Participation of traditional birth attendants in prevention of mother-to-child transmission of HIV services in two rural districts in Zimbabwe: a feasibility study

In the year 2000, the member countries of the United Nations agreed to reduce the mortality rate of children younger than five years of age by two-thirds and maternal mortality rate by three quarters by 2015 as part of the Millennium Development Goals (MDGs) [1]. However, these goals are unlikely to be achieved due to the inability of current maternal and child health programmes to reach the poorest households. Achieving the health MDGs will be a major challenge in the years ahead, and yet these goals must be attained if we are to succeed in reversing the global HIV/AIDS epidemic [2].

Women account for half of the 33.2 million people living with HIV-1 in 2007. Sub-Sahara Africa remains the most affected region where more than two-thirds (68%) of HIV-infected people live with females constituting 61% of those infected [3]. Thus; high levels of maternal mortality co-exist with high levels of HIV prevalence among women of childbearing age [4]. In this context, there are important disparities with respect to access to health care for women [5]. Data from the World Bank shows that in the poorest 20% of households in most developing countries, more than 90% of deliveries take place at home [6]. Consequently, each year more than 60 million women worldwide deliver without the assistance of skilled care [7].

With such high maternal mortality rates in resource-poor settings, priority interventions through the 'Safe Motherhood Initiative' have been proposed and implemented. This public health strategy emphasises safe delivery through the provision of skilled birth attendants, improved basic obstetric services in health facilities, development of prenatal care, access to emergency obstetric care in hospitals, and family planning as key interventions to reduce neonatal and maternal mortality [8]. It is now 20 years since the Safe Motherhood initiative was launched and little progress has been reported [9, 10]. Accomplishments have been achieved concerning greater knowledge about what works and what does not, but overall the reduction in maternal mortality has been modest with a decline of 5.4% between 1990 and 2005. The regions of Sub-Saharan Africa, western Asia and south Asia have shown little progress [11, 12]. The stated reasons for this have included: absence of a clear focus, strategic errors such as focusing only on mother's risk of complications through screening at antenatal consultations, and an over reliance on traditional birth attendants (TBAs) [13, 14].

Skilled attendance at birth is a key indicator for measuring progress towards improved women's health. Available data from developing countries show an important increase in skilled attendance at birth: from 45% to 54% between 1990 and 2000, except for the sub-Saharan Africa region, where coverage has stagnated at approximately 40% [15]. Additionally, a recent report confirms that world-wide, for the year 2007, an estimated 63% of all births were attended by a skilled health-care worker with considerable variations between developed regions (99%) as compared to developing countries (59%) [16].

In Zimbabwe, maternal mortality rates have risen to over 880 deaths per 100,000 live births [17] and HIV/AIDS is seen as one of the major contributing factors [18]. Current national data shows that although more than 90% of pregnant women reportedly attend formal health facilities for antenatal care at least once during pregnancy, more than 31% of deliveries take place outside the formal health system (an increase compared to the 1999 data recorded in 1999 of 23%) with selected provinces reporting up to 42% [19]. These deliveries are assisted by either trained, untrained TBAs or family members.

Zimbabwe has one of the greatest HIV burdens in the world with an average antenatal HIV prevalence rate of 15.6% [20]. Prevention of mother-to-child transmission of HIV (PMTCT) is among the key HIV prevention strategies in the country's national HIV/AIDS response. In spite of the important efforts and the rapid expansion of the national PMTCT programme, uptake of PMTCT remains suboptimal. Certain steps of the intervention cascade need to be substantially improved to increase the coverage of services particularly in the later stages of the intervention.

