Knowing but not knowing: providing maternity care in the context of HIV/AIDS in rural Zimbabwe

Abstract

Individual interviews with 25 nurses and midwives revealed their experiences with providing maternity care in rural Zimbabwe. These first-hand accounts especially illuminate the complexities of providing maternity care in the context of HIV/AIDS. The caregivers described feeling troubled by knowing statistics about the magnitude and high prevalence of HIV (from official sources and the media) while they witnessed the increase in disease and the deaths of women, children and colleagues around them. They expressed frustration with a lack of information regarding the HIV status of their female patients - a situation exacerbated by HIV stigma and poor healthcare organisation. The social relationships between the caregivers and women in the study area sometimes meant that the caregivers did not effectively apply universal precautions, such as use of gloves during births. The situation described by the caregivers emphasises that contextual factors must be addressed to meet the increased demands and challenges of providing maternal healthcare in endemic HIV/AIDS countries such as Zimbabwe.

Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis

“…Staff shortages and work overload jeopardised health workers’ ability to provide timely care, and manage routine care as well as emergency cases. In addition, shortage of staff sometimes led health workers to exceed their scope of practice, and influenced a health facility's ability to provide 24-hour care.Afsana 2001; Anwar 2009; Barua 2011; Bradley 2009; Conde-Agudelo 2008; Fränngård 2006; Fujita 2012; Graner 2010; Hassan-Bitar 2011; Ith 2012; Khalaf 2009; Lugina 2001; Maputle 2010; Mathole 2006; Mondiwa 2007; Spangler 2012; Thorsen 2012; VSO 2012Moderate confidenceDue to minor concerns about coherence; and minor concerns about methodological limitationsA lack of specialists or experienced staff, including absence of health workers with key skills such as anaesthetists, influenced the provision of care and supervision of junior staff. When no specialists were available, some tasks such as emergency obstetric care were not delivered at all, or tasks were transferred to health workers who were not properly qualified or trained to deliver them.…”

“…eclampsia or HIV in pregnancy. In contrast, training allowed midwives to practice assisting women to deliver in non-supine positions and enabled them to get accustomed to this practice.Afsana 2001; Barua 2011; Blum 2006; DeMaria 2012; Fujita 2012; Graner 2010; Lester 2003; Mathole 2006High confidence-Health worker competencies and opportunities for on-the job training were sometimes limited by poor scheduling of in-service education sessions, high cost of continuing education for health workers, inequitable selection for professional development opportunities, lack of ongoing training and follow-up, and shortage of instructors for upgrading courses. In addition, the variation in quality of pre-service training resulted in varying levels of need for in-service training, and these needs were not always met, resulting in wide variation in proficiency among health workers.Fränngård 2006; Ith 2012; Pettersson 2006; Spangler 2012Moderate confidenceDue to minor concerns about methodological limitations and relevance; and moderate concerns about adequacyLearning through practical application facilitated acquisition of skills and confidence.…”

“…This was sometimes further compounded by lack of information sources such as internet access, and poorly resourced hospital libraries. In addition, lack of training and skills in networking, epidemiology, research appraisal, or critical thinking about clinical practice limited health workers' awareness and receptivity to clinical practice changes, and this lack of skills led some professionals to prefer old, familiar procedures.Afsana 2001; Belizan 2007; Conde-Agudelo 2008; Lugina 2001Low confidenceDue to moderate concerns about relevance and adequacy; and minor concerns about methodological limitations STANDARDS AND PROTOCOLS Lack of guidelines/protocols, or where they were inconsistent or health workers were not aware or were uncertain of them, could impact patient care and outcomes and cause harm.Barua 2011; de Carvalho 2012; Khalaf 2009; Lugina 2001; Mathole 2006Low confidenceDue to moderate concerns about adequacy; and minor concerns about methodological limitationsHealth workers did not always adhere to protocols/guidelines, even when they were aware of them. Guidelines/protocols were not followed for a number of reasons.…”

“…Lack of supplies sometimes led to poor outcomes and increased the length of stay in health facilities. Lack of supplies could determine if a new clinical practice was implemented and maintained over time.Anwar 2009; Belizan 2007; Bradley 2009; de Carvalho 2012; Foster 2006; Fränngård 2006; Graner 2010; Ith 2012; Lester 2003; Mathole 2006; Penfold 2013; Pitchforth 2010; Spangler 2012; VSO 2012Moderate confidenceDue to moderate concerns about methodological limitationsLack of drugs or supplies meant mothers or their carers had to purchase their own. This sometimes led to wasted time in procuring the drugs and supplies and the creation of informal markets and corruption at health facilities.Barua 2011; Foster 2006; Fränngård 2006; Lester 2003; Pitchforth 2010; Spangler 2012; VSO 2012Low confidenceDue to moderate concerns about methodological limitations and adequacy; and minor concerns about coherenceLack of equipment limits health workers' ability to deliver quality care to mothers and their babies.…”

“…This sometimes led to wasted time in procuring the drugs and supplies and the creation of informal markets and corruption at health facilities.Barua 2011; Foster 2006; Fränngård 2006; Lester 2003; Pitchforth 2010; Spangler 2012; VSO 2012Low confidenceDue to moderate concerns about methodological limitations and adequacy; and minor concerns about coherenceLack of equipment limits health workers' ability to deliver quality care to mothers and their babies. As a result of this lack of equipment, mothers and their babies sometimes received poor quality care.Barua 2011; Fränngård 2006; Graner 2010; Lester 2003; Molina 2011; Penfold 2013; Pettersson 2006; Pitchforth 2010High confidence-Lack of blood or limited infrastructure to manage blood transfusion limited health workers from delivering appropriate care.Afsana 2001; Anwar 2009; Ith 2012Moderate confidenceDue to moderate concerns about adequacy; and minor concerns about relevanceLack of equipment, supplies, or drugs sometimes wasted health workers' time, increased their workload and risk of infection, and led to low morale.Belizan 2007; Bradley 2009; Foster 2006; Graner 2010; Lester 2003; Mathole 2006; Penfold 2013; Pitchforth 2010; VSO 2012Moderate confidenceDue to moderate concerns about methodological limitations; and minor concerns about coherencePoor, incomplete, and non-systematised patient information could lead to delayed or incorrect management of high-risk mothers, or interfered with continuity of care.Molina 2011; Pettersson 2006Low confidenceDue to serious concerns about adequacyLack of or unreliable supply of electricity, including a lack of fuel to run generators, and lack of water influenced health providers' ability to deliver quality care.…”