1. Where do women who deliver at home fall through the cracks in the PMTCT Continuum of Care? Descriptive evidence from Zimbabwe Karen A Webb 1, D Patel 1, G Mujaranji 1, B Engelsmann 1 1 Organisation for Public Health Interventions and Development (OPHID) Trust, Harare, Zimbabwe International AIDS Conference 2012 Session: Challenges in Scaling Up PMTCT

2. Internationally 60 million non-facility births each year worldwide Results in preventable maternal and infant morbidity and mortality Limits PMTCT programme coverage Non-adherence to ARVs to prevent vertical transmission Zimbabwe Adult HIV prevalence 15%; Women 15-49 18% Increasing trend of home deliveries Percentage national home delivery in Zimbabwe 1999-2010 Background: Home delivery limits maternal and newborn health and PMTCT programmes 1 in 3 women in Zimbabwe deliver at home

3. Objective: Describe the process of home delivery and services received by mothers ante, peri and postpartum to identify gaps in the PMTCT Continuum of Care and generate recommendations for intervention.

4. Methods Methods: Descriptive, retrospective study of mothers who delivered at home in the previous 12 months in Mashonaland Central Province Mixed-method sampling: Systematic selection: facility registers of home births Purposive sampling: community level chain-referral Household-level interviews using pilot-tested, structured questionnaire Data entered using Epi Info V3.5.1 and descriptive analysis conducted using SPSS for Windows V16.0 355 women who delivered at home from catchment of 12 health facilities

5. Results: Women who delivered at home shared characteristics with the most vulnerable and isolated Rural - 81% Young - mean age 26 Limited education - Primary highest for 60% Apostolic (60.5%) or Traditional Religious Beliefs (18.9%) Resource constrained - 10.4% women, 28.4% partners formally employed Trend between increased parity and home delivery - even though 89% said home delivery unplanned Limited social support - 96% children in the household, few stay with partners

6. Results: ANC attendance rates improving but uptake is too late and # of visits not optimal Antenatal Services Intrapartum Services Postpartum / Postnatal Services 1 23 80.2% booked for ANC 78% HIV tested in pregnancy, 89.8% of whom booked for ANC However… ANC uptake late - 20+ weeks for 57.2% of women Only 24.2% attended 4+ ANC appointments

7. Results: There is more than meets the eye regarding the reasons why women deliver at home. Percentage grouped number one reasons for home delivery Fees still greatest barrier in areas with free maternity services Unskilled Birth Attendant costs approximate or exceed clinic fees High ANC uptake –with adequate planning, transport for service uptake possible Antenatal Services Intrapartum Services Postpartum / Postnatal Services 12 3

8. Results: High rates of postnatal care for babies, but uptake is not prompt. Antenatal Services Intrapartum Services Postpartum / Postnatal Services 88.2% babies taken for post- natal check-ups – only 37.5% within 72 hours after birth 3 2 1 18/20 HIV+ mothers brought in babies within 72 hours Time after birth post natal care for child accessed 63%

9. Results: The picture of postnatal care and services for mothers following home delivery is poor. Antenatal Services Intrapartum Services Postpartum / Postnatal Services 3 2 1 Significantly fewer mothers accessed postnatal care for themselves (64%) than for their babies (p< 0.0001 Pearson’s Chi-square) Only 30% reported receiving post-natal counselling

10. Results: ‘Zero uptake’ group emerged that failed to access services at critical stages along the continuum How do we find and support these increasingly invisible women? No ANC No ANC, HIV test No ANC, HIV test, PNC Mother Compounded Zero Uptake Cascade of Zero Uptake of PMTCT Continuum of Care Services Big jump from non facility birth to next level

11. Summary: There is good news and bad news about uptake along the PMTCT continuum of care for mothers who deliver at home. Antenatal Services Intrapartum Services Postpartum / Postnatal Services 321 0 facility based delivery ANC uptake and postnatal care for babies >80% Zero Uptake group dropping off at each stage of continuum… <20% before 14 weeks 24% 4+ ANC <38% babies received PPC Low PNC and counselling for mothers

12. Discussion: What are we going to do about the chasm of skilled attendance at birth? Antenatal Services 20% Postpartum / Postnatal Services 40% Intrapartum Services 40% Preventable infections and complications for mothers and babies – including vertical transmission Late Uptake Reduced PMTCT programme coverage Non adherence to ARVs Postnatal care not Prompt Low postnatal counselling = knowledge and feeding practices Non adherence to ARVs

13. Conclusion Identify and fill the cracks in the continuum: Early uptake, retention Reduce home delivery rates: priority area for unlocking coverage/adherence required for achieving virtual elimination of new paediatric infections Know Your Zero Uptakes for targeted and evidence-based outreach and intervention Health systems interventions: fees, distance Community-based interventions: demand generation, MNCH gatekeepers, supportive community environment for uptake and retention across the continuum

14. THANK YOU – TATENDA – SIYABONGA

15. Strengths and Limitations No conflicts of interest Mixed method sampling provided access to ‘unregistered’ home births and identification of zero uptakes Recall bias Friendship/proximity biases Possible social desirability bias to explain discrepancies in data Generalizability

16. Skilled Attendance or Skilled Attendants at Delivery? Best Case: “Skilled Attendance” Delivery with skilled attendant at facility Quality maternity services – ensure facility birth = skilled attendance EmONC Preventable infections and complications beyond HIV Supervised/supported PMTCT program adherence *Multi-level action and infrastructural health system and community-based support. Skilled Attendant: Striking balance between optimal public health and reality Working with TBAs Strengthening community- facility linkages Birth-packs for HIV positive women, including prophylaxis for home use Innovations: packaging (ARV pouch) and engagement strategies. *Targeted interventions building on existing capacities Skilled birth attendant coverage least equitable MNCH intervention in 54 country retrospective review (Barros et al, 2012)

17. Home Delivery Study Sampling Methodology: Example of Process

18. Women who delivered at home PMTCT programme progression 78% tested for HIV (n=277) 7% of those tested self-reported being HIV positive (n=20) Of positives, 15/17 (83%) enrolled in PMTCT programme 100% reported receiving ARVs to prevent vertical transmission Regimens reportedly received regimens behind current recommendations for both mothers and children