Janet M. Turan

HIV/AIDS AND MATERNITY CARE IN KENYA: HOW FEARS OF STIGMA AND DISCRIMINATION AFFECT UPTAKE AND PROVISION OF LABOR AND DELIVERY SERVICES

Abstract Although policies and programs exist to promote safe motherhood in sub-Saharan Africa, maternal health has not improved and may be deteriorating in some countries. Part of the explanation may be the adverse effects of HIV/AIDS on maternity care. We conducted a study in Kisumu, Kenya to explore how fears related to HIV/AIDS affect womens uptake and health workers’ provision of labor and delivery services. In-depth qualitative interviews with 17 maternity workers, 14 pregnant or postpartum women, four male partners and two traditional birth attendants; as well as structured observations of 22 births; were conducted at four health facilities. Participants reported that fears of HIV testing; fears of involuntary disclosure of HIV status to others, including spouses; and HIV/AIDS stigma are among the reasons that women avoid delivering in health facilities. Maternity workers now have to take into account the HIV status of the women they serve (as well as their own fears of becoming infected and stigmatized) but do not seem to be adequately prepared to handle issues related to consent, confidentiality and disclosure. Importantly, it appeared that women of unknown HIV status during labor and delivery were likely to be targets of stigma and discriminatory practices and that these women were not receiving needed counseling services. The findings suggest that increasing infection control precautions will not be enough to address the challenges faced by maternity care providers in caring for women in high-HIV-prevalence settings. Maternity workers need enhanced culturally sensitive training regarding consent, confidentiality and disclosure. Furthermore, this study points to the necessity of paying more attention to the care of women of unknown HIV-serostatus during labor and delivery. Such interventions may improve the quality of maternity care, increase utilization and contribute to overall improvements in maternal health, while also enhancing prevention of mother-to-child-transmission and HIV care.

HIV-related Stigma as a Barrier to Achievement of Global PMTCT and Maternal Health Goals: A Review of the Evidence

The global community has set goals of virtual elimination of new child HIV infections and 50 percent reduction in HIV-related maternal mortality by the year 2015. Although much progress has been made in expanding prevention of mother-to-child transmission (PMTCT) services, there are serious challenges to these global goals, given low rates of utilization of PMTCT services in many settings. We reviewed the literature from low-income settings to examine how HIV-related stigma affects utilization of the series of steps that women must complete for successful PMTCT. We found that stigma negatively impacts service uptake and adherence at each step of this “PMTCT cascade”. Modeling exercises indicate that these effects are cumulative and therefore significantly affect rates of infant HIV infection. Alongside making clinical services more available, effective, and accessible for pregnant women, there is also a need to integrate stigma-reduction components into PMTCT, maternal, neonatal, and child health services.ResumenLa comunidad internacional se ha fijado metas de eliminación virtual de las nuevas infecciones por el VIH infantil y una reducción de 50 por ciento en la mortalidad maternal relacionada con el VIH para el año 2015. Aunque se ha avanzado mucho en la expansión de la prevención de la transmisión materno-infantil (PTMI), existen serios desafíos para estos objetivos globales, dada las bajas tasas de utilización de los servicios de prevención en muchos lugares. Revisamos la literatura sobre estes temas en paises de bajos recursos para examinar cómo el estigma afecta a la utilización de una serie de pasos que las mujeres deben completar para una PTMI exitosa. Se encontró que el estigma afecta negativamente la aceptación del servicio y la adherencia en cada paso de la cascada de los servicios de PTMI. Los ejercicios de simulación indican que estos efectos sean acumulativos, y afectan significativamente las tasas de infección por VIH en infantes. Además de hacer que los servicios clínicos son más disponibles, efectivos y accesibles para las mujeres embarazadas, también se necesita integrar componentes de la reducción del estigma en los servicios de la salud maternal, neonatal, infantil, y de PTMI.

