FACTORS INFLUENCING UTILIZATION OF PREVENTION OF MOTHER TO CHILD TRANSMISSION (PMTCT) SERVICES AMONG PREGNANT WOMEN ATTENDING ANTE-NATAL CLINIC IN UNIVERSITY OF CALABAR TEACHING HOSPITAL (UCTH)
This study sought to assess the factors influence the utilization of PMTCT services among pregnant women in antenatal clinic in University of Calabar Teaching Healthcare (UCTH), Calabar. The specific Objectives of the Study were: to assess the level of knowledge about PMTCT services, determine the socio-economic factors influencing utilization of PMTCT services and to identify the cultural/religion factors influencing utilization of PMTCT services among pregnant women in UCTH. Three research questions were raised and a hypothesis formulated to guide the study as follows: There is no significant relationship between level of knowledge and utilization of PMTCT services among women. The study was a descriptive research where 85 pregnant women who attended antenatal clinic in UCTH were selected through the purposive sampling technique. Data were collected by administering questionnaire. Data were analyzed using frequency tables and percentages, the findings of the study revealed that: Majority of the respondents have good knowledge about PMTCT services. The socio-economic factors influencing utilization of PMTCT services among pregnant women were: stigmatization and discrimination by healthcare personnel; dependence of women on their husbands to make healthcare decisions; distance to PMTCT facilities; unavailability of PMTCT services and attitude of health personnel (nurses) towards people living with HIV. Cultural/religious beliefs do not hinder utilization of PMTCT services. The hypothesis was tested for significance at 0.05 level and 1 degree of freedom, using the Chi-Square (X2) analysis. The result showed that the calculated value 55.45 is higher than the critical value (3.84). Thus, the null hypothesis was rejected, indicating that there is significant relationship between level of knowledge and utilization of PMTCT services among women. Based on the findings, conclusion was drawn. It was recommended amongst others that: there is need for involvement of the stakeholders in the healthcare system in bridging the gap between knowledge and utilization of PMTCT services among women.
Table of Contents
Title page - - - - - - - - - - i
Certification- - - - - - - - - - ii
Dedication- - - - - - - - - - - iii
Acknowledgement- - - - - - - - - iv
Abstract - - - - - - - - - - v
Table of contents- - - - - - - - - - vi
List of tables- - - - - - - - - - ix
1. Background of the study- - - - - - - - -1
1.2 Statement of problems - - - - - - - -2
1.3 Purpose of the study- - - - - - - - -3
1.4 Objectives of the study- - - - - - - - -3
1.5 Research questions- - - - - - - - -4
1.6 Hypothesis- - - - - - - - - - -4
1.7 Scope of the study - - - - - - - - -4
1.8 Significance of the study- - - - - - - -4
1.9 Limitations- - - - - - - - - - -5
1.10 Operational definition of terms- - - - - - - -5
2.1 Theoretically- - - - - - - - - -6
2.1.2 Knowledge about prevention of mother to child transmission (PMTCT) among pregnant women- - - - - - - - -10
2.1.3 Factors influencing utilization of PMTCT- - - - - 12 2.2 Conceptual framework- - - - - - - - -19
3.1 Research design- - - - - - - - - -22
3.2 Research setting- - - - - - - - - -22
3.3 Research population- - - - - - - - -23
3.3.1 Target population- - - - - - - - - -23
3.3.2 Accessible population- - - - - - - - -23
3.4.1 Sample Size- - - - - - - - - -23
3.4.2 Sampling technique- - - - - - - - -23
3.5 Instruments for data collection- - - - - - - -24
3.6.1 Validity of the instrument- - - - - - - -24
3.6.2 Reliability of the instrument- - - - - - - -24
3.7 Method of Data Collection- - - - - - - -25
3.8 Method of data analysis- - - - - - - - -25
3.9 Ethical considerations- - - - - - - - -25
DATA ANALYSIS AND RESULTS
4.1 Socio-Demographic Variables- - - - - - - -26
4.2 Results for Research Questions- - - - - - - -28
4.3 Result of Research Hypothesis- - - - - - - -34
DISCUSSION OF FINDING
5.1 Discussion of Findings- - - - - - - - -36
5.1.1 The knowledge of pregnant women in UCTH about prevention and control of HIV/AIDS.- - - - - - - - - - -36
5.1.2 Socio-economic factors influencing utilization of PMTCT services among pregnant women.- - -- - - - - - - -37
5.1.3 Cultural/religion factors influencing utilization of PMTCT services among
pregnant women in UCTH.- - - - - - - -38
5.1.4 Relationship between level of knowledge and utilization of PMTCT services among women- - - - - - - - -39
1. Summary- - - - - - - - - - -39
5.3 Conclusion- - - - - - - - - - -41
5.4 Recommendations- - - - - - - - - -41
APPENDIX i (QUESTIONNAIRE)
APPENDIX ii (LETTER OF INTRODUCTION)
LIST OF TABLES
Table 1: Socio-Demographic Data
Table 2: Level of knowledge about PMTCT services among pregnant women in UCTH
Table 3: Socio-economic factors influencing utilization of PMTCT service in UCTH
Table 4: Cultural/ religious factors influencing utilization of PMTCT service in UCTH
Table 5: chi-square (X2 ) Analysis of the relationship between level of knowledge and utilization of PMTCT service
1. Background of the study
The greatest challenge to human kind in the 21st century is the epidemic of Acquired immune Deficiency Syndrome (AIDS).Human Immune Deficiency Virus (HIV) is the causative organism of AIDS which was first discovered in the year 1981. Despite years of campaigns, advocacy, control programmes and awareness exercises taken to curb HIV/AIDS spread, there is still a worrisome rate of increase of the infection. According to UNAIDS (2006), about 33.3 million people are estimated to live with Human immune Deficiency virus globally; 22.5 million of this population are from the sub-Saharan Africa.
