Article Text
Abstract
Objectives: To explore whether private midwives can perform HIV counselling and testing, provide antiretroviral treatment and contraceptives, and how this affects access to services especially among young and HIV-positive women.
Methods: A formative study was conducted between January and April 2009 to assess care-seeking practices and perceptions on the prevention of mother-to-child transmission (PMTCT) and family planning services in Wakiso district, central Uganda. A household survey supplemented by 12 focus group discussions and 66 key informant interviews was carried out between January and April 2009.
Results: 10 706 women, mean age 25.8 years (14–49 years) were interviewed. The majority of women, 4786 (57%) were in the lowest wealth quintile; 62.0% were not using family planning (p<0.000); 56.2% did not access HIV counselling and testing because they feared knowing their HIV status (p<0.013), while 66.5% feared spouses knowing their HIV status (p<0.013). Access to these services among the young women and those with no education was also poor. Private midwives provide HIV testing to 7.8% of their clients; 5.9% received antiretroviral drugs and 8.6% received contraceptives. Client satisfaction with services at private midwifery practices was high. Private midwives are trusted and many clients confide in them. An intervention through private midwives was perceived to improve access because of short distances and no transport costs. Adolescents prioritised confidentiality, while subsidising costs, community sensitisation and focusing on male spouses were overwhelmingly recommended.
Conclusions: Private midwives clinics are potential delivery outlets for PMTCT in Uganda. A well-designed intervention linking them to the public sector and the community could increase access to services.
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It is currently estimated that 20% of HIV transmission in Uganda is due to mother-to-child transmission.1 Implementation of the prevention of mother-to-child transmission (PMTCT) and other interventions to mitigate the effects of the HIV/AIDS epidemic have resulted in a high proportion of women (63%) who know that HIV can be transmitted from a mother to a child, and 65% of women who know that there is a drug that can reduce the risk of transmitting HIV to the infant.2 3 4 Despite this awareness, only 28% of pregnant women in Uganda receive HIV counselling during antenatal care (ANC) and only 6% are offered an HIV test.5 Poor access is attributed to the fact that only 29% of health facilities offer HIV testing services; 28% provide any of the components of PMTCT services and just 15% provide a full package as described in the policy.6
Utilisation of PMTCT services is partly influenced by access to essential maternity services such as ANC, delivery and postnatal care. Although 94% of pregnant women in Uganda attend ANC at least once during pregnancy, only 42% of pregnant women deliver at health facilities and 26% attend postnatal care.3 This limits access to PMTCT services. Several studies have shown that stigma, fear of receiving a positive result, lack of confidentiality, long distances to voluntary counselling and testing (VCT) sites and delays in returning HIV test results are constraints to accessing PMTCT.7 8 9 10 Based on these observations, it has been recommended that alternative delivery models for VCT such as VCT mobile clinics, home-based VCT and the private health sector be implemented to increase access to and uptake of VCT.9 10
In order to address poor access and utilisation of PMTCT services, an intervention has been proposed with the main objective of examining the feasibility of involving the private health sector to provide HIV testing and antiretroviral drugs to pregnant women in Wakiso district, Uganda. The intervention study was structured into three phases. The first phase was a formative study; the second phase is an intervention that aims at training private midwives to offer PMTCT, family planning services through a voucher scheme that enables the poor to access the services; while the third phase is an evaluation process that involves cost-effective analyses of the interventions. This article presents the results from the first phase of the study that specifically assessed the feasibility of increasing access to PMTCT services through the private health sector in Uganda.
