed to collect qualitative and quantitative data: one for women
(pregnant or who had delivered during the last year) and one for TBAs, both of
which were pre-tested in a nearby district (Kadoma district) to translate the
tool from English to Shona and refine and validate the questionnaire. For the
questionnaire on women, information was systematically collected on
socio-demographic variables, health seeking behaviours for the last pregnancy,
knowledge on HIV/AIDS and perceptions concerning the participation of TBAs in
PMTCT services. The questionnaire for TBAs included data on socio-demographic
variables, their background and the trainings they have received, their scope
of activities as a TBA, their knowledge, attitude and practice with regards to
HIV/AIDS, and their willingness to participate in the PMTCT program.


3.8.1    Health Facilities


Two health facilities were randomly selected
into the study from the district of Chegutu.


3.8.2    Primary participants


Health workers and TBAs were be selected
through stratified random sampling.


3.8.3    Key informants

Key informants were purposively selected for
the study


3.9       Data


3.9.1    Primary participants


Interviewer administered questionnaires were
used to collect data.


3.10     Pretesting of
data collection tools

Pretesting of the questionnaires was done to
ensure reliability and validity. The questionnaires were pretested in Kadoma


3.11     Key Informants

An interview guide for key informants was
used to elicit information on the role of TBAs in PMTCT


3.12     Data Collection
and Analysis

The questionnaires were
administered to the women and TBAs in the community using selected interviewers
who were student nurses in their final year of training. Four interviewers were
recruited and a one-day training session was conducted on interview and
sampling techniques, selection criteria of the women and TBAs and content and
application of the questionnaires. During this training session, the questionnaires
were also translated into vernacular language.

The completed
questionnaires were verified by the supervisor and data was entered into a
specifically designed database throughout the survey. Prior to analysis,
missing data was checked against the survey forms.

The questionnaire was created in Epi infoTM
for data analysis. Quantitative and categorical
data was entered and analyzed in Epi InfoTM
(3.5.4), which was also used to generate frequencies, means and proportions.