In recognition of the fact that health research can bring numerous tangible benefits to the health status of people, IJMA shall be a catalyst for developing the next generation of top-notch researchers, scientists, academics, and public health leaders in the developing world by providing a platform for peer mentorship, intellectual exchange, and academic publishing.

  • <h7>It is morally wrong to make a mother choose between treatment for herself and treatment for her newborn.  It is morally wrong that people should be dying of AIDS when treatment is available.</h7><p><i>Michel Sidibe, UNAIDS Executive Director</i></p>
  • <h7>It is morally wrong that babies are still being born with HIV when we know how to prevent it.  It is morally wrong that children are still growing up as AIDS orphans. </h7><p><i>Michel Sidibe, UNAIDS Executive Director</i></p>
  • <h7>To be a partner for women and girls against violence and injustice, you do not have to be experts on human rights or gender. You do have to be committed to always asking in your daily work: 'How can I better engage women and girls to understand what they need'</h7><p><i>Michel Sidibe, UNAIDS Executive Director</i></p>
  • <h7>When the history of our times is written, will we be remembered as the generation that turned our backs in a moment of global crisis or will it be recorded that we did the right thing?</h7><p><i>Nelson R. Mandela, The Nelson Mandela Foundation</i></p>
  • <h7>No disease group is as vast and complex in scope as the noncommunicable diseases (NCDs). Incorporating social determinants such as income and education, the NCDs call for an equally massive and comprehensive response</h7><p><i>Mirta Moses, Director, PAHO.</i></p>
  • <h7>There are 1.2 billion adolescents across the world, 9 out of 10 of these young people live in developing countries.  Millions are denied their basic rights to quality education, health care, protection and exposed to abuse and exploitation. </h7><p><i>UNICEF, 2011</i></p>
  • <h7>A society that cuts itself off from its youth severs its lifeline; it is condemned to bleed to death.</h7><p>Kofi Annan, former United Nations Secretary-General</p>
  • <h7>Of all the forms of inequality, injustice in health care is the most shocking and inhumane.</h7><p>Rev. Martin Luther King, Jr. </p>

About the Journal

The International Journal of MCH and AIDS (IJMA) is a multidisciplinary, peer-reviewed, global health, open access journal that publishes original research articles, review articles, clinical studies, evaluation studies, policy analyses, and commentaries/opinions in all areas of maternal, infant, child health, (MCH) and HIV/AIDS in low and middle-income countries, and in populations experiencing health disparities around the world. The journal focuses on the social determinants of health and disease as well as on the disparities in the burden of communicable, non-communicable, and neglected tropical diseases affecting infants, children, women, adults, and families across the life span in developing countries and around the world.

One of the central remits of the journal is to focus on the intersection between MCH and HIV/AIDS issues around the world but more especially in the low and middle-income countries (LMICs), as classified by the World Bank. Diseases impacting populations in LMICs, also known as developing countries or the global South, are currently under-documented and underreported in existing peer-reviewed journals. IJMA therefore places a huge emphasis on the documentation and dissemination of work and new findings for neglected tropical diseases, especially when those papers are the products of collaboration between researchers in the global North and South.

IJMA’s primary focus is on the broader life-span trajectory of MCH and HIV/AIDS issues in developing countries. The journal’s Editors recognize that there are widening socioeconomic and health inequalities in populations in developed countries; therefore, IJMA welcomes high-quality papers, opinion articles, and commentaries from scientists, researchers, policy experts, and other professionals working with health disparity populations and issues in the developed countries of the world. This includes cross-national studies that compare health and social inequalities between and within racial or different social and economic groups, as well as within or between developing and developed countries.

The journal covers, but is not limited to, the following global health subject areas:

  • Life expectancy, cause-specific mortality, and human development,
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    substance use, violence and injury,
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    disability status, etc.,
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IJMA Cover Page-Volume 1, Number 1 (2012)

EDITOR-IN-CHIEF: Romuladus E. Azuine, DrPH, MPH, RN

EDITOR: Gopal K. Singh, PhD, MS, MSc

NON-PROFIT PUBLISHER: Global Health and Education Projects, Inc., Washington, DC, USA

FREQUENCY: Continuous –accepted papers are published on a rolling basis

ISSN: 2161-864X (Online)

ISSN: 2161-8674 (Print)




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Original Article

International Journal of MCH and AIDS
Volume 2, Issue 1, 2013, Pages 163 – 172
Costs and Patterns of Financing Maternal Health Care Services in Rural Communities in Northern Nigeria: Evidence for Designing National Fee Exemption Policy
Nnennaya N. Kalu-Umeh, MBBS, MPH; Mohammed N. Sambo, MBBS, FWACP; Suleiman H. Idris, MBBS, FWACP; Abubakar M. Kurfi, MBBS, MPH
International Journal of MCH and AIDS
Volume 2, Issue 1, 2013, Pages 163 – 172
Costs and Patterns of Financing Maternal Health Care Services in Rural Communities in Northern Nigeria: Evidence for Designing National Fee Exemption Policy

Nnennaya N. Kalu-Umeh, MBBS MPH;1 Mohammed N. Sambo, MBBS FWACP;2 Suleiman H. Idris, MBBS FWACP;2 Abubakar M. Kurfi, MBBS MPH.3

1National Health Insurance Scheme, Corporate Headquarters, Plot 297, P.O.W. Mafemi Crescent, Off Solomon Lar Way, Utako District, Abuja, Nigeria.

2Department of Community Medicine, Faculty of Medicine, Ahmadu Bello University, Zaria, Nigeria.

3National Health Insurance Scheme, Kaduna Zonal Office, No. 2, Waziri Drive, Off Alkali Road, Kaduna, Nigeria.