The Role of HIV-Related Stigma in Utilization of Skilled Childbirth Services in Rural Kenya : A Prospective Mixed-Methods Study

Janet Turan and colleagues examined the role of the perception of women in rural Kenya of HIV-related stigma during pregnancy on their subsequent utilization of maternity services.

The Stigma of Having an Abortion: Development of a Scale and Characteristics of Women Experiencing Abortion Stigma

CONTEXT Although abortion is common in the United States, women who have abortions report significant social stigma. Currently, there is no standard measure for individual-level abortion stigma, and little is known about the social and demographic characteristics associated with it. METHODS To create a measure of abortion stigma, an initial item pool was generated using abortion story content analysis and refined using cognitive interviews. In 2011, the final item pool was used to assess individual-level abortion stigma among 627 women at 13 U.S. Planned Parenthood health centers who reported a previous abortion. Factor analysis was conducted on the survey responses to reduce the number of items and to establish scale validity and reliability. Differences in level of reported abortion stigma were examined with multivariable linear regression. RESULTS Factor analysis revealed a four-factor model for individual-level abortion stigma: worries about judgment, isolation, self-judgment and community condemnation (Cronbachs alphas, 0.8-0.9). Catholic and Protestant women experienced higher levels of stigma than nonreligious women (coefficients, 0.23 and 0.18, respectively). On the subscales, women with the strongest religious beliefs had higher levels of self-judgment and greater perception of community condemnation than only somewhat religious women. Additional differences were found by race, age, education, religiosity and motherhood status on the subscales. CONCLUSION This valid and reliable scale can be used in research examining abortion stigma and related outcomes (e.g., womens health, relationships and behavior). The scale can also be used to evaluate programs and interventions that aim to reduce the stigma experienced by women who have abortions.

Intimate partner violence and engagement in HIV care and treatment among women: a systematic review and meta-analysis

Objective:We aimed to estimate the odds of engagement in HIV care and treatment among HIV-positive women reporting intimate partner violence (IPV). Design:We systematically reviewed the literature on the association between IPV and engagement in care. Data sources included searches of electronic databases (PubMed, Web of Science, CINAHL and PsychoInfo), hand searches and citation tracking. Methods:Two reviewers screened 757 full-text articles, extracted data and independently appraised study quality. Included studies were peer-reviewed and assessed IPV alongside engagement in care outcomes: antiretroviral treatment (ART) use; self-reported ART adherence; viral suppression; retention in HIV care. Odds ratios (ORs) were pooled using random effects meta-analysis. Results:Thirteen cross-sectional studies among HIV-positive women were included. Measurement of IPV varied, with most studies defining a ’case’ as any history of physical and/or sexual IPV. Meta-analysis of five studies showed IPV to be significantly associated with lower ART use [OR 0.79, 95% confidence interval (95% CI) 0.64–0.97]. IPV was associated with poorer self-reported ART adherence in six studies (OR 0.48, 95% CI 0.30–0.75) and lower odds of viral load suppression in seven studies (OR 0.64, 95% CI 0.46–0.90). Lack of longitudinal data and measurement considerations should temper interpretation of these results. Conclusion:IPV is associated with lower ART use, half the odds of self-reported ART adherence and significantly worsened viral suppression among women. To ensure the health of HIV-positive women, it is essential for clinical programmes to address conditions that impact engagement in care and treatment. IPV is one such condition, and its association with declines in ART use and adherence requires urgent attention.