The delivery of PMTCT services through this outlet was explored because access to HIV prevention and PMTCT services in the public sector is low, yet HIV/AIDS is one of the leading causes of morbidity and mortality among pregnant women and children in Uganda.11 Recent reports have shown that 6.5% of Ugandan adults are infected with HIV and women have higher rates. Women in the age group 30–34 years have the highest prevalence of HIV among all age groups.5
Methods
Study area and population
The formative study was conducted in Wakiso district in central Uganda. The district has an area covering 2807 sq km, bordered by Lake Victoria in the south, Mpigi and Mubende districts in the west, Luwero district in the north, and Mukono district in the east. Although the district is on the outskirts of Kampala, the capital city, most people (92%) live in rural areas.12 The total population of the district is 1 158 200, with an annual population growth rate of 4.1%. Wakiso district is inhabited by the Baganda, an indigenous ethnic group whose main occupation is subsistence farming. The district was selected to implement the study because it has one of the highest HIV prevalence rates at 8%.5
Design for the formative study
The formative study was conducted between January and April 2009 in parishes excluding those selected for the intervention study. A single-stage cluster sampling design was used in which parishes constituted clusters. The list of all parishes in Wakiso district was obtained from Uganda Bureau of Statistics. All households in the selected parishes were enumerated. A household survey was conducted targeting all households in 11 randomly selected parishes to collect data on the household characteristics, sociodemographic characteristics and health-seeking practices for family planning, HIV/AIDS and other essential health services. These data were supplemented by focus group discussions (FGD) and key informant interviews (KII). KII targeted civic leaders, HIV-positive women, local council officials, private midwives, midwives in public facilities, teachers, pregnant and non-pregnant women. FGD targeted pregnant women aged 20–49 years, non-pregnant women aged 20–49 years, men aged 20–55 years and adolescents aged 15–20 years. Participants for the FGD and KII were selected with the help of local council officials. The local council officials were instrumental in introducing interviewers to the communities for the household survey. Another survey was conducted to assess the availability of policies that support PMTCT and family planning. The assessment was made in 26 randomly selected private midwives clinics drawn from a list of all registered private midwives clinics in the study area.
Data collection
Two structured questionnaires were developed with one designed to capture household characteristics and the other to capture individual women’s health-seeking practices. The surveys were carried out by research assistants who had completed an advanced level of education; they were trained for one week including classroom lectures on interviewing techniques, role-plays and field work to familiarise them with the tools. The questionnaire for women was administered by female research assistants to avoid situations in which, due to cultural considerations, women do not feel comfortable to discuss sexual and health issues with men.
FGD and KII guides were designed to capture data on the following themes: the burden of disease, health-seeking practices for maternity services, PMTCT, family planning and exploring access and barriers to these services. The feasibility of private midwives delivering family planning and PMTCT was explored. The study tools were pre-tested and revised before the actual field work. FGD were conducted by two female research assistants who are social scientists with experience in conducting qualitative research. All participants spoke Luganda, the local dialect. FGD were conducted in a free and quiet environment with approximately seven to 10 participants each. FGD were tape-recorded with permission from the participants while notes were taken by one of the research assistants. A total of 12 FGD (one with adolescent girls, one with adolescent boys, two with men, two with pregnant women and six with non-pregnant women) were conducted involving a total of 123 participants composed as follows: 18 pregnant women, 67 non-pregnant women, 20 adolescents and 18 men. In addition, a total of 66 KII were conducted (table 1).
Data analyses
Data were entered into EpiInfo version 6.0, cleaned and transferred to Stata version 8.2. Bivariate analysis was performed to study relations between variables that could explain health-seeking practices. The sample size calculations for the survey were based on the ability of the study to detect a difference as a small as 1% in the proportion of pregnant women accessing HIV testing services, estimated at 6%;5 a power of 80% and a 5% level of significance. The minimum sample size targeted was 6472 women in the reproductive age group. Qualitative data were analysed following guidelines described in the Focus Group Manual for Social Research in Tropical Diseases.13
Computation of the wealth index
A proxy index for the socioeconomic status of the household was computed using a number of household variables, namely: type of material used for the construction of the house roof, wall and floor; type of fuel used for lighting; type of material used for cooking; type of toilet facility; type of bathroom; type of kitchen; ownership of transportation assets; ownership of communication assets and main source of information by the household.3
Ethical issues
The study was approved by the Uganda National Council of Science and Technology (reference HS485). Verbal consent was obtained from all respondents who participated in the study.
Results
Background characteristics of respondents
A total of 10 706 women was interviewed (100% response rate), their mean age was 25.8 years (14–49 years); and the majority, 7339 (69.0%) were aged between 20 and 34 years. This is expected since the target population was sexually active women. Similarly, the majority of respondents, 8619 (78.5%) attained primary education and 5012 (47.0%) secondary education. The majority of women, 7063 (66.0%) were married (table 2). Most respondents, 4786 (57%) were in the lowest wealth quintile. Similarly, most participants were involved in agriculture, few in retail business, whereas the majority were housewives with no income-generating activities.