In 2006, 19 578 pregnant women were identified nation-wide as HIV-infected, of whom 60% received some form of antiretroviral (ARV) prophylaxis to prevent transmission of the virus to their babies. This translated to approximately 30% coverage of the total number of HIV positive pregnant women in need [21]. Limited ANC services with an increase in home deliveries is not only reducing access to a skilled practitioner through maternal services but also restricts the opportunities to provide PMTCT services in a context of an accelerated economic crisis [22, 23], specially in rural areas [24]

Recent data shows that, in low-and middle-income countries, the proportion of HIV-positive pregnant women receiving antiretroviral prophylaxis for PMTCT in 2006 was 23% [25]. Globally, PMTCT coverage is far below what is required to meet the United Nations target of reducing the proportion of children infected with HIV by 50% in 2010 [26]. The attainment of these figures will need that 80% of all pregnant women accessing antenatal care receive services for PMTCT of HIV [27, 28]. This will require strengthening of maternal and child health services as well as the health systems and the development of new interventions to improve the uptake of PMTCT services.

Antenatal care as well as deliveries in an institutional setting with skilled health workers for all women remains a distant reality. In resource-poor countries, between 60% and 90% of deliveries in rural areas are assisted by TBAs [29, 30]. Preference for home births is associated with cultural norms and religious beliefs. TBAs speak the local language, have the trust of community members and can provide psychosocial support at birth [31].

Public health programmes are seeking to enhance the role of TBAs by encouraging their participation in PMTCT programmes [29, 32, 33]. Given the potential coverage of the underserved population, participation of TBAs has been piloted to help improve the coverage and quality of services offered to rural populations; their participation being defined by a package of activities that they are allowed to perform.

The main objective of this study was to evaluate the acceptability and feasibility of reinforcing the role of TBAs in the family and child health services through their participation in the PMTCT programmes in two rural districts of Zimbabwe.

Current PMTCT programmes do not reach many of the women who need them due to socio-cultural, economic, systemic and programmatic factors [38–40]. Home deliveries by traditional birth attendants are common in rural Zimbabwe and are increasing [19]. Furthermore; PMTCT programmes require complementary approaches to prevent missed opportunities in this evolving context. This report is among the first attempts to evaluate the feasibility and acceptability of the participation of TBAs in PMTCT programmes [33].

TBAs in this rural context are elderly, married or widowed and have a minimum level of education. These socio-demographic characteristics are similar to those of TBAs in other settings [41]. Untrained TBAs were younger, had less experience than trained TBAs and learned to attend births by themselves or by helping another TBA. The decrease in training programmes for TBAs in Zimbabwe could explain for the younger age amongst untrained TBAs.

The integration between community health workers such as TBAs and the formal health services can bring valuable benefits to community-based public health interventions and open ways for a number of activities related to prevention and care as has been shown in other reports [42, 43]. Complementary approaches, in which community-based interventions are paired with the strengthening and/or expansion of services at the health facility level, also have the potential to address a variety of other health challenges, such as uptake of HIV testing and compliance to PMTCT regimens [33, 44].

Recent studies have alluded to problems associated with home deliveries with reference to uptake of PMTCT interventions [45, 46]. The present study has demonstrated that beyond TBAs' current activities which include assistance during delivery and in the postpartum stage, they are willing to expand their scope of work in mother-and-child activities to include PMTCT with some limitations identified such as accompanying the child to the health centre for medication and assisting the health centre in the documentation of ANC services. This data suggests the need to strengthen the health care network system between the formal health services and the communities including TBAs. For this, integrating the services of TBAs into the mainstream health care delivery system is required. The existing health care system will have to build-up a partnership with TBAs who operate in the informal sector and help develop communication skills in the referral process. Furthermore, health authorities and health staff need to recognise the cultural and practical contribution of TBAs to the health system.

The success of community-based interventions that emphasize the participation of TBAs depends on the role and status of TBAs in a given community. In India, a 62% reduction in neonatal mortality was achieved through a community-based approach that included training of TBAs and local women to treat sick newborns at home [47]. Furthermore, a trial in Pakistan reported substantial benefits in the reduction of perinatal mortality and maternal mortality by training and integrating TBAs in the health system [48].

Our results reveal that TBAs in this setting have limited knowledge on HIV/AIDS issues in general and PMTCT in particular. This can be improved through the training of these women who are already available and working in the community. This training will need to be tailored to the tasks that they are expected to perform, the knowledge and skills required and adapting the training curricula to the corresponding education level. A recent meta-analysis of 60 studies indicated that training TBAs was associated with significant improvements in their level of knowledge and the quality of advice they provided on family and child health [49].