Social context and drivers of intimate partner violence in rural Kenya: Implications for the health of pregnant women

More than half of rural Kenyan women experience intimate partner violence (IPV) in their lifetime. Beyond physical consequences, IPV indirectly worsens maternal health because pregnant women avoid antenatal care or HIV testing when they fear violent reprisal from partners. To develop an intervention to mitigate violence towards pregnant women, we conducted qualitative research in rural Kenya. Through eight focus group discussions, four with pregnant women and four with male partners, and in-depth interviews with service providers, we explored the social context of IPV using an ecological model. We found that women experienced physical and sexual IPV, but also economic violence such as forced exile from the marital home or losing material support. Relationship triggers of IPV included perceived sexual infidelity or transgressing gender norms. Women described hiding antenatal HIV testing from partners, as testing was perceived as a sign of infidelity. Extended families were sometimes supportive, but often encouraged silence to protect the family image. The broader community viewed IPV as an intractable, common issue, which seemed to normalise its use. These results resonate with global IPV research showing that factors beyond the individual – gender roles in intimate partnerships, family dynamics and community norms – shape high rates of violence.

First aid for obstetric haemorrhage: the pilot study of the non-pneumatic anti-shock garment in Egypt.

Objective  To compare the effect of non‐pneumatic anti‐shock garment (NASG) on blood loss from obstetric haemorrhage with standard management of obstetric haemorrhage.

Stigma as experienced by women accessing prevention of parent-to-child transmission of HIV services in Karnataka, India

Abstract In Karnataka, India only one-third of HIV-infected pregnant women received antiretroviral prophylaxis at delivery in 2007 through the state governments prevention of parent-to-child HIV transmission (PPTCT) program. The current qualitative study explored the role of HIV-associated stigma as a barrier to access PPTCT services in the rural northern Karnataka district of Bagalkot using in-depth interviews and focus group discussions with HIV-infected women who had participated in the PPTCT program, male and female family members, and HIV service providers. Participants discussed personal experiences, community perceptions of HIV, and decision-making related to accessing PPTCT services. They described stigma toward HIV-infected individuals from multiple sources: healthcare workers; community members; family; and self. Stigma-related behaviors were based on fears of HIV transmission through personal contact and moral judgment. Experience and/or fears of discrimination led pregnant women to avoid using PPTCT interventions. Government, cultural, and historical factors are described as the roots of much the stigma-related behavior in this setting. Based on these formative data, PPTCT program planners should consider further research and interventions aimed at diminishing institutional and interpersonal HIV-associated stigma experienced by pregnant women.

A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Nigeria.

To determine whether the non‐pneumatic anti‐shock garment (NASG) can improve maternal outcome.

Mechanisms for the Negative Effects of Internalized HIV-Related Stigma on Antiretroviral Therapy Adherence in Women: The Mediating Roles of Social Isolation and Depression

Background: Internalization of HIV-related stigma may inhibit a persons ability to manage HIV disease through adherence to treatment regimens. Studies, mainly with white men, have suggested an association between internalized stigma and suboptimal adherence to antiretroviral therapy (ART). However, there is a scarcity of research with women of different racial/ethnic backgrounds and on mediating mechanisms in the association between internalized stigma and ART adherence. Methods: The Womens Interagency HIV Study (WIHS) is a multicenter cohort study. Women living with HIV complete interviewer-administered questionnaires semiannually. Cross-sectional analyses for the current article included 1168 women on ART for whom data on medication adherence were available from their last study visit between April 2013 and March 2014, when the internalized stigma measure was initially introduced. Results: The association between internalized stigma and self-reported suboptimal ART adherence was significant for those in racial/ethnic minority groups (AOR = 0.69, P = 0.009, 95% CI: 0.52 to 0.91), but not for non-Hispanic whites (AOR = 2.15, P = 0.19, 95% CI: 0.69 to 6.73). Depressive symptoms, loneliness, and low perceived social support mediated the association between internalized stigma and suboptimal adherence in the whole sample, as well as in the subsample of minority participants. In serial mediation models, internalized stigma predicted less-perceived social support (or higher loneliness), which in turn predicted more depressive symptoms, which in turn predicted suboptimal medication adherence. Conclusions: Findings suggest that interconnected psychosocial mechanisms affect ART adherence, and that improvements in adherence may require multifaceted interventions addressing both mental health and interpersonal factors, especially for minority women.