Understanding Predictors of Early Antenatal Care Initiation in Relationship to Timing of HIV Diagnosis in South Africa

Self-reported continuity and coordination of antenatal care and its association with obstetric near miss in Uasin Gishu county, Kenya

BACKGROUND

Continuity and coordination of care are core principles of high-quality primary health care. Optimising continuity and coordination improves maternal satisfaction. However, their association with morbidity and mortality outcomes is unclear. The obstetric near-miss approach can be used to investigate whether continuity and coordination influences the occurrence of a severe maternal outcome.

AIM

To compare self-reported continuity and coordination of care between obstetric near-miss survivors and those without near miss during pregnancy, delivery and postpartum.

SETTING

Uasin Gishu county, Rift Valley region, Kenya.

METHODS

A cross-sectional survey targeting 340 postnatal mothers. Continuity of care index (COCI) and modified continuity of care index (MCCI) were used to estimate longitudinal continuity. The Likert scale was administered to measure perceived continuity and coordination of care. Mann-Whitney U test and binomial logistic regression were used for hypothesis testing.

RESULTS

COCI and MCCI were lower among near-miss survivors (COCI = 0.80, p = 0.0026), (MCCI = 0.62, p = 0.034). Near-miss survivors scored lower on items assessing coordination between a higher-level provider and usual antenatal clinic (mean = 3.6, p = 0.006) and general coordination of care during pregnancy (mean = 3.9, p = 0.019). Presence of a non-life-threatening morbidity in pregnancy was associated with occurrence of near miss (aOR = 4.34, p = 0.001).

CONCLUSION

Near-miss survivors scored lower on longitudinal continuity and coordination of care across levels. Further research should focus on strengthening coordination, determining the optimal level of longitudinal continuity and improving systems for early identification and management of morbidities in pregnancy.Contribution: The results of this study show that while longitudinal and relational COC is important during the antenatal period, the presence of a non-life-threatening condition in pregnancy remains the most important predictor of the occurrence of a near miss.

Type of occupation and early antenatal care visit among women in sub-Saharan Africa

Background

Type of occupation has been linked to early antenatal care visits whereby women in different occupation categories tend to have different timing for antenatal care visits. Different occupations require varying levels of commitment, remuneration and energy requirements. This study, therefore, sought to investigate the association between the type of occupation and early antenatal care visits in sub-Saharan Africa.

Methods

This is a secondary analysis of Demographic and Health Survey data from 29 countries in sub-Saharan Africa conducted between 2010 and 2018. The study included 131,912 working women. We employed binary logistic regression models to assess the association between type of occupation and timely initiation of antenatal care visits.

Results

The overall prevalence of early initiation of antenatal care visits was 39.9%. Early antenatal care visit was high in Liberia (70.1%) but low in DR Congo (18.6%). We noted that compared to managerial workers, women in all other work categories had lower odds of early antenatal care visit and this was prominent among agricultural workers [aOR = 0.74, CI = 0.69, 0.79]. Women from Liberia [aOR = 3.14, CI = 2.84, 3.48] and Senegal [aOR = 2.55, CI = 2.31, 2.81] had higher tendency of early antenatal care visits compared with those from Angola.

Conclusion

The findings bring to bear some essential elements worth considering to enhance early antenatal care visits within sub-Saharan Africa irrespective of the type of occupation. Women in the agricultural industry need much attention in order to bridge the early antenatal care visit gap between them and workers of other sectors. A critical review of the maternal health service delivery in DR Congo is needed considering the low rate of early antenatal care visits.

Association between viral suppression during the third trimester of pregnancy and unintended pregnancy among women on antiretroviral therapy: Results from the 2019 antenatal HIV Sentinel Survey, South Africa

OBJECTIVES

About half of the pregnancies among women living with HIV (WLWH) receiving antiretroviral therapy (ART) in sub-Saharan African countries are reported to be unintended. Unintended pregnancy is associated with late initiation of antenatal care (ANC), and may delay provision of viral load monitoring services, antenatal adherence counselling and support, and other services that promote sustained viral suppression throughout pregnancy. This study examines the association between unsuppressed viral load during the third trimester of pregnancy and unintended pregnancy among women who initiated ART before pregnancy.