Corresponding author email:


Background: As population and access to information increases, so does the demand for health services. Unfortunately, many people who genuinely require these services do not usually have access to them. To increase access, various financing options have been used. Despite this, maternal morbidity and mortality rates remain high and spending is still largely out of pocket. This study assesses maternal health problems, preferred sources of care and the pattern of financing in a semi-rural community in North Western part of Nigeria.

Methodology: A cross-sectional descriptive study design was used. The study population consisted of women within the reproductive age group who had experienced childbirth 12 months or less prior to the study. A sample size of 240 was drawn using cluster and random sampling techniques. Interviewer administered questionnaires were used and the results were analyzed using Statistical Package for Social Sciences (SPSS).

Results: The mean age of the respondents was 29 years and 49% had no personal income. Fever was the commonest problem. Although majority received antenatal care, those who lacked antenatal care mostly cited financial difficulties. Nearly half of the women delivered at home as opposed to a health facility. On average, women spent between Nigerian Naira (N) N1, 350-N14, 850 (USD$9-99) for a total package of maternal health services. Out of pocket spending by the husbands or household heads and the women themselves accounted for 73.3% of expenses.

Conclusion and Public Health Implications: In Nigeria, women are still vulnerable to common and preventable causes of maternal morbidity and mortality due to lack of access to antenatal health care. Out of pocket spending is still a popular method of financing. Harmonization of fee exemption policies can improve access to maternal healthcare.

Key words: maternal health • maternal healthcare • financing • rural health care • Nigeria • health care financing • fee exemption

Copyright © 2013 Kalu-Umeh et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


More than two decades after the launch of the Safe Motherhood Campaign in 1987, over half a million women most of whom live in developing countries continue to die of maternal causes each year.[1] Nigeria accounts for approximately 2% of the world population; yet with an estimated 59,000 annual maternal deaths and a maternal mortality of 545 per 100,000, Nigeria is a leading contributor to the high maternal mortality rate in Sub-Saharan Africa.[2] Nigeria also accounts for almost 10% of the world’s maternal deaths.[3] There are several reasons advanced for this high level of maternal mortality. According to the 2008 National Demographic Health Survey, only 35% of Nigerian women deliver in hospitals and the leading barrier to access is lack of finances for treatment. One in three women mentioned distance and transportation difficulties as the major problem while 41% of the respondents were concerned about lack of drugs.[4] Some other factors that prevent women from accessing maternal health services include indirect costs, women’s lack of authority for decision-making and multiple demands on their time, as well as the attitude of healthcare workers.[5]

Many of the common causes of maternal mortality in Nigeria such as post-partum hemorrhage, sepsis and anemia are readily preventable, detectable and manageable. Key interventions such as ensuring antenatal care attendance and having a skilled attendant at delivery have also been identified and used to improve maternal health care in many countries. However, the use of such interventions has been found to be limited in developing countries like Nigeria. [6] One of the reasons for this is the level of health care financing, especially by the government. The introduction of user fees has been widely implemented in government health programs as a means of alleviating pressure on constrained budgets as demands for services increase. However, this has proved to be a significant barrier to access. As more people realize that health systems should not only be concerned with improving peoples’ health but also protect them against the financial costs of illness, there has been growing calls world-wide for the removal of user fees (especially for basic health services at the primary health care level). This is important in view of the fact that currently, out-of-pocket expenditure represents 70% of health expenditure in Nigeria. [7] Apart from increasing access, it will also reduce morbidity and mortality, especially for the vulnerable groups such as young children and pregnant women. These exemptions may however not ensure universal access because informal fees and other costs associated with accessing healthcare are not affected; furthermore, exemption mechanisms may be poorly implemented.

Many sub-Saharan African countries have introduced “free” maternity services in a bid to eliminate poverty as an important barrier to maternal health service access and utilization. Some states in Northern Nigeria such as Kano, Katsina, Kaduna and the Federal Capital Territory, Abuja have also introduced similar schemes in public hospitals. One of the visible positive effects of such schemes has been the recorded increase in the number of women attending formal antenatal and delivery services. However, without adequate planning and financing, “free” maternity services could result in overstretched facilities, overworked staff and dissatisfied clients.


This study was conducted in a community where ‘free’ maternal health services had been instituted in government owned health facilities, in order to assess the actual financial implications for the women and their families. Overall, we sought to provide evidence for proper planning and equitable allocation of resources, thereby increasing access to maternal health services. In general, the objectives of the study were to determine the cost of maternal health care in the designated community; and determine the pattern of financing of maternal healthcare in the community. Specifically, we sought to (1) identify the commonest maternal health problems in the community; and (2) identify the sources of maternal healthcare in the community.


Study area

Idon is one of the wards that constitute Kajuru Local Government Area (LGA) in the southern part of Kaduna state, North Western Nigeria. It is less than one hour’s drive from the state capital and comprises 5 communities namely – Ayakun, Upinin, Akyagba, Ikawur and Idon gida – with a total population of 8,952. Idon is a densely populated semi-rural area and the major ethnic group is the Kadara who are mostly Hausa-speaking. Other tribes are the Hausa, Fulani, Yoruba and Igbo who are attracted by the agricultural and commercial activities as well as the proximity to a major road. The main occupations are subsistence farming, cattle rearing, trading, and some civil service. The commonest source of water is from shallow wells though the government has provided boreholes for the community. Waste disposal is by open dumping in specified areas and most houses have pit latrines. There is one general hospital and one primary health center that serve the entire ward; there is also one public primary school and a secondary school. Most girls get married in their teens and start child bearing soon after.