The present study adds weight to the need of reinforcing TBA's knowledge on MTCT prevention measures before they can contribute to the provision of PMTCT services. At the moment, in this rural setting, TBAs' advice to women on HIV/AIDS issues (including PMTCT) is not frequent. At national level, there is a need to up-date the national TBA training manual by including basic concepts of HIV prevention [50]. In Tanzania, it has been shown that TBAs, if given additional skills and motivated, can be used effectively in program implementation and contribute to reaching women who deliver outside health facilities with PMTCT interventions (from counselling to providing single-dose nevirapine [sdNVP]) [51]. After careful selection, training and sustained and regular supervision, TBAs played an important role in supporting and referring pregnant mothers for facility-based PMTCT services in Uganda [52].

Performing a blood test was one of the activities TBAs refused to practice in the study. The application of this intervention by community workers such as TBAs is directly related to the national policy of each country and if ever promoted will need to include continuous supervision and follow-up. The first reported PMTCT programme to use TBAs to provide confidential HIV counselling and testing utilizing an oral fluid rapid test has been in Cameroon [32]. TBAs also dispense NVP to HIV positive women and ensure that the newborn receives postpartum NVP prophylaxis as an integrated strategy in the PMTCT programme. This approach has been done through community participation, training and complemented with supervisory nurses who visit villages at monthly basis.

Involving TBAs in PMTCT interventions is supported by various individual reports that have shown improvement of TBAs' effectiveness in the provision of public health interventions [53, 54]. A recent systematic review showed that TBA training appears to increase antenatal care attendance rates by 38% [55].

In these two rural districts of Zimbabwe, the success of MTCT prevention programmes could be improved by strengthening community-based programmes, and include TBAs who could: establish links between the community and health services and, provide health education to encourage increased use of ANC services, hence accessibility to PMTCT; sensitize communities aiming at a family-centred PMTCT approach [24, 56] including information and communication of basic concepts on PMTCT and the importance of HIV testing for the pregnant women and their partners; provide community-based counselling and testing services for HIV [33, 57]; support of and adherence to follow-up of PMTCT regimens [45, 50]; provide mother-infant adequate referral [58, 59]; counsel women to bring newborns to a health centre for the infant dose of NVP; supervision of home administration of infant dose NVP through single-dose blister packs for newborns [60, 61]; support women to adopt safer infant feeding practices and promote and support of family planning and; provide care and support to affected families. The dispensing of medications to women in PMTCT programmes as has been reported elsewhere will strongly depend on the national policy of each country and the availability of an efficient training and supervision system [32, 51].

Even though doubts have been stated on the possible significance of health improvements that would be gained by attributing HIV prevention and care tasks to TBAs during home deliveries in developing countries [62, 63], our data allow the assumption that using these primary health workers for community health interventions including PMTCT may have a potential improvement of perinatal and maternal health indicators.

Another important finding was a positive association between women who delivered at home and the opportunity they had to choose the place of delivery. Decision-making power, gender inequalities and social pressure especially from spouses and other relatives has been reported to significantly influence the use of maternal and child health care [64, 65]. It has been well documented in Africa that women lack the power to make independent decisions with regard to their own health care and that of their children [66]. Even though this study did not explore in detail gender and decision making health issues, we can suggest that measures aimed at encouraging women to deliver in health centres will have to involve men if they are to be successful. Furthermore, socio-economic factors can also explain this situation as educated women tended to be better economically empowered than non-educated women and could take decisions on their own [67].

In this study, many of the women who had delivered with a TBA and TBAs themselves cited cost fees as a major determinant of choice of place of delivery, which is consistent with other findings in similar settings [5, 68]. This factor, as well as the quality of care expressed in this study as negative experiences women encounter during their interactions with health workers in previous pregnancies, have been acknowledged as important reasons for the non-use of maternal services including PMTCT services and delivering outside the formal health service [69]. In situations such as the one experienced here where women combine TBAs and professional care and where TBAs encourage women to use ANC service, strengthening existing basic antenatal service delivery in general and before introduction of additional interventions such as PMTCT programmes in particular is needed [39].

