Kasenga F, Hurtig AK, Emmelin M. Home deliveries: implications for adherence to nevirapine in a PMTCT programme in rural Malawi.AIDS Care 2007 May;19(5):646-52.
To follow women in a prevention of mother-to-child transmission (PMTCT) program in rural Malawi up to delivery, regardless of place, and to assess how the women and their babies adhere to nevirapine prophylaxis.
Prospective, longitudinal observational study with cross-sectional sampling.
Thyolo District, a rural district in southern Malawi with 16% HIV prevalence. Up to 46% of pregnant women in the area deliver outside the hospital. The study took place at Malamulo mission hospital, a 300-bed teaching hospital that serves an estimated population of over 70,000 people.
A total of 719 mothers were registered in the Malamulo Hospital antenatal clinic from January to June 2005. Of 604 women who accepted HIV testing, 75 (12.4%) women tested HIV-positive and were included in the PMTCT program and in this study. The mean age of the women was 25.5 years (SD 4.9). Most (98.7%) of women were married. Ten women (13.3%) were illiterate and 32 (42.7%) had not completed primary school. Twenty-nine women (38.7%) traveled fewer than 5 km to the hospital, nearly half (49.3%) traveled 5-10 km, and the remaining (12%) traveled more than 10 km.
Women who opted to take an HIV test underwent pre- and post-test counseling sessions and, if found HIV-positive, were included in the PMTCT program and in the study. Nevirapine 200mg tablets were given to HIV-positive mothers at 32-38 weeks of gestation to take when labor started. It was not possible to provide the mothers with the nevirapine syrup for the baby, due to difficulties of storage and a short shelf life. At the hospital, nevirapine syrup (2mg/kg) was given to the baby within 72 hours of delivery. If a mother did not go to the hospital for delivery, she was expected to return within 72 hours of delivery to ensure administration of nevirapine to the newborn child.
Women were followed up from the antenatal clinic to delivery by use of routine antenatal, PMTCT, and PMTCT delivery registers. Women who did not return for delivery in the hospital were traced and interviewed in their homes. Data on place of delivery, support, reasons for non-hospital delivery, and outcome of delivery were collected from the traced mothers who had not delivered at the hospital.
Of 75 HIV-positive women, 60 (80%) came for check-ups during gestation weeks 32-38. These women were then provided with nevirapine to be taken at the time of labor. There were no sociodemographic differences noted between the women who received nevirapine and those who did not. Forty women (53%) delivered in the hospital and 35 (47%) did not. Although the proportion of women living fewer than 5 km from the hospital was higher in the group who delivered in the hospital (47.5 versus 28.6%), the difference was not significant. No other socioeconomic differences were observed. However, women who delivered in the hospital were only found among the group who had returned to the antenatal clinic after week 32 when nevirapine was handed out. Among the women who did not deliver in the hospital, 20 (57%) picked up the nevirapine before delivery. Of the 35 women who delivered at home, it was possible to trace 27 (77.2%); the remaining 8 were lost to follow-up). Twenty-six of the women (96.3%) who were traced had delivered in the home of a traditional birth attendant and one woman (3.7%) on the way to the hospital. Common reasons for not delivering in the hospital were lack of money (66.6%), distance (45%) and being sick (22.2%). All women who delivered in the hospital had taken their nevirapine tablets, and all the babies had had their nevirapine syrup except the baby who died soon after delivery. Of the 27 traced women who had not delivered in the hospital, 16 (59.3%) had picked up nevirapine from the PMTCT clinic, and all of these women had also taken their tablets during labor. However, none of their babies were taken back to the health facility to be given nevirapine syrup. Of the 27 babies born outside the hospital, three (11.1%) of them died soon after delivery and four (14.8%) were reported by their mothers to be underweight.
The authors conclude that, because most of the women who had not delivered in the hospital had delivered at the home of a traditional birth attendant, traditional birth attendants might be crucial in efforts aiming to increase adherence to nevirapine among women and their babies.
The results of this study may be biased, as eight out of 35 (23%) women who delivered outside the hospital were lost to follow-up. Further, this study is observational in design, and no causal relationships can be established. There was also limited power to detect differences in sociodemographic characteristics in the hospital and home delivery groups because of the small sample size.
Several studies have reported a severe loss to follow-up from registration up to delivery in PMTCT programs.(1, 2, 3, 4) However, few studies so far have assessed adherence to nevirapine outside the hospital setting. In one study from Zambia, non-adherence was strongly associated with home deliveries.(5) Similarly, the study presented here suggests that the women who do not come to the antenatal clinic late in pregnancy are not likely to be seen later in the hospital for delivery.
Adherence to antiretroviral prophylaxis is an enormous challenge among marginalized HIV-infected women, especially in rural areas. This study suggests that uptake of single-dose nevirapine is highly influenced by the site of delivery. Because delivery outside the hospital is common in much of sub-Saharan Africa, PMTCT could be greatly enhanced through alternate care providers, such as traditional birth attendants. Other potential means to increase adherence to PMTCT include intensified educational campaigns and strengthened antenatal and delivery services. Additional research is needed to study barriers and promoting factors for the delivery of antiretroviral prophylaxis to the mothers and the infants, as well as to assess interventions to improve uptake of PMTCT services.
- Manzi M, Zachariah R, Teck R, Buhendwa L, Kazima J, Bakali E, et al. High acceptability of voluntary counselling and HIV-testing but unacceptable loss to follow up in a prevention of mother-to-child HIV transmission programme in rural Malawi: scaling-up requires a different way of acting. Trop Med Int Health 2005 Dec;10(12):1242-50.
- Perez F, Mukotekwa T, Miller A, Orne-Gliemann J, Glenshaw M, Chitsike I, et al. Implementing a rural programme of prevention of mother-to-child transmission of HIV in Zimbabwe: first 18 months of experience. Trop Med Int Health 2004 Jul;9(7):774-83.
- Stringer JS, Sinkala M, Maclean CC, Levy J, Kankasa C, Degroot A, et al. Effectiveness of a city-wide program to prevent mother-to-child HIV transmission in Lusaka, Zambia. AIDS 2005 Aug 12;19(12):1309-15.
- Temmerman M, Quaghebeur A, Mwanyumba F, Mandaliya K. Mother-to-child HIV transmission in resource poor settings: how to improve coverage? AIDS 2003 May 23;17(8):1239-42.
- Albrecht S, Semrau K, Kasonde P, Sinkala M, Kankasa C, Vwalika C, et al. Predictors of nonadherence to single-dose nevirapine therapy for the prevention of mother-to-child HIV transmission. J Acquir Immune Defic Syndr 2006 Jan 1;41(1):114-8.