Background
Methods
Study design
Study area
Name and level of study Health facilityd
| Year when PMTCT services starteda
| Provides maternity Services |
---|---|---|
Mbale Hospital | 2002 | Yes |
Bufumbo HC IV | 2005 | Yes |
Bukedea HC IV
b
| 2005 | yes |
Iki Iki HC III | 2008 | yes |
Nakaloke HC III | 2008 | yes |
Maluku HC III | 2008 | no |
Namatala HC III | 2008 | no |
Namakwekwe HC III | 2008 | no |
Busamaga HC III | 2008 | no |
TASO Mbale
c
| 2008 | no |
Total
|
10 health facilities
|
Study participants
Data collection methods
Individual interviews with health workers
Key informant interviews
Observation during PMTCT clinic days
Data analysis
Ethical considerations
Results
Social demographic characteristics of study participants
Characteristic | Frequency n = 24 n (%) |
---|---|
Sex | |
Male | 07 (29) |
Female | 17 (71) |
Health worker category
| |
Doctor | 02 (08) |
Clinical officer | 03 (13) |
Nurse/midwife | 15 (62) |
Counsellor | 04 (17) |
Length of involvement in PMTCT
| |
Less than 2 years | 04 (17) |
2-5 years | 15 (62) |
More than 5 years | 05 (21) |
Ever attended training on PMTCT
| |
Yes | 21 (87) |
No | 03 (13) |
Would like more training on PMTCT (all yes) | 24 (100) |
Respondents by level/type of health facility
| |
Mbale Hospital | 6(25) |
TASO | 5(21) |
HC IVs | 3(12) |
HC IIIs | 10(42) |
Emerging themes for strengthening the PMTCT programme
Themes | Sub-themes |
---|---|
Ensure constant availability of supplies for PMTCT | Provide requirements for health workers to offer PMTCT services - HIV test kits, ARVs for mothers and babies |
Ensure availability of skilled and up-to-date health workers (HWs) | Re-fresher training for all health workers when PMTCT policies and guidelines change |
Provide support for mothers beyond HIV testing | Psycho-social support for women through support groups and follow-up visits by health workers. |
Ensure adequate integration and universal rollout of PMTCT services | Avail maternity services at lower health facilities, provide ARVs for mothers in ANC |
Deal with the challenge of continuing HIV stigma | Provide ARVs and other drugs within the maternal and child health clinics |
Address heavy work load of health workers | Adequate number and categories of HWs, supportive PMTCT aids - IEC materials |
Ensure constant availability of supplies for PMTCT
I can't say we are doing well. We sometimes lack test kits, Nevirapine for mothers and that for babies. These are the things that make PMTCT. We are even worried that things may get worse because PREFA which has been giving us most of these supplies is closing this month (March 2010). For me, government needs to do everything possible to avail us with at least HIV testing kits and ARVs for mothers and their babies (Health Worker, Mbale Hospital).
Like now we do not have nevirapine. If we get a mother who needs it we can only refer her to Budaka HC IV. If they also do not have it they will refer her to Mbale Hospital and this makes the process very costly for women and their families. Transport by boda boda (motorcycle) to Budaka costs 2 500 Uganda shillings (about 1.4 USD) if the mother has the money she goes. The truth is that most women cannot afford that money. ....these are the things government should address if they want the PMTCT programme to work (Health worker, Health Centre A).
We need government and donors to listen and understand us. We have practical health care needs which frustrate us. Like when we are few health workers, or we do not have nevirapine to give the mothers and their babies what do you do in such cases? The bad thing is that community leaders and every one else expect good services without giving us the needed tools to work (Health worker, Mbale Hospital)
We encourage women to come with their partners to test, but there are times when some men come and by bad luck we have no HIV test kits. It frustrates me, because it is really very hard to convince men to come with their wives for antenatal and when we miss them because of shortages it takes us a step behind....( Health worker, Health Centre C).
At TASO, we counsel and encourage pregnant women in our programme to give birth at the nearby health facilities. But many women, even those who go to health centres for delivery, call us or come here for ARVs for their babies when those drugs are not in hospital. The lack of PMTCT drugs puts an extra burden on these mothers (Health worker, TASO).
As a district we have extended PMTCT services, especially HIV testing, to all health centre IIIs. What we need to work on now is to ensure that the supplies for PMTCT are sustained at those health facilities. Shortage of testing kits and nevirapine are common complaints whenever we have PMTCT review meetings. We need a special fund designated for HIV activities rather than relying on donors all the time. Donor projects usually leave gaps when they end which the district cannot fill (District official).
We do not have enough gloves, cotton wool and other supplies, so we tell mothers to buy them. We do not like it because we know some of the women cannot afford, but we have to do it .... These supplies should be part of the PMTCT programme (Health worker Mbale Hospital).
At TASO we know that most of the HIV positive women are poor and cannot afford to pay for transport to a health facility for delivery, buy drugs and even maama kits. Some mothers in our programme whom we assess and find they cannot afford we give them some of the requirements, like gloves; Government should provide maama kits to all pregnant women including those who are HIV positive (Health worker, TASO Mbale).