METHODS

This was an analysis of data from a national antenatal survey conducted at 1 589 public health facilities in South Africa between 1 October and 15 November 2019. Consenting pregnant women aged 15-49 years attending ANC during the survey period were enrolled. Demographic and clinical data were collected through interview and medical record review. Pregnancy intention was assessed using two questions from the London Measure of Unplanned Pregnancy, and responses were categorized as "unintended," "undecided," and "intended." Blood specimens were collected from all women and tested for HIV; and if positive, a viral load test was performed. A survey domain-based poisson regression model examined the association between unsuppressed viral load during the third trimester of pregnancy and unintended pregnancy among women who initiated ART before pregnancy. Viral suppression was defined as viral load <50 copies/mL.

RESULTS

Of 10 901 WLWH with viral load data available, 63.3% (95% confidence interval (CI): 62.4%-64.1%) were virally suppressed. Among the 2 681 women (representing 24.1% of all WLWH with viral load data) who initiated ART before pregnancy and were in their third trimester at the time of enrolment, 74.4% (95% CI: 73.0%-75.8%) were virally suppressed. In the same population, the proportion virally suppressed was lower among women whose current pregnancies were unintended (72.1%, 95% CI: 70.1%-74.1%) compared to women whose pregnancies were intended (78.3%, 95% CI: 75.9%-80.5%). In multivariable analyses adjusted for age, gravity, marital status, education, location of facility and syphilis status, unintended pregnancy was associated with unsuppressed viral load during the third trimester (adjusted relative risk: 1.3, 95% CI: 1.1-1.4) among women who initiated ART before pregnancy.

CONCLUSION

The identified association between unsuppressed viral load and unintended pregnancy among pregnant women who initiated ART before pregnancy highlights the need to strengthen routine assessment of fertility preferences and provision of contraceptive services to reproductive age WLWH receiving ART.

Time of HIV diagnosis, CD4 count and viral load at antenatal care start and delivery in South Africa

Background

Despite the success of prevention of mother to child transmission (PMTCT) program in South Africa, the 30% HIV prevalence among women of childbearing age requires the PMTCT program to be maximally efficient to sustain gains in the prevention of vertical HIV transmission. We aimed to determine the immunologic and virologic status at entry into antenatal care (ANC) and at childbirth among HIV positive women who conceived under the CD4<500 cells/μl antiretroviral therapy (ART) eligibility threshold and universal test and treat (UTT) policies in the Gauteng province of South Africa.

Method

We conducted a retrospective cohort study of 692 HIV positive adult (>18 years) postpartum women who gave birth between September 2016 and December 2017. Demographic, viral load (VL) and CD4 data at ANC start (3–9 months before delivery) and delivery (3 months before/after) were obtained from medical records of consenting women. We compared CD4≥500 cell/μl and viral load (VL) suppression (<400 copes/ml) rates at ANC start and delivery among women with a pre-pregnancy ART, women known HIV positive but with in-pregnancy ART and newly diagnosed women with in-pregnancy ART. Predictors of having a high CD4 and suppressed VL were assessed by log-binomial regression.

Results

Of the 692 participants, 394 (57.0%) had CD4 data and 326 (47.1%) had VL data. Overall women with a pre-pregnancy ART were more likely to start ANC with CD4 count≥500 cell/μl (46.3% vs 24.8%, adjusted risk ratio (aRR) = 1.9; 95% confidence interval (95% CI): 1.4–2.5), compared to newly diagnosed women. This difference was no longer apparent at the time of delivery (aRR 1.2 95% CI: 0.4–3.7). Similarly, viral suppression at delivery was higher among women with pre-pregnancy ART (87.2% vs 69.3%, aRR 1.3, 95% CI: 1.1–1.6) as compared to the newly diagnosed women. Viral suppression rate among newly diagnosed women increased substantially by the time of delivery from 43.5% to 69.3% (p = 0.001).

