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

BACKGROUND: Childbirth with a skilled attendant is crucial for preventing maternal mortality and is an important opportunity for prevention of mother-to-child transmission of HIV. The Maternity in Migori and AIDS Stigma Study (MAMAS Study) is a prospective mixed-methods investigation conducted in a high HIV prevalence area in rural Kenya, in which we examined the role of women's perceptions of HIV-related stigma during pregnancy in their subsequent utilization of maternity services. METHODS AND FINDINGS: From 2007–2009, 1,777 pregnant women with unknown HIV status completed an interviewer-administered questionnaire assessing their perceptions of HIV-related stigma before being offered HIV testing during their first antenatal care visit. After the visit, a sub-sample of women was selected for follow-up (all women who tested HIV-positive or were not tested for HIV, and a random sample of HIV-negative women, n = 598); 411 (69%) were located and completed another questionnaire postpartum. Additional qualitative in-depth interviews with community health workers, childbearing women, and family members (n = 48) aided our interpretation of the quantitative findings and highlighted ways in which HIV-related stigma may influence birth decisions. Qualitative data revealed that health facility birth is commonly viewed as most appropriate for women with pregnancy complications, such as HIV. Thus, women delivering at health facilities face the risk of being labeled as HIV-positive in the community. Our quantitative data revealed that women with higher perceptions of HIV-related stigma (specifically those who held negative attitudes about persons living with HIV) at baseline were subsequently less likely to deliver in a health facility with a skilled attendant, even after adjusting for other known predictors of health facility delivery (adjusted odds ratio = 0.44, 95% CI 0.22–0.88). CONCLUSIONS: Our findings point to the urgent need for interventions to reduce HIV-related stigma, not only for improving quality of life among persons living with HIV, but also for better health outcomes among all childbearing women and their families. Please see later in the article for the Editors' Summary

Unadjusted logistic regression of predictors of health facility birth attitude (n = 1759).

1<p>120 participants refused to answer.</p>2<p>87 participants refused to answer.</p>3<p>78 participants refused to answer.</p>*<p>p<.05.</p>**<p>p<.01.</p

Predictors of a Positive Attitude towards Delivery in a Health Facility (high HFBA score) (n = 1636) – multivariate model accounting for clustering by site^a,b.

*<p>p<.05.</p>**<p>p<.01.</p>a<p>Odds ratios (ORs) were calculated using mixed effects logistic regression adjusted for clustering by site.</p>b<p>Risk ratios (RRs) were calculated using binomial regression adjusted for clustering by site.</p

Agreement on the 11 Health Facility Birth Attitude (HFBA) items (N = 1777).

<p>Agreement on the 11 Health Facility Birth Attitude (HFBA) items (N = 1777).</p

Relationships among HIV-related stigma, HFBA and intended type of assistance during delivery.

<p>Relationships among HIV-related stigma, HFBA and intended type of assistance during delivery.</p

Socio-demographic and HIV-related characteristics of MAMAS study participants (N = 1777).

1<p>obtained from medical chart after the interview, based on offer of HIV testing during the first ANC visit.</p

Baseline perceptions of HIV-related stigma by HIV status at the time of the postpartum questionnnaire (<i>n</i> = 411).

<p>More women were tested for HIV during the interim between the first ANC visit and the postpartum questionnaire, resulting in more HIV+ women, more HIV-negative women, and fewer HIV status unknown women.</p

Multivariate logistic regression of HIV-related stigma measures and other individual-level predictor variables on delivery in a health facility (<i>n</i> = 381).

<p><i>n</i> is less than 407 due to small numbers of missing values on individual variables.</p>a<p>Estimates also account for clustering by site (health facility) as a random effect.</p>c<p>Reference category.</p><p>OR, odds ratio.</p

Comparison of baseline socio-demographic characteristics of MAMAS Study participants followed up after the birth versus lost to follow-up (<i>n</i> = 598).

a<p>For continuous variables, the mean followed by the median and range in parentheses are presented. For categorical variables, <i>n</i>'s are given followed by percentages in parentheses.</p>b<p>Data on this variable were available for women who reported currently living with a male partner.</p>c<p>Woman's self report.</p