Thank you for coming........... One of the things you need to know when you are pregnant is to be prepared for the baby. So you should buy Maama kit which has gloves, at least 2 pairs, two pieces of plastic sheets about 2 metres each, razor blade, cotton wool and remember sheets for the baby etc. If you cannot buy every thing at once buy one item at a time so that by the time you come to give birth you have these requirements. Things have changed, how do you expect us (health workers) to assist you to give birth without gloves? Would you be willing to give birth on a bed which another woman has used without covering it? That is why we want you to buy polythene sheets. I know it is hard for you but it is hard for us health workers as well (Health worker, Mbale Hospital).
Ensure availability of skilled and up-to-date health workers
Most health workers have been trained on PMTCT but things are changing very fast. We need regular updates otherwise we shall be challenged by mothers and communities. Some of the issues in PMTCT can be addressed in brief seminars at health units but for major changes, like introduction of new drugs for PMTCT, formal training of health workers is required... (Health worker, Mbale Hospital)
The issue of drugs still puzzles me. I am sure, I am not alone. We received Combivir last week to give pregnant mothers but I am not sure when I should give it to the mother. We have not been trained on use of these drugs (Health worker, Health Centre C)
Issues of infant feeding should also be addressed in health worker training. Some documents indicate that HIV positive women should continue breast feeding for 6 months while others indicate that breastfeeding for a long time increases the risk of HIV transmission for the baby. What should we tell the HIV positive mothers?. We need more training and reference materials (Health worker, Health Centre C).
There is more emphasis these days on couple counselling, family planning for HIV positive mothers, use of ARVs during pregnancy and breastfeeding, and the training sessions most health workers attended did not cover these topics. Health workers, often in support supervision visits and PMTCT meetings, have raised this need. We need to conduct district wide refresher training for health workers. The problem we have is that PMTCT guidelines keep changing and we need to re-train health workers time and again but resources are not always readily available to reach all health workers (District official).
Provide support for mothers beyond HIV testing
The actual areas for support among women become vivid after women have tested HIV positive but most of the education and counselling in practice focuses on the period before testing. This needs to change so that we (health workers) are provided an opportunity to meet regularly with these women, guide them on disclosure of HIV status, infant feeding... When we had support groups, mothers would meet and share their concerns and advise each other. This was very helpful. Improving the PMTCT programme should have more programmes reaching out to women than what it is now, where we wait for the women to come to us (Health worker, Mbale Hospital).
If health facilities can have, for example, support groups we can link them to our community volunteers and expert clients who can support and encourage women who have just tested HIV positive through use of testimonies (Key informant, TASO Mbale).
The challenge we get these days, very few programmes are willing to support community interventions. Every new programe that comes wants to finance health facility based activities yet we need to reach the people where they live and that is where most of the things that hinder PMTCT are located. (District Official)
One of the major challenges that we need to address in strengthening the PMTCT programme is to reach men, educate them, encourage them to test and be part of the programme. This may not be easy but we need to reach them...Men hold the key to success or failure of the programme (District Official).
TASO has tried to use HIV positive men to reach out to men. Each of the 11 TASO centres has a Positive mens' union (POMU). These are HIV positive men who have come to terms with their diagnosis; they educate communities through radio programmes and music, dance and drama, with messages targeting men (Key informant, TASO).
The challenge we have as a district in the PMTCT programme is the short nature of projects of our partners. Central and local governments need to come up with long term plans and budgets for HIV programmes so that the partners can contribute towards those plans (District Official)Government is not doing enough. There should be a conditional grant by Government for HIV. Donor driven programmes leave out some programmes, for example PREFA left out psycho-social support programmes yet they were very helpful (District official).
Ensure adequate integration and universal rollout of PMTCT services
Our mothers get tossed around. They go to Mbale Hospital and they are sent back this way. Yet here we do not conduct deliveries. Some mothers get lost along the way. We should be able to provide all services. (Health Worker, Health Centre B).
Dealing with the challenge of continuing HIV stigma
We need to provide all the care for preventing HIV transmission to babies and treatment of mothers under the same roof. So that those who fear to go to TASO they are treated by the same health facility, where they are tested and counselled (District Official).When we refer HIV positive women to TASO for ARVs most do not like it. One woman told us she will not go to TASO, even if it means her dying, she will die. Her main fear was that once she goes to TASO the news about her HIV status will reach her husband whom she feared will mistreat her. (Health worker Health Centre B).
Address heavy work load of health workers
It is good you have been here with us; you have seen the numbers of women we see and the number of health workers. On average we see 40 new mothers who need HIV counselling and testing and about 20-30 antenatal re-attendees per day. Even the space and time are not enough for us to attend to each mother and give them the best. (Health worker, Mbale Hospital)....The same health worker is expected to counsel, test, examine the mothers, and fill many registers. It is too much, even a very good health worker cannot offer his/her best in this environment (Health Worker, Health Centre B).
We are always too busy. You cannot get time to read the guidelines. By the time the day ends you are very exhausted (Health worker, Mbale Hospital).We need simplified and summarized messages like posters for quick reference. (Health worker Health Centre D).Discussions with key informants also revealed that indeed the work load of health workers involved in the PMTCT programme at some health facilities was high and more health workers were required for quality provision of health services.