Access to family planning and PMTCT services through private midwifery practices
Of all the women (pregnant and non-pregnant) surveyed, the majority, 7810 (73.0%), had ever tested for HIV through different outlets; whereas of the 1232 women who were pregnant, 999 (81.1%) had tested for HIV. Most women, 4404 (57.0%), received HIV testing from hospitals, 1347 (17.4%) from health centres, 744 (9.6%) from private clinics and 608 (7.8%) tested from private midwives. Most clients in the study area receive other services from public hospitals and health centres. Nevertheless, the private health sector (private clinics, private midwives and drug shops) provides a substantial proportion of services. Currently, private midwives provide 7.8% of HIV testing, 8.6% of family planning and 7.6% of antiretroviral drugs (table 2).
Over three-quarters of respondents (FGD) agreed that private midwives would increase access to services if they were trained and provided with supplies. The basis for this was that some pregnant women already visited private midwives and other women could benefit from these services if they were subsidised:
“With this intervention, the women can access family planning better and be able to plan the number of children they produce” a woman respondent at a FGD at Gayaza
“it will be good because private midwives provide good care and know us better since they are within our community” a woman respondent at a FGD at Namasuba
The following recommendations were made by the respondents at all FGD and KII so that the intervention with private midwives can reach many pregnant women and other clients who may need the services:
Community sensitisation using drama, peer groups for adolescents, public address system, radios and posters was highly recommended.
Community health workers and women councillors were recommended as suitable to distribute vouchers to poor women.
It was recommended that midwives should be trained to improve their skills and facilitated to have enough drugs and equipment so that they can provide quality services.
It was recommended that midwives should be trained to improve their skills in effective communication, ensuring confidentiality, and provide adolescent-friendly services.
There was a need to expand the infrastructure at some midwives clinics in order to accommodate a large volume of clients.
It was recommended that men should be sensitised to support their spouses to go for HIV testing during pregnancy and subsequent care.
Trust in the services provided by the private midwives
Most pregnant women and non-pregnant women in all the FGD said they trusted private midwives. Interviews with most key informants also confirmed this view. However, approximately half of the adolescents frequently mentioned confidentiality as an important factor for them to access services at private midwives clinics. Adolescents were concerned that some service providers at public health facilities and private midwives were rumour mongers and they disclose clients’ HIV status, which causes stigma in the community. In FGD with men, the issue of transparency and the proper use of vouchers by private midwives was a concern.
Access and equity to HIV prevention services
Access to family planning was low among women in the lowest wealth quintile, especially among the young and those with no education (table 3). Women and children were perceived to be most in need because they are the ones with the heaviest burden of HIV/AIDS. Pregnant women would be saved from walking long distances and long queues at public health facilities.
“The free service will help us because we have no money and most men do not mind” a pregnant woman at a FGD at Wakiso
“The children have a high chance of being born with HIV virus. The mothers will then get free and accessible services to prevent HIV. Protecting children is important because they are the future generation” a pregnant woman at a FGD at Wakiso
The adolescents were believed to be in most need of HIV prevention services due to a perceived higher risk of HIV infection:
“There are many youths who have HIV infection and we are at a very high risk of being infected especially by sugar daddies. Oh, the youths are mostly at risk due to cross-generational sex” an adolescent at a FGD at Nabingo
Barriers to HIV prevention services
In all the FGD and KII, participants and respondents ranked the main constraints that women experience in accessing ANC services. Although women trusted services provided by private midwives, most of them ranked high costs to seeking care as the main constraint, especially the cost of HIV tests. It was reported that the cost ranges from 5000 to 10 000 Ugandan shillings (US$2.5–5.0). Due to the high cost of services, the voucher system to enable most people to access services was strongly supported.
The second most important barrier to accessing ANC, reported in all FGD with women, was harsh midwives who abuse women at the health units. The third constraint was perceived to be the long queues at health facilities, whereas the fourth was fear to be tested for HIV, which is perceived to be compulsory at ANC in public facilities (table 4).
The policy environment
The availability of policies that support PMTCT and family planning was assessed. The assessment was made in 26 randomly selected private midwives clinics. Few private midwives, seven (27%) had reproductive health guidelines, 15 (58%) had PMTCT guidelines, three (12%) sexual adolescent health and seven (27%) infant feeding practices. However, almost all private midwives, 24 (92%) had policy guidelines on family planning. Private midwives acknowledged that getting guidelines and policies was difficult.