Conclusion

These results show that pre-pregnancy ART improves immunologic and virologic control during pregnancy and call for renewed efforts in HIV testing, linkage to ART and viral monitoring.

Reasons for late presentation for antenatal care, healthcare providers' perspective

BACKGROUND

Antenatal care (ANC) provides healthcare services to pregnant women in an attempt to ensure, the best possible pregnancy outcome for women and their babies. Healthcare providers' understanding of their patient's behaviour and reasons for engagement in care and their response to this insight can influence patient-provider interactions and patient demand for ANC early in pregnancy. We examined the insight of healthcare providers into women's reasons for starting ANC later than the South African National Department of Health's recommended 20 weeks gestation. We also looked at the impact of late ANC presentation on overall healthcare providers' work experiences and their response in their interactions with patients.

METHODS

In-depth interviews were conducted with 10 healthcare providers at Maternal Obstetrics Units (MOU) and Primary Healthcare Centres (PHC) in Gauteng, South Africa. Healthcare providers were selected with the assistance of the facility managers. Data analysis was conducted using the qualitative analysis software NVivo 11, using a thematic approach of pinpointing, examining, and recording patterns within the data.

RESULTS

Healthcare providers were aware of patients need for secrecy in the early stages of pregnancy because of fears of miscarriage and women's preference for traditional care. Women with prior pregnancies presumed to know about stages of pregnancy and neglected to initiate ANC early. Barriers to early ANC initiation also include, women's need to balance income generating activities; travel cost to the clinic and refusal of care for coming after the daily patient limit has been reached. Healthcare providers encounter negative attitudes from un-booked patients. This has a reciprocal effect whereby this experience impacts on whether healthcare providers will react with empathy or frustration.

CONCLUSIONS

Timing of ANC is influenced by the complex decisions women make during pregnancy, starting from accepting the pregnancy itself to acknowledging the need for ANC. To positively influence this decision making for the benefit of early ANC, barriers such as lack of knowledge should be addressed prior to pregnancy through awareness programmes. The relationship between healthcare providers and women should be emphasized when training healthcare providers and considered as an important factor that can affect the timing of ANC.

Perceptions of HIV Preexposure Prophylaxis Among Young Pregnant Women from Rural KwaZulu-Natal, South Africa

Young sub-Saharan women are at particularly high risk of HIV acquisition during pregnancy and the postpartum period and would potentially benefit from preexposure prophylaxis (PrEP). From June to August 2016, we interviewed 187 HIV negative pregnant women 18-24 years old in Tugela Ferry, Kwazulu-Natal province, a rural and among the poorest subdistricts in South Africa. Demographic data, HIV and PrEP knowledge, HIV risk, and readiness for oral tenofovir-based PrEP were collected using an information-motivation-behavior model-formatted instrument. Mean age was 20.3 years, 179 (95.7%) were unemployed, and 137 (73.3%) reported sex with one partner in the last month. Most were concerned that their sexual partner (95.2%) potentially had HIV or had other sexual partners in the last month (36.4%). Despite this, only 7 (3.7%) women reported that condoms had been used consistently during sex; most (97.3%) felt powerless to negotiate condom use with their partner. There was widespread interest in taking PrEP (97.3%), and most women (>97%) reported possessing the skills to take pills regularly, would commit to monthly visits, and were motivated to remain HIV negative to take care of their families. Young pregnant rural South African women are cognizant of their HIV risk and interested in prevention. Impending motherhood may portend increased interest in HIV prevention. We identified three potential obstacles to successful PrEP rollout among young pregnant women: hesitation about PrEP effectiveness (46%), perceived HIV stigma (53.5%), and risk compensation through decreased condom use (9.6%). Comparative studies of motivations, skills, and rates of initiation and adherence among pregnant and nonpregnant women are needed to inform optimal implementation efforts.