Study population

The study population comprised of women, resident in Idon, within the ages 15-49 years who had experienced childbirth within one year preceding the commencement of the study and was willing to participate. Girls below the age of 15 years, women above the age of 49 years, women who had not been pregnant and delivered within the preceding twelve months and those who refused to participate were excluded from the study.

Sample size determination

The sample size for the study was determined using the formula n = z2pq/d2 where

z = 1.96 at 95% confidence interval

p = 0.2 (this was the proportion of women who had been pregnant and delivered within the preceding one year estimated from a pilot study in the same area)

q = (1-p) = 0.8

d = 5%= 0.05


n = .962 x 0.2 x0.8/ 0.052 3.8416 x 0.16/ 0.0025

n = 245.86

Adjusted for a population less than 10,000


Study method:

A cross sectional descriptive study was carried out between May and June 2010. A minimum sample size of 240 was estimated using a p value of 0.2 (which was obtained from a pilot study in the same LGA) and a significance level of 5%. A two-stage sampling method was used. First, the study area (ward) was divided into five clusters (communities) and Idon gida was randomly selected. Houses within the chosen cluster were numbered and then randomly selected to eliminate bias. Where there was more than one eligible respondent in a household, selection was made by balloting. The process was repeated until the minimum sample size was attained.

Study instrument:

The questionnaires consisted of six sections covering the socio-demographic profile, the obstetric history / common maternal problems, the sources of maternal healthcare services, the cost of the services, the pattern of financing and recommendations for the improvement of the financing of maternal care. The pre-tested interviewer- administered questionnaires were used to interview women within the reproductive age group who had been pregnant and delivered within the last twelve months.

Data management:

The interviewer-administered questionnaires were manually checked for completeness and consistency before data entry and analysis using the statistical package for social sciences (SPSS) version 16.0.

Ethical Approval:Ethical clearance was obtained from the Department of Community Medicine, Ahmadu Bello University, Zaria. Permission was sought and obtained from the local government and from the community head before the commencement of the study. In addition, before the administration of questionnaires, the aim of the study was explained to participants. Their verbal consent was obtained and their privacy and confidentiality ensured.Results:Socio-demographic characteristics:The minimum age of the respondents was 16 and the maximum age was 45, with a mean age of 29 years (+2SD). Most of them were Kadara and Hausa by ethnicity (n=128 and 34 respectively), and Christians by religion (n=192). 220 women were married. Forty-five respondents were full time housewives (totally reliant on their spouses) but the majority were farmers (n=87). The majority of the husbands were also farmers (n=104). Fifty three women had no formal education. Compared with the husbands, fewer respondents (n=34, n=39) had post-secondary education. The average monthly income for the respondents in this study was N2, 196. At the rate of N150 to a dollar, this equals US$14.6 per month or about US$0.5 per day. Most of the respondents (n=117) had no income. Only 3 of them earned more than US$66.70 monthly. In stark contrast to the income levels, the average household consisted of eight individuals.Table 1: Socio-demographic characteristics of respondents.

Characteristics Categories Frequency Percent
Age (years) 15-19
Tribe Kadara
Religion Christianity
Marital status Married
Educational level None
Occupational status Farming
Civil servant
Private employee

Maternal Health problems:

Nearly half (n=117) had had one or more previous abortions- either spontaneous or induced. Ninety one of the respondents had medical problems that necessitated treatment in their last pregnancy. Fever, which could be characteristic of malaria or other infections, was the commonest health problem that made women seek treatment during their last pregnancy (n= 27). Hemorrhage (n=16) and anemia (n=15) were also mentioned (see table 2).

Table 2: Health problems experienced in the last pregnancy

Health problem Frequency Percent
Severe vomiting
Prolonged obstructed labor
Total 91 100

Sources of maternal healthcare:

209 of the respondents received ante-natal care from a variety of sources- public and private. One hundred and four women received ante-natal care from the primary health center, their main reasons being close proximity to the center (n=76) and the time saved (n=16). Eighty-five women received ante-natal care from the general hospital which was further away; for them, the experience of the health workers (n=41) and distance (n=27) as well as cost (n=12) were the main factors that influenced their choice. Only 20 women attended antenatal care at a private healthcare facility. Of the 31 women who did not receive ante-natal care, 18 cited financial difficulties as the main reason. Others mentioned geographical distance (n=6) and cultural/ religious reasons (n=7). In addition, 101 women – nearly half – delivered their babies at home. Only 40 out of the 240 respondents (one-sixth) received all three aspects of maternal healthcare (antenatal, delivery and post-natal care)

Antenatal Care costs:

As depicted in table 3, most of the respondents (n=127) spent nothing on transportation costs for antenatal care because they walked to the facility of their choice. Ultrasound scans were responsible for 62.8% N110, 805 or (US$738.70) of total antenatal care costs for all the respondents while medications and laboratory tests accounted for 11.6% N20, 430 or (US$136.20) and 8.4% N14, 869.5 or (US$99.13) respectively. Transportation costs amounted to only N6640.5 or (US$44.27). The average amount spent on antenatal care per woman was N735 or (US$4.90).

Delivery care costs:

The cost of delivery ranged from free to N5650.5 or (US$376.70) with an average cost of N450 or (US$3) for normal deliveries as against N13950 or (US$93) for complicated deliveries requiring Caesarean sections. The cost of caesarean sections accounted for 65.7 % N166, 995 or (US$1,113.30) of total delivery costs for all the respondents while normal delivery accounted for only 19.3% N49005 or (US$326.70). Medications and transportation were responsible for N11895 US$79.30 and N11260.7 US$75.07 respectively.

Post-natal care costs:

Less than 50% of the women in this study had postnatal care (n=106) compared to number that received antenatal care (n=209). The average cost of post-natal care per woman was less than N288 or US$1.92.