Over 55% of these people living with HIV are women of reproductive age who become pregnant. HIV infection in women of reproductive age increase the epidemic of peri-natal HIV (UNAIDS, 2006). About 2.5million children live with HIV globally and 1.8million are from sub-Saharan Africa. Worldwide, over 1700 children become infected with HIV daily (UNAIDS 2006).
In Nigeria, about 69,400 children became infected with HIV through mother-to-child transmission in 2011. This has led to a rise in the total number of children living with HIV in the country to an unprecedented 440,000 (UNAIDS, 2012).
Majumali, (2011), opined that, Virtually all HIV infection in children occurs following mother to child transmission during the antenatal period (pregnancy), intranatal period (labour/delivery) and the post-natal period. Mother-to-child transmission of HIV is about 5-10% during pregnancy, 10-20% during labour and 10-15% during breastfeeding.
There is an estimation of about 20-45% chances of a baby born to an HIV positive mother to become infected without effective interventions to prevention of mother-to-child transmission. With effective interventions, such as use of antiretroviral drugs both for mother formula feeding etc., the risk of mother to child transmission has been shown to reduce by 5%. Primary preventive measures (prevention of new infections in parents, avoiding new pregnancies in HIV infected women) and secondary preventive measures (preventing transmission of HIV from an infected mother to her infant) are the three approaches in reducing mother to child transmission (MTCT) promoted by the World Health Organisation (WHO), (McIntyres $ Gray 2004).New approaches in preventing MTCT to <2% includes use of combined anti-retroviral prophylaxis, elective caesarean section and by avoiding prolonged breastfeeding or mixed feeding.
In Nigeria, despite these preventives measures of mother to child transmission, research has shown poor utilization of these services. Thus, the need for this study.
1.2 Statement of problems
Mother to child transmission of HIV has a lot of impact on the health of the mother and infant including the economy of the country. MTCT increases the prevalence of HIV in infants thereby resulting in increased infant and maternal morbidity and mortality.
Despite the introduction of improved preventive services of MTCT of HIV over the years, HIV infections via MTCT (vertically/ perinatal transmission) is still on the increase in Nigeria. In 2011, about 440,000 infants were infected with HIV (UNAIDS, 2012).
During the researcher’s clinical experience in the antenatal clinic UCTH, it was observed that despite availability of this prevention of MTCT services, very few women utilized the services. For this reason, this pertinent question formed the birth rock of this study: What then are the factors that influence the utilization of prevention of mother to child transmission services?
1.3 Purpose of the study
The purpose of the study is to ascertain the factors influencing the utilization of PMTCT services among pregnant women in antenatal clinic in UCTH.
1.4 Objectives of the study
The specific objectives of the study are:
1. To assess the level of knowledge about PMTCT services among pregnant women in UCTH.
2. To determine the socio-economic factors influencing utilization of PMTCT services among pregnant women in UCTH.
3. To ascertain the cultural/religion factors influencing utilization of PMTCT services among pregnant women in UCTH.
1.5 Research question
1. What is the level of knowledge about PMTCT services among pregnant women in UCTH?
2. To what extent do socio-economic factors influencing utilization of PMTCT services among pregnant women in UCTH?
3. What are the cultural/religion factors influencing utilization of PMTCT services among pregnant women in UCTH?
There is no significant relationship between level of knowledge and utilization of PMTCT services among women.
1.7 Scope of the study
The study is delimited to pregnant women that attended antenatal clinic in University of Calabar Teaching Hospital.
1.8 Significance of the study
It is very important that factors influencing the utilization of PMTCT services in a resource poor setting should be studied. It is important in the context of cross river state where health resources are unevenly distributed between rural and urban areas including distribution of health care providers.
Practically: The findings of this study will be handy for cancelling purposes in ensuring increased utilization of PMTCT services.
Research: The result of this study will increase the existing knowledge on utilization of PMTCT services and will also serve as research as a resource material for further research work.
Nurse/midwife: The findings of this study will help to improve the attitude of Nurses in delivery of PMTCT services to ensure its utilization by pregnant women thereby decreasing the rate of MTCT.