Women's cited fear of HIV testing and knowing one's HIV status was due to discrimination and stigmatization or breach of confidentiality. Fear of knowing one's HIV status has been described previously as an important reason for drop out from PMTCT services and low levels of HIV status disclosure [70]. Songok et al raised concern that non-compliance to the intrapartum dose of sdNVP in a PMTCT programme in Kenya, was due to mothers giving birth at home and fear of TBAs knowing [71]. Presence of TBAs discouraged them from taking the dose for fear of exposing their HIV status. It is thus important to extend and reinforce partnerships among different stakeholders at health centre and community level to support education and access to health information for all women in particular and the community in general in order to prevent stigma and discrimination. In addition, training, deployment and supervision of community health workers including TBAs, must emphasize the importance of confidentiality and the need to support women in the process of disclosure of their HIV-serostatus. HIV status disclosure may lead to improved access to HIV prevention and treatment programmes, increased opportunities for risk reduction and awareness of HIV risk to untested partners, which can result in greater uptake of voluntary HIV testing and counselling, [72] and adherence to the advise given to prevent postnatal and sexual HIV transmission [73].

Qualitative results shown in the FGDs confirm the willingness of TBAs to participate in PMTCT interventions. Nevertheless, as we found in the community survey, women who had delivered in a health centre or with a TBA agreed that for TBAs to be involved in PMTCT activities they need to be trained.

Several potential limitations should be addressed in conjunction with our findings. First, the sample was limited to two rural districts of Zimbabwe and as so, may not be representative of the whole of Zimbabwe. Nevertheless, the socioeconomic characteristics of women of reproductive age considered in this study reflect those of Zimbabwe and many other African settings. Second, respondents' accounts of subjective events around pregnancy and childbirth may have been prone to recall bias. However, studies have shown that the recollection of various factors related to pregnancy and delivery is accurate, even over long periods [74]. A third consideration relates to possible inconsistencies especially where the respondent could not understand the agreed Shona terminologies as this might have affected the understanding of some questions by the respondents. This was controlled to some extent through training of data collectors on the terminologies to be used for the Shona translations to minimize errors and through piloting of the tools.

We conclude that when health professionals are not available, TBAs are a significant workforce in maternity care in high HIV burden countries of sub-Saharan Africa such as Zimbabwe. Our findings suggest that in Zimbabwe, although the long-term provision of ANC services should remain in the hands of skilled attendants, encouraging the participation of TBAs in public health programmes could help to increase the coverage of mother-child health care including PMTCT. This approach has a potential to prevent missed opportunities in a context where an important number of pregnant women resort to home deliveries. Furthermore, implementation of more complex regimens for PMTCT as recommended by the WHO and planned by the Zimbabwean PMTCT programme requires not only on site availability of appropriate ARV drugs and the ability to assess the state of HIV disease of identified HIV-infected pregnant women as well as their eligibility for HAART but also monitoring and support for the administration of these short-course regimens [75]. Community health workers can have an important role in the decentralized programmatic implications of adding more complex PMTCT regimens to current basic PMTCT services, mainly with regards to support and drug adherence follow-up. A challenge for policy makers in developing countries is to make the best use of available human resources including TBAs but also to plan and implement a definite public health strategy based on essential obstetric care provided by skilled attendants.

Identifying roles for community workers such as TBAs can facilitate the improvement of mother-child health when strategies such as upgrading existing lower-level facilities, improving and building referral systems, training and supervision are considered. Here, it will be necessary to adopt health policies that do not coerce but rather legitimize and acknowledge the practice of TBAs and integrate them into specific health programmes. There is very limited evidence-based data on community interventions and the impact of community health workers in improving maternal health, including their role in HIV/AIDS interventions. Operational research in this field is still needed since it is likely that in the foreseeable future, community health workers including TBAs could contribute to the uptake and adequate coverage of PMTCT services that are needed to fulfil the MDGs in HIV/AIDS in many countries in sub-Saharan Africa and elsewhere.