Total maternal care costs:

The average cost of total maternal care therefore came to approximately N1350 or US$9 for normal delivery and N14850 or US$99 for caesarean sections per woman.

Pattern of financing:

Sixty women confirmed that the maternal services they received were ‘free’ or paid for by the government. In most cases however, the husband or household head paid (n=134), while in 42 cases, the women themselves had to pay for the services. In four cases, a religious or charity organization paid for the women. Furthermore, 63 of the respondents had at one time or the other had difficulties in paying for maternal health services. Of this number, 46 decided to manage without treatment, while 16 decided to sell an asset and one took a loan from friends. Twelve out of the 29 cases that were delayed resulted in avoidable complications and in 6 cases there were miscarriages. In response to how they felt the government could assist them in the financing of maternal healthcare, 53 of the respondents felt it was not in their place to recommend for the government and thus refused to answer this question. Fifty-one women reported that they were satisfied with the current state of affairs, and that the government should continue with the free maternal and child health scheme. Six respondents felt that women also needed to be empowered financially.

In addition, there were statistically significant associations between the monthly income of the women and difficulty in payment for maternal health services (p=0.000, p<0.05); as well as between delay in treatment due to difficulty in payment and the outcomes of the delay (p=0.000, p<0.05).

Table 3: Cost of Maternal Healthcare among the respondents

Category Services Cost (Naira) Percent
Antenatal care Ultrasound scan
Laboratory investigations
Hospital admission
Other treatment
Total 176340 100
Delivery care Caesarean section
Normal Delivery
Delivery materials
Other treatment
Total 254180 100
Postnatal care Family planning
Total 14620 100

Table 4: Inability to pay immediately and treatment outcome

Outcome of delay in treatment Inability to pay immediately
Yes (%) No (%) Total frequency (%)
No difference 11(37.9) 26 (100.0) 37(67.3)
Complications 12(41.4) 0(0.0) 12(21.8)
Loss of pregnancy 6(20.7) 0(0.0) 6(10.9)
Total 29(100.0) 26(100.0) 55(100.0)
X2= 23.989, df = 2, p=0.000


Many respondents could not accurately determine the income of their spouses so this information was not requested. Determining their own income was also a challenge for some women as their income varied from day to day or week to week; estimates were therefore used. In addition, the findings of the study cannot be generalized for other communities except those with similar characteristics.


In this study, 53 of the women did not have any formal education. This finding is not unusual in the North Western part of Nigeria although there is increasing focus on girl child education. Female education is also a critical factor in maternal and child mortality reduction because the woman’s income is more likely to be used for household needs such as food, education, medicine and other family needs.[8] Educated women are also more likely to make important family decisions about nutrition, healthcare and the use of resources.

The average monthly income for the respondents in this study was N2, 196. At the rate of N150 to a dollar, this equals US$14.6 per month or about US$0.5 per day. These findings highlight the socioeconomic status of women living in the area. Seventy-one households consisted of 10 to 14 people. The more individuals who need to be cared for may mean less money is available for women’s maternal healthcare needs.

Fever, which could be characteristic of malaria or other infections, was the commonest health problem; it was followed by hemorrhage. This is worth noting in view of the fact that antimalarial and antibiotics are part of the essential drug list in Nigeria; misoprostol has also been recently added. Similar studies done in Maiduguri in Northern Nigeria and the Ejisu district in Ghana found hemorrhage, obstructed labour, hypertensive diseases in pregnancy and sepsis to be important contributors to maternal morbidity and mortality.[2 9, 10]

Many factors limit the utilization of maternal health services in the rural areas in developing countries including Nigeria. These factors include the availability, accessibility and quality of services as well as the social characteristics of the users and their communities. In this study, the majority of the women who did not receive ante-natal care cited financial difficulty as the main reason. In another study in Bangladesh which reviewed findings from a national survey, almost half of the women were found to have had complications during pregnancy however only one in three sought treatment from a trained provider, the principal reason being the cost of care.[11 8]

While most respondents who received ante-natal care considered distance to be the major factor that influenced their choice of source of care, only 16 mentioned financial costs or affordability. This was most likely due to the state government’s free maternal and child health package was offered at both public facilities in the community- the primary health center and the general hospital- which catered for the needs of over 90% of the women in this study. The package was not offered at private health facilities and accordingly, affordability was not a factor in the choice of private hospitals. Other studies have also shown that the cost of seeking institutionalized care can act as a deterrent in the case of poor households.[9] Additionally, there is evidence that medical expenses can push even non-poor households below the poverty line.[13 11]

Health workers in the general hospital were considered to be most experienced; in addition to being the most geographically accessible, primary health centers were considered to have the least waiting times to service. It must be noted that despite the high rates of antenatal care attendance (only 31 did not attend at all), 101 women- nearly half- delivered their babies at home. This supports the 2008 National Demographic Health Survey findings that states that of the 70% of births that occur in rural areas only 27% are assisted by skilled birth attendants. [4]

Nearly every woman who attended antenatal care at the general hospital delivered at those hospitals whereas of the 104 women who utilized the primary health center, only 31 deliveries were taken. The reasons are not farfetched. Culturally, many women in the area prefer to deliver at home and usually have a female relative/ neighbor/ friend who double as a local midwife or traditional birth attendant to assist them. Indeed, some studies show that Nigerian women rate the services of traditional birth attendants as being better than that of medical healthcare practitioners especially with regards to interpersonal relationships and flexibility of payment options.