Discussion
The results of the present study show that some private midwives are currently providing HIV counselling and testing, antiretroviral drugs and contraceptives to a number of clients. Client satisfaction with services at private midwifery practices was high and they are trusted. However, many clients were not using family planning and others were not accessing HIV counselling and testing because they feared knowing their HIV status, whereas others feared spouses knowing their HIV status. Access to these services among young women and those with no education was also poor. The constraints experienced in accessing PMTCT were high costs, unfriendly midwives, long distances to health units, long waiting times, fear of being tested for HIV and lack of support by male spouses.
Delivering PMTCT services though private midwives fits into the current policy framework in Uganda that recognises the importance of the private health sector in improving health outcomes.14 Private midwives are authorised by government to provide services such as ANC, delivery care, postnatal care, family planning, immunisations, management of sexually transmitted diseases and HIV counselling. The feasibility and the cost-effectiveness of this approach needs to be assessed.
It has been observed elsewhere that public–private partnerships present opportunities for countries to meet the challenges of increasing demand for care.15 16 17 With the rapid expansion of antiretroviral treatment in sub-Saharan Africa, the private health sector has been identified as an important source of treatment.18 19 20 21 22 However, it has been acknowledged that private clinics are used by those who can afford them and may not help improve care for the poorest population groups.23 In this article, women in the lowest wealth quintile, those with low education and the young had low access to PMTCT; yet they had the greatest need to have an HIV test. One of the ways proposed by respondents in this study on how to reach these women is through community health workers. This and other innovative ways to reach vulnerable women with PMTCT need to be identified and tested.
Access to HIV counselling and testing in Uganda has been found to be poor; only 29% have ever tested for HIV. A quarter of women (25%) and a fifth of men (21%) have ever been tested and received results.24 The use of the wealth index has been used to assess coverage and equity, and it was found that women in the lowest quintile had poor access to HIV testing (17.8%) compared with those in the highest wealth quintile (38.9%).24 In the intervention study, household surveys will be carried out and wealth indices constructed to enable the identification of vulnerable women who may benefit from subsidised PMTCT services.
Key messages
Delivery of PMTCT services in the public sector is low in Uganda, thus identifying alternative delivery outlets is urgently required.
The main constraints to access PMTCT are high costs, unfriendly midwives, long distances and poor quality of care at health units.
Access to PMTCT among young women, poor women and those with no education is low.
Private midwives are a potential delivery outlet for PMTCT, but require training and to be linked to the public and the community to address access issues.
Using Andersen’s model25 to draw policy implications, it is suggested that government address the following health system issues in order to increase access to PMTCT and contraception: strengthen public–private patternships by facilitating training of the private sector and supervision; increase service delivery outlets by expanding health infrastructure improve staffing levels and equip them with appropriate skills.
One of the main constraints that limit access to PMTCT and family planning services is lack of support from spouses who do not like to go for HIV testing and do not support their spouses to have HIV tests. Stigma about HIV testing has also been documented elsewhere.26 27 In Uganda, negative attitudes of spouses need to be addressed if the sexual and reproductive health of women is to be improved. We suggest further studies to test effective interventions that enable dialogue with male spouses to promote health-seeking for PMTCT and family planning services.
The implication of these findings to the intervention design is that private midwives will be trained to offer effective counselling and HIV testing, ensure confidentiality and adolescent-friendly services and design information leaflets with explanations on the benefits of HIV testing, contraception and the involvement of spouses. In addition, community health workers will be trained to identify poor and vulnerable women and target male spouses with information on the benefits of PMTCT.
Acknowledgments
The authors would like to thank the District Director of Health Services Wakiso District, Dr Mukisa, the field officer Mr Steven Kalake, Ms Fatuma Nakisseka and Ms Violet Birungi for their support during field work; and all the women, adolescents and men who participated in this study. Ms Charity Wamala and Jolly Namuddu are thanked for their participation in the qualitative data collection and analyses.
Contributors: AKM conceptualised the study and was the lead writer. All authors participated in the analysis and writing the manuscript. PM provided detailed comments on the manuscript.
REFERENCES
Footnotes
Funding This study was funded by a grant from The Bill & Melinda Gates Foundation through the Grand Challenges Exploration Initiative.
Competing interests None.
Ethics approval The study was approved by the Uganda National Council of Science and Technology (reference HS485).
Patient consent Obtained.
Provenance and Peer review Not commissioned; externally peer reviewed.
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