Improving the childbirth experience
April 2013 - A thirty-five year-old woman, seven-months into her pregnancy, looks attentive as she is counselled in a consultation room about the treatment and care she and her unborn baby need to receive because of her HIV-positive status.
The woman, who wants to be known only as Tecla, already has four healthy children from her first husband, who died in an accident. She concedes that her HIV-positive diagnosis came as a shock because she was not suffering from any obvious illnesses and had previously tested HIV negative three times. Initial results of the 2010 Modes of Transmission study found that about 56 per cent of new HIV infections occur among individuals in low risk heterosexual relationships where one partner is HIV positive and the other is not, like in the case of Tecla. “I haven’t told anyone except for my (second) husband,” says Tecla. She adds that her second husband, a soldier who also tested positive, “is supportive”.
Tecla’s journey by public transport to the hospital took five hours because the mini bus she travelled in broke down. Although weary, Tecla is keen to hear the advice from a specially-trained nurse and do whatever she can to prevent passing on the HIV virus to her unborn baby and to keep herself and her family healthy. If she does not participate in a Prevention of Mother to Child Transmission (PMTCT) programme, she has a 30 per cent chance of passing the virus to her unborn baby.
Tecla is right to be so concerned. The standard of health care has fallen dramatically in Zimbabwe. Many highly skilled health personnel have left the country due to the socio-economic crisis and some health facilities charge user fees which are prohibitive for the poor.
In addition, the under-five mortality rate has increased by 20 per cent and maternal mortality has doubled since 1990. Today, in every 138 live births, one pregnant woman or new mother will die just before, during or just after giving birth. Even if they survive, their newborn babies are particularly vulnerable. Some 94 children in every 1000 live births die before their fifth birthday, a significant number of those soon after birth. Most of the causes are preventable.
HIV and AIDS are a major risk factor. They contribute indirectly to 26 per cent of maternal deaths and directly to 21 per cent of under-five mortality. However, Tecla is more fortunate than many other pregnant women as she attends the Neshuro District Hospital. Some 200 kilometres from Masvingo, it is one of the model sites where services in maternal and child health, supported by UNICEF, are working much better than in most places, and unlike other hospitals, she did not have to pay anything to access the services.
This Continuum of Care model is one that connects quality essential maternal, newborn and child health packages throughout pregnancy, childbirth, childhood and adolescence. It is made possible when there are strong links between the home, community health services and the district hospitals.
Tecla has been referred from the health clinic in her village to this district hospital where she will be started on what is known as the “More Efficacious ARV prophylaxis regime” for PMTCT. This means that she will receive the latest preventive and treatment measures for PMTCT recommended by the World Health Organization (WHO) and adapted by the country. The hospital is equipped with a portable Point of Care machine which measures the amount of immune T cells in her blood (the CD4 count) in just 20 minutes. It is used by nurses who were recently trained with UNICEF support. Before, blood samples had to be sent off to a medical laboratory at the provincial hospital for testing and analysis, a process that could take weeks.
If the HIV-positive pregnant woman has a CD4 count below 350 she will be put on lifelong antiretroviral therapy (ART) immediately for PMTCT and for her own health. “We are now strides ahead because we can test for HIV, measure the CD4 count and offer ART all on the same day,” says Dr Itai Matibiri who works at the hospital. “Before, we used to lose some of the women who tested HIV positive while waiting for the results.”
Tecla says she appreciates having her antenatal care and HIV and AIDS services all in one place. “I would not want to queue in a special clinic to receive the HIV drugs,” she says.
As there are no comprehensive obstetric care services near Tecla’s home, and she could develop complications during the last stages of her pregnancy or during childbirth, Tecla is advised to use the maternal waiting home for pregnant women at the hospital a few days before her expected delivery date. The waiting shelter has a capacity for 27 expectant mothers, and is equipped with beds, mosquito nets and bed linen. The women need to bring their own food but there is a kitchen where they can cook. Tecla plans to stay there a few days before she gives birth, but she concedes, “I am worried about who will look after my younger children while I am here.” Her youngest child is 10 years.
Another major advance, says the doctor, is that in surrounding villages, like that of Tecla’s, the Dried Blood Spots (DBS) test for early infant diagnosis for HIV is now available. Tecla can reliably have her baby tested for HIV at six weeks instead of waiting 18 months.
Hopefully Tecla will successfully adhere to the PMTCT programme, but if her baby becomes infected, and is left untreated, the baby will have a 35 percent chance of dying by its first birthday and a 53 percent chance of dying before the age of two. However if an HIV-positive baby receives prophylactic antibiotics, such as cotrimoxazole, as well as ART, soon after diagnosis, the baby has a good chance of surviving childhood and living a long, healthy life.
The nurse, Vhasaison Josam, also advises Tecla about infant feeding. This is another way she could pass on the virus to her baby if she is not careful. She has opted to exclusively breastfeed her baby up to six months like she did the rest of her children. It is one of the safest forms of infant feeding, especially because Tecla will be on ART herself.
Once back in her village, Tecla and her newborn baby will be supported by village health workers. With UNICEF support, the village health workers in the area have been trained to ensure that Tecla and her children are living in a healthy, hygienic environment and that the children are well nourished. They are also trained to advise the mother when to seek medical health and to remind pregnant women who live in remote areas or who are at risk to use the maternal waiting homes at the hospitals. They also follow up on other preventive health measures, especially vaccinations for children under five. A disturbing fall in vaccinations has led to measles now accounting for eight per cent of childhood deaths.
Tecla says all her children except the last one had their vaccinations on time. “I didn’t control the vaccines of the last one properly as she was at my grandmother’s home while I worked.” Tecla, who was doing trading at the time, has now opted to stay at home and farm, mainly subsistence farming.
Tecla is also adamant that she will adhere to the ART treatment and the PMTCT programme. “I will manage to adhere because I have to,” she says.