Some of the health workers, especially from public health facilities, were also said to assist at home deliveries. Apart from this, the primary health facility in the study area lacked adequate facilities to effectively manage obstetric emergencies. For example, there was no electricity or running water in the facility. It was manned by Community Health Extension Workers and a few nurses who gave health talks, routine antenatal services, immunization and the treatment of common diseases such as malaria. Cases that appeared difficult to handle or occurred at night were usually referred to the general hospital. Many women were aware of the need for specialized care during the antenatal and delivery periods but not during postnatal period. For many of them, the essence of being pregnant and cared for during that period is to have a safe delivery.

Several studies on out-of-pocket costs of maternity care in low income countries in sub-Saharan Africa and Asia have consistently shown that out-of-pocket costs of maternity care vary considerably depending on the type of delivery (normal or complicated), as well as the type of health facility (public vs. private) and the level of the health system.[11] In Uganda, Malawi and Ghana, for example, out-of-pocket costs for normal delivery (including user fees, travel costs and accommodation costs) ranged from US$2.30–22.80 in Uganda, US$0.40–7.90 in Malawi, and US$12.60–20.70 in Ghana. Fees for complicated deliveries were higher, ranging from US$13–59 in Uganda to US$68–140 in Ghana.[12] With respect to the mean cost of delivery by place of delivery, it is by far much cheaper for the women to deliver at home N332.92 or (USD2.12) than in the private health facilities N12, 638.57 or (USD84.25) in the community.

In other studies in Kenya and Tanzania, costs of normal delivery were significantly higher at private facilities than at government facilities. In Kenya, costs at private/mission facilities were twice as high as those incurred at government facilities, and in Tanzania, these costs were almost four times as high. In contrast, mean costs at mission health centers in Burkina Faso (US$3.1) were lower than those incurred at government health centers because such sites subsidized the costs of drugs and supplies.[11] Although only 18 of the respondents in this study paid unofficial or extra fees, these fees have been found to be quite substantial in some studies. For instance, in a study in Bangladesh, unofficial fees were on average 12 times higher than official fees.[13] Another study in India reported that such fees were five times the formal fees, and represented 80% of total out-of-pocket expenses.[14] A Tanzanian study also found that 73.3% of spending was actually out of pocket which is in line with the over 70% estimated for Sub-Saharan Africa.[15, 18] Notably, none of the respondents was covered by any form of health insurance whatsoever. Considering the fact that there is a National Health Insurance Scheme in place, which can help to prevent the catastrophic effects of healthcare financing and efforts, are being made to expand the scheme to rural areas, opportunities exist for intervention in the community. It might also be interesting to compare the pattern of maternal healthcare financing in the study area prior to the commencement of the free maternal health scheme and after.

It is worthy of note that treatment was only delayed in less than half of the cases that reported difficulties in paying for maternal health services. This was due mostly to familiarity with the health workers and in some instances, compassion. This brings to the fore the importance of the attitudes of health workers in maternal healthcare. However, six women still ended up with miscarriages.

Most women in the study felt it was improper for them to recommend for the government or that things should be left as they were as far as maternal healthcare financing and services were concerned. Interestingly, this highlights the social status of many women who cannot picture themselves as voices to be heard or as agents of change. Many of them were among the 60 who did not pay for the services. Others were concerned about the extension of the programmer to more rural areas, private hospitals and the less privileged. Adequate free drugs and the financial empowerment of women were also mentioned; the latter they said could be done through loans and setting up of small scale industries and government-assisted local cooperative groups. Very few women felt that more awareness needed to be created among the husbands and household heads on the importance of maternal healthcare for women. They felt the men could be reached at social gatherings and places of worship in the community.

Conclusion and Public Health Implications

From the research findings, the commonest maternal health problems identified by the women were fever, hemorrhage and anemia. The sources of maternal healthcare available to the women in the community were the traditional birth attendants, the private hospitals, the primary health center and the general hospital. A lot of women in the community still delivered in their homes as opposed to health facilities where there was a higher chance of having a skilled attendant at delivery and thus preventing maternal and infant mortality. The problems encountered in seeking maternal healthcare include financial difficulties, socio-cultural factors and distance. Most of the spending was still out of pocket. On the average, the women lived in households of 5-9 individuals and the majority (n=117) had no income; but average earnings were less than half a dollar a day which translates to N2190 or (US$14.6) a month or N26280 or (US$175.2) annually. On the other hand, the average total cost of maternal care was N1, 323 or (US$9) for normal delivery which is almost month’s earnings. Where Caesarean sections were involved, the average total cost of maternal care was N14, 873 or (US$99), almost equivalent to seven months (untouched) earnings.


1. The registration and training of traditional birth attendants in the community.

2. The institution of regular home visits by the health workers to pregnant and recently delivered women.

3. Increased advocacy to the husbands, traditional and religious leaders to increase support for health facility utilization.

4. Improvement of health facilities as well as retraining of staff.

5. The introduction of a harmonized fee exemption policy (including the private sector) or community health insurance scheme.

Acknowledgements: The authors would like to acknowledge the assistance of the Kaduna State Ministry of Health and the Kajuru Local Government Secretariat.

Competing interests: The authors declare that they have no competing interests.


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8. Koenig M A, Jamil K, Streatfield PK, Tulshi S, Al-Sabir A, Arifeen SE et al. Maternal Healthcare seeking behaviour in Bangladesh: findings from a national survey. International Family Planning Perspectives, 2007; 33(2):75-82.

9. Kowalewski M, Mujinja P, Jahn A. Can mothers afford maternal health care costs? User costs of maternity services in rural Tanzania. African Journal of Reproductive Health 2002; 6:66–73.

10. Martey JO, Djan JO, Twum S, Browne EN, Opoku SA. Maternal mortality and related factors in Ejisu district, Ghana. East African Medical Journal 1994; 71 (10): 656-60.

11. Perkins M, Brazier E, Themman E, Bassane B, Diallo D, Mutunga A et al. Out of pocket costs for facility based maternity care in three African countries. Health Policy and Planning 2009; 24 (4): 289-300.