Government: The findings of this study will help improve policies on findings and distribution of PMTCT services in both rural and urban areas to ensure its utilization.
Major limitation was encountered during this study because the Teaching Hospital was on strike and many patients were not (accessed) reached. Also some respondents refused to divulge their information for confidential purposes.
1.10 Operational definition of terms
Factors: are variables that influence utilization of PMTCT services
Utilization: refers to the process of using PMTCT services
PMTCT services: are services that aims at offering preventive measures towards mother to child transmission.
Ante natal: refers a period from conception to the onset of labour
This chapter deals with the review of related literature. The review is divided into the following: theoretical, empirical and conceptual review.
Prevention of mother to child transmission of HIV
According to UNAIDS (2012), PMTCT begins with the non-pregnant woman. Preventing mother-to-child transmission is achievable. Between 2009 and 2011, 409,000 new infections were averted among children UNAIDS (2012).
The success of preventing HIV transmission from mothers to their children requires multiple interventions not only during pregnancy, labour and breastfeeding, but among all women and girls. Without adequate comprehensive intervention, about a third of HIV positive women will transmit the virus to their children during pregnancy, labour and delivery and through breastfeeding (WHO 2012). To control vertical transmission various interventions have been developed since the discovery of MTCT. Preventive interventions aimed at reducing MTCT largely focuses on prevention of intra-partum and post-partum transmission of HIV.
Current effective interventions aimed at reducing MTCT includes use of antiretroviral to decrease maternal viral load, elective caesarean section (aimed at reducing exposure to maternal secretions during vaginal delivery) and the avoidance of breastfeeding (de cook, 2004).
Use of antiretroviral prophylaxis
In developing countries, the use of antiretroviral medications in combination with other medication or alone lowers the risk of MTCT. There was a major breakthrough in the prevention of vertical transmission of HIV in 1994 by the Paediatric AIDS Clinical Trial Group. The breakthrough demonstrated Zidovudine monotherapy reduces the risk of MTCT in the non-breastfeeding population (Connor, 2004). Zidovudine monotherapy is administered in the second and third trimesters of pregnancy and intravenously during delivery while given to infants at 6 weeks after birth. Also, combined therapy with two or more antiretroviral drugs is assumed to be effective in the reduction of the risk of perinatal transmission than monotherapy. There is also the use of Highly active antiretroviral therapy.
Option B+ is the latest treatment option recommended by the WHO or PMTCT (WHO, 2012). Unlike other treatment options, Option B+ recommends that all HIV positive pregnant women are placed onto a triple antiretroviral regimen for PMTCT, irrespective of their CD4 count and continuing for life. Option B+ reduces the risk of MTCT of HIV and all future pregnancies.
Modification of Obstetrical practices
Several obstetrical measures to prevent mother to child transmission should be implemented when possible.
The risk of MTCT of HIV will be increased following an increase in maternal-to-foetal vaginal secretion exposure and maternal-to-foetal blood exposure.
Time of rupture of membranes should also be shortened following vaginal delivery; and progress of labour should be measured using the partograph to prevent prolonged labour which increases the risk of MTCT.
⦁ Avoiding instrumentations
Standard operating procedures during vaginal delivery for PMTCT should be adhered to such as avoidance of instrumentation e.g. forceps delivery, vacuum delivery, and episiotomies should be avoided.
⦁ Caesarean delivery
The secretions and fluids excreted in the birth canal during labour are known to infect the foetus as it passes through the birth canal. Delivery by elective caesarean section is efficacious in reducing mother to child transmission of HIV. Gray (2004) asserted that elective caesarean is a cost-effective intervention for the prevention of vertical transmission of HIV when safely available. In a wide range of circumstances even with the risk of 1% in vaginal deliveries, this is achievable with highly active antiretroviral therapy (Mrus 2011). However, incidence rates of postpartum morbidity after caesarean section delivery in women with advanced AIDS are higher than with vaginal delivery. Scheduled caesarean delivery is recommended at 38weeks for women with viral load of more than 1000 copies/mL (receiving ARV or not) and for women with unknown HIV viral load .
⦁ Immediate care of the infant
Immediately after birth, infant should be cleaned of all maternal blood and secretions. The sites for vitamin k and vaccines injections should be properly cleaned to prevent introduction of HIV to the new born iatrogenically. ARV prophylaxis should begin as soon as possible after delivery.
⦁ Infant feeding
Breastfeeding remains an important route of transmission; however, benefits of replacement feeding in Africa are becoming less clear due to competing co-morbidities. PMTCT can be achieved through exclusively breastfeeding (not more than 6months) or exclusive formula feeding and avoidance of mixed feeding. All HIV infected mothers should be encouraged to exclusively breastfeed their babies for the first six months, after which complementary feeds are introduced and breastfeeding continues for up to 12months. Breastfeeding should be accompanied with maternal ART or ARV prophylaxis and/ or infant ARV prophylaxis. If a mother has previously passed through the PMTCT programme, the reason for the change in policy on infant feeding in the context of HIV should be explained in simple term..