HIV care need not hamper maternity care: a descriptive analysis of integration of services in rural Malawi

Abstract

Objective To evaluate the use of reproductive health care and incidence of paediatric HIV infection during the expansion of antiretroviral therapy and services for the prevention of mother-tochild transmission in rural Malawi, and the influence of integration of these HIV-related services into general health services.Design Descriptive analysis.Setting Thyolo District, with a population of 600 000, an HIV prevalence of 21% and a total fertility rate of 5.7 in 2004.Population Women attending reproductive health services care in 2005 and 2010.Methods Review of facility records and databases for routine monitoring.Main outcome measures Use of antenatal, intrapartum, postpartum, family planning and sexually transmitted infection services; incidence of HIV infection in infants born to mothers who received prevention of mother-to-child transmission care.Results There was a marked increase in the uptake of perinatal care: pregnant women in 2010 were 50% more likely to attend at least one antenatal visit (RR 1.50, 95% CI 1.48-1.51); were twice as likely to deliver at a healthcare facility (RR 2.05, 95% CI 2.01-2.08); and were more than four times as likely to present for postpartum care (RR 4.40,. Family planning consultations increased by 40% and the number of women receiving treatment for sexually transmitted infections doubled. Between 2007 and 2010, the number of HIV-exposed infants who underwent testing for HIV went up from 421 to 1599/year, and the proportion testing positive decreased from 13.3 to 5.0%; infants were 62% less likely to test HIV positive (RR 0.38, 95% CI 0.27-0.52).Conclusions During the expansion and integration of HIV care, the use of reproductive health services increased and the outcomes of infants born to HIV-infected mothers improved. HIV care may be successfully integrated into broader reproductive health services.

The role of the parents’ perception of the postpartum period and knowledge of maternal mortality in uptake of postnatal care: a qualitative exploration in Malawi

“…For example, studies in Indonesia, Malawi, and Ghana have divulged that women who had to pay more in terms of the waiting time and distance to the facility were less likely to utilize maternal care 14,15,27,31. Correspondingly, in most of the health facilities in Africa, mother and baby care are separated 34,35. Therefore, women who have given birth are supposed to go to the facility two or three times within a short period of time for neonatal and postnatal care.…”

Achieving development goals for HIV, tuberculosis and malaria in sub-Saharan Africa through integrated antenatal care: barriers and challenges

“…Weak program links, health systems, and financial infrastructure are cited as a prominent barriers to ANC attendance and integrated ANC service delivery (systematically reviewed in [18, 39, 40]). For example, the provision of HIV treatment at specialised ART clinics separate to ANC clinics reduced uptake of HIV services in pregnant women by around 50% [21, 29, 30]. To counter this problem, governments, in conjunction with non-governmental organisations, have begun integrating HIV services and PMTCT into primary healthcare and ANC with the recognition that HIV-specific resources could be allocated diagonally (aiming for disease-specific results through enhanced health systems) [18, 41].…”

“…Enablers that have helped overcome identified structural barriers in integrated ANC, reproductive health and primary care services include streamlined funding, effective distribution/logistical systems, integrated health information systems [21, 30, 33, 44], provision of all services on the same site [21, 57], free or low-cost testing and treatment [57], holistic, comprehensive healthcare delivered by multi-skilled health workers or different health workers under the same roof [57], provision of support (psychosocial, financial) to encourage treatment adherence and clinic attendance [57–59], and well-supported trained healthcare staff [33, 42, 49, 60–63]. Careful consideration of these enablers in the design and implementation of integrated ANC, HIV, TB and malaria services is required and will generate demand for such integrated services.…”

“…Studies conducted in sub-Saharan Africa focusing on the integration of HIV testing and treatments into ANC clinics and IPTp access at ANC have cited the need to attend health clinics on multiple occasions and at separate locations, taking time away from work or parenting obligations, and costly and timely transport options as major barriers to returning to health clinics [11, 21, 30, 33, 64–68]. These access issues were relevant to receiving HIV test results and initiating and adhering to HIV treatment and PMTCT services [21, 29, 30, 33, 62, 64], and similar problems were identified with TB services and the need to return to clinics to provide a second sputum to confirm a diagnosis [65]. These considerations support the principles underpinning integrated ANC models by underscoring the importance of streamlining service provision across multiple antenatal and disease-specific needs.…”

The role of family planning in elimination of new pediatric HIV infection

“…For example, an evaluation of a PMTCT program in Ethiopia – which uses PMTCT as an entry point to comprehensive, integrated care for the mother, her child and family members – reported high levels of postpartum contraceptive use among PMTCT clients in addition to other relevant PMTCT outcomes [12]. Another study from Malawi found the scale up and integration of PMTCT and ART services into primary care services from 2005 to 2010 were associated with not only a substantial reduction in the proportion of HIV-exposed infants testing positive, but also a 40% increase in family planning consultations [13*]. …”