12. Levin A, Dymetraczenko TT, McEuen M et al. Cost of maternal healthcare services in three Anglophone African countries. International Journal of Health Planning and Management 2003; 18: 3-22.

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15. Kruk ME, Mbaruku G, Rockers PC, Galea S. User fee exemptions are not enough: out of pocket payments for free delivery services in rural Tanzania. Tropical Medicine and International Health 2008; 13(12): 1442-1451.

Original Article

International Journal of MCH and AIDS
Volume 2, Issue 1, 2013, Pages 152 – 162
Individual and Community Perspectives, Attitudes, and Practices to Mother-to-Child-Transmission and Infant Feeding among HIV-Positive Mothers in Sub-Saharan Africa: A Systematic Literature Review.
Alexander Suuk Laar, MPH; Veloshnee Govender, MPH
International Journal of MCH and AIDS
Volume 2, Issue 1, 2013, Pages 152 – 162
Individual and Community Perspectives, Attitudes, and Practices to Mother-to-Child-Transmission and Infant Feeding among HIV-Positive Mothers in Sub-Saharan Africa: A Systematic Literature Review.

Alexander Suuk Laar, MPH1, Veloshnee Govender, MPH2

1Project Fives Alive! Department of Health, National Catholic Health Service, Tamale. Ghana.

2Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa, Anzio Road Observatory, 7925.

Corresponding author email:


Objectives: International guidelines on infant feeding for HIV-positive mothers promote Exclusive Replacement Feeding (ERF) (infant formula or animal milk) or exclusive breastfeeding (with no supplements of any kind). A mixed feeding pattern, where breastfeeding is combined with other milks, liquid foods or solids, has been shown to increase the risk of transmission of HIV and is strongly discouraged. However, little is known about the ability of women to adhere to recommended feeding strategies to prevent mother-to-child transmission (MTCT) of HIV from breast milk. The objective of this study was to assess the individual and community-level factors that affect perspectives, attitudes and practices of HIV-positive mothers on MTCT and infant feeding in sub-Saharan Africa as documented in peer-reviewed and grey literature.

Methods: This work is based on an extensive review of peer-reviewed articles and grey literature from the period 2000-2012. The literature search was carried out using electronic databases like, Medline Ovid, Google scholar, Pubmed and EBSCOhost. Both quantitative and qualitative studies written in English language on HIV and infant feeding with particular emphasis on sub-Saharan Africa were included.

Results: The review found low adherence to the chosen infant feeding method by HIV-positive mothers. The following factors emerged as influencing infant feeding decisions: cultural and social norms; economic conditions; inadequate counselling; and mother’s level of education.

Conclusions and Public Health Implications: Unless local beliefs and customs surrounding infant feeding is understood by policy makers and program implementers, Prevention of Mother-to-Child Transmission (PMTCT) programs will only be partially successful in influencing feeding practices of HIV-positive women. Hence programs should provide affordable, acceptable, feasible, safe and sustainable feeding recommendations that do not erode strong cultural practices. Advice to HIV-positive mothers should be based on local conditions that are acceptable to the community.

Key words: mother-to-child-transmission • PMTC and infant feeding • Cultural and social norms • HIV/AIDS • Sub-Saharan Africa • Ghana

Copyright © 2013 Laar and Govender. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Globally, of the 33.3 million individuals infected with HIV,[1] 22.5 million live in sub-Saharan Africa (SSA).[1, 2] Sub-Saharan Africa remains the region most heavily affected by HIV, accounting for approximately 69 per cent of people living with HIV globally.[3] Over the past decade, HIV prevalence among women attending antenatal clinics has unprecedentedly risen leading to an increase in HIV-positive children born to HIV-infected mothers’ worldwide.[4] According to Illiff and colleagues, 30-50% of women will pass the virus to their infants; and more than a third of all transmissions will occur during breastfeeding without appropriate interventions.[5]

In 2010, an estimated 390, 000 [340, 000–450, 000] children were newly infected with HIV of which more than 90% were living in Sub-Saharan Africa.[3] In 2008, of the 430,000 paediatric HIV infections worldwide, between 129,000 and 194,000 were attributable to breastfeeding.[4] In the absence of any interventions, the rate of Mother to Child Transmission (MTCT) in developing countries can be as high as 45 per cent with prolonged breastfeeding of up to 24 months.[5] Post-natal transmission of HIV, predominantly through breastfeeding accounts for approximately half of all MTCT in Sub-Saharan Africa where breastfeeding is prolonged.[5] In this region, HIV/AIDS accounted for 7.7 per cent of deaths of children under five years.[6]

Several studies have tried to estimate the net effect of HIV/AIDS on child mortality in Africa.[7-10] One of such studies by Adetunji in 2000, provided an overview by comparing point estimates of under-five mortality in the late 1980’s and early 1990’s, using published estimates from Demographic and Health Surveys (DHS). The study found that in Africa, HIV mortality accounted from 13% to 61% of under-five mortality depending on the country, demonstrating that the HIV/AIDS epidemic is reversing many of the gains made in child survival.[8]

Over the past decade, the WHO in partnership with other UN agencies has issued several guidelines in relation to the PMTCT and infant feeding. While each successive guideline has varied in light of evidence, a common recommendation for the prevention of transmission has been the avoidance of breastfeeding and replacement with infant formulae when possible and considered adequately safe, and discouraging of mixed feeding (combining breastfeeding with other fluids and solids). While this has clearly been successful in developed countries, this is often not been the case in developing countries and much of Sub-Saharan Africa,[11] more specifically, with regards to infant feeding. Although formula is the recommended infant feeding option for HIV-infected mothers in developed countries, this may not be a feasible or preferred choice for women in resource-poor communities and developing countries for many reasons. These include the prohibitive cost, poor infrastructure to ensure consistent availability and cultural beliefs that may compel mothers to continue breastfeeding. These socially and culturally embedded practices need to be understood and taken into account when designing and implementing infant feeding programs in the context of MTCT of HIV.

Breastfeeding is the norm in most of the world, and for good reasons such as the best nutrition for babies, protection against deadly childhood diseases, delay return to fertility, being costless, and promotion of bonding and social/emotional development in babies.[12-14] Other benefits of the promotion of Exclusive Breastfeeding (EBF) include: a healthful behavior for HIV-unexposed infants and their mothers, requires minimal preparation, is not dependent upon outside materials[4] and among other benefits which are incalculable. Yet, in today’s society, breastfeeding is often thought of as unnecessary due to diseases. The HIV epidemic coupled with the assumed benefits of infant formula for the children of all HIV-infected mothers have in complex ways, changed public ideas about infant feeding and represents a threat to well established breastfeeding practices.[15] The rise in HIV/AIDS cases puts new focus on breastfeeding as a route of transmission from mother to child especially in Africa.

Infants across all regions of the world are breastfed, although not always exclusively and there is significant variation in the percentage of infants who are ever breastfed among regions and among countries within a region.[16] According to Young and colleagues, current rates of EBF are well below targeted levels in both HIV-affected and unaffected populations around the world though increasing rates of EBF is one of the most powerful interventions to save child lives.[4] The promotion of breastfeeding could prevent 13–15% of child deaths in low-income countries.[17] In Sub-Saharan Africa, the issue of HIV transmission through breastfeeding is of public health importance particularly in countries where HIV affects significant proportion of the population and where breastfeeding is the cultural norm.[18] Studies have confirmed that about a third of HIV transmission from mother to child occurs through breastfeeding.[19, 5] This is as a result of inappropriate infant feeding practices.

According to WHO, appropriate feeding practices play a crucial role in preventing mortality and in achieving optimal health outcomes for infants and young children during the first 6 months of life.[20] Despite, the many advantages of EBF and ERF, a woman’s initial decision to EBF or ERF can be hindered by a range of societal, household, and individual factors. In light of the gap between policy and practice, the purpose of this review is to deepen our understanding of why this gap exists. We examined the evidence in terms of factors affecting perspectives, attitudes and practices of HIV-positive mothers and communities on mother-to-child-transmission and infant feeding in Sub-Saharan Africa region.


This work is based on an extensive review of peer-reviewed articles and grey literature based on the aim and objectives of the study, covering the period 2000-2012 (12 years). The literature search for peer-reviewed articles were carried out using electronic databases like, Medline Ovid, Google scholar, Pubmed and EBSCOhost, keeping in mind the fact that different authors use different terminologies. Key words and phrases like “HIV” “HIV and infant feeding”, “infant feeding practices,” “influence of breastfeeding duration,” “replacement feeding or alternative feeding”, “international infant feeding guidelines”, “WHO infant feeding guidelines”, “developing countries”, “low-income countries”, “middle-income countries”, “sub-Saharan Africa”, “resource poor settings”, “socio-economic status”, “educational status”, “counseling”, “cultural norms and practices”, “stigma” PMTCT, were used to identify the relevant literature after which duplicate records and irrelevant titles were removed. Both quantitative and qualitative studies on HIV and infant feeding with particular emphasis on sub-Saharan Africa were included. Only papers written in English which met the inclusion criteria were selected for this review.

In all, a total of 215 articles were identified through the searching. After articles excluded based on region, study subjects and year of publication, 34 articles both quantitative and qualitative English language studies met the inclusion criteria. Figure 1 presents a flowchart representing the overall selection process for the studies reviewed in this paper. This paper is based on a review of existing literature and did not require ethical approval.


Figure 1. Process for searching the relevant literature.


For the review, 34 articles comprising of 9 qualitative, 18 quantitative and 7 both quantitative and qualitative studies were analyzed. The results were categorized based on the following attributes: socio-economic, PMTCT and infant feeding counseling and cultural and social norms. Based on information gathered from the study findings, we developed a conceptual framework (figure 2) that demonstrated the interrelationships between the attributes that affect breastfeeding among mothers who are positive for HIV/AIDS. These factors influence considerations of and the relative importance of affordability, feasibility, acceptability, and sustainability of feeding options recommended for HIV-Positive mothers and the decision by the mother to adopt a particular option or combination thereof.


Figure 2. Conceptual framework

HIV- positive mothers’ exposure to PMTCT and infant feeding counseling.

Infant feeding counseling based on international guidelines is considered a basis in the prevention of MTCT of HIV in Sub-Saharan Africa. In this setting, the quality of the infant feeding counseling and the knowledge and practices of nurses or PMTCT counsellors providing the services have been called into question.

An increasing body of research documents the shortcomings of infant feeding counseling particularly in terms of counsellors’ knowledge about PMTCT and counseling skills.[21-23] A qualitative study in Moshi, Kilimanjaro region investigating counsellors’ infant feeding advice to HIV-positive women, reported that infant feeding options were not accurately explained and that informed choice of infant feeding method, as recommended in the guidelines, was seriously compromised by inadequate information leading to directive counseling.[24] In that same Kilimanjaro Region of Tanzania, a study which evaluated HIV-positive women’s knowledge following infant feeding counseling showed that the women demonstrated a good understanding of HIV transmission through breastfeeding and recommended infant feeding options.[25]

One of such studies conducted in Zambia, assessed the knowledge and understanding of HIV-positive mothers who had received pre and post-test HIV counseling of the WHO recommended infant feeding guideline reported that 35 percent of the women surveyed, understood the risk of transmission of HIV through breastfeeding.[26] This knowledge was a key factor in them opting to exclusively breastfeed in order to avoid transmitting HIV to their infants. Similarly a study conducted in Harare, Zimbabwe demonstrated that women’s knowledge of HIV and infant feeding options had improved with increased exposure to counselling.[27] Moreover, counselled mothers were 8.4 times more likely to uptake EBF than the mothers who were not exposed to counselling.[27]

In South Africa, it was reported that despite receiving counseling, knowledge and understanding of feeding options was poor.[28] This was demonstrated by the fact that 85 percent of the women who had been counselled could not define the term EBF. A Tanzanian study came out with similar findings.[29] In addition, the women’s knowledge on safe preparation of infant formula was poor and this was attributed to the fact that this had not been demonstrated to them by counsellors. The problem of poor quality counseling was also reported in a study of nurse counsellors in northern Tanzania where cousellors were not able to give quality and relevant advice to HIV-positive women on how best to feed their infants.[30] According to Ehrnst and Zetterstrom, the recommendations given and the way in which counseling is performed are the most important determinants of a mother’s decision about how to feed her infant.[31]

In Eastern Uganda, a study, which assessed how infant feeding counseling was done and experienced by counsellors and mothers in the context of infant feeding guidelines and its implications for implementation, found the counseling sessions often improvised and the tendency to simplify messages giving one-sided information was seen.[32] In that same study, different health workers presented contradicting simplified perspectives in some cases. Chopra et al. report that counseling is central to preparing mothers for making a proper informed choice about adequate feeding practices to prevent their infants from acquiring HIV infection.[28]

Socio-economic status of HIV-positive mothers

For mothers in Sub-Saharan Africa, an appropriate choice of infant feeding is fundamental to optimizing infant survival and minimizing infant morbidity and mortality. A woman’s socio-economic status may well be predictive of her acceptance of PMTCT of HIV care, and likely infant feeding behaviors.

The guidelines on HIV and infant feeding needs to be cognizant of and reflective of the fact that HIV/AIDS and poverty are inextricably linked.[33] In a context of HIV/AIDS and poverty, women are particularly vulnerable as they are among the poorest in most sub-Saharan African societies.[34] This is illustrated in the following country studies across Sub-Saharan Africa. A study in Kilimanjaro (Tanzania) on recommended replacement infant feeding options, reported that women considered formula as unaffordable but if the formula was distributed free of charge, the majority of them (82 percent) would choose this option.[35] In a Ugandan study, it was reported that HIV-positive mothers started breastfeeding their babies once UNICEF stopped donating free infant formula, suggesting issues of cost (affordability) influencing their shift.[36] Similarly in South Africa, HIV-positive women opted for replacement feeding when formula milk was provided free. Moreover, women of lower socio-economic status found it difficult to continue formula feeding when there was an interruption in the supply of free formula.[37] Similar results were reported from Kenya[38] and Nigeria.[39] Taken together, all these studies are unanimous in reinforcing that socio-economic factors are critical influences in the choices women make with regard to infant feeding.

Besides the cost of formula, other socio-economic considerations including access to clean water, electricity, and other infrastructure necessary for the safe and hygienic preparation of formula milk needs to be considered. In the Nigerian study, poor access to clean water for the preparation of formula milk was an important barrier to replacement feeding.[39] In South Africa, it was found that women who possessed a kettle, flask and electricity found it easier to feed their infants with formula milk during the night.[37] Still in South Africa, in the province of KwaZulu Natal, it was reported that women who intended to use replacement feeding were more likely to have access to clean water and a regular income.[40] Similarly, in a cross-sectional study in Eastern Uganda, the higher the educational levels and socio-economic status of women, the more likely they were to adopt appropriate infant feeding practices.[41] In a rural Kisumu District, in Kenya, higher socioeconomic status was significantly associated with lower risks of premature cessation of EBF.[42]

Cultural and social norms and practices of infant feeding options.

International guidelines on infant feeding for HIV-positive mothers promote replacement feeding (infant formula or animal milk) or exclusive breastfeeding (with no supplements of any kind). A mixed feeding pattern, where breastfeeding is combined with other milks, liquid foods or solids, has been shown to increase the risk of transmission and is strongly discouraged. Mothers’ adoption of and adherence to the recommended feeding methods is an issue.[43, 29] In the region of Sub-Saharan Africa, infant feeding practices are linked directly to a mother’s social and cultural norms.[44] Studies of feeding practices in different countries have shown a large variety of beliefs and traditions related to infant feeding. While some of these can encourage EBF or ERF others may discourage it. There are many cultural and practical obstacles to the practice of EBF.[45] Evidence has shown that some traditional beliefs, practices and rites encourage use of prelacteal feeds, as well as giving extra water, herbs and “teas” to breastfeeding babies.[46, 47] Moreover, feeding the infant water is also regarded as cultural gesture to welcome the child into the world.[48]

The influence that families and communities exert is the same irrespective of the HIV status of the women. Breastfeeding is seen as the only acceptable infant feeding method and the only way to fulfil ideals of a cultural norm and being a good mother.[25, 49] In a qualitative study in South Africa which examined infant feeding decision making and practices among HIV-positive women, it was found that key characteristics of women who achieved success in exclusivity (either in their breastfeeding or formula feeding) included the ability to resist pressure from the family to introduce other fluids and to recall key messages on MTCT risks and mixed feeding.[50]

In addition, societal expectations and norms also exert a powerful influence. In Botswana, it was found that although formula feeding among HIV-positive women was strongly encouraged by counsellors and formula was provided by the clinic, women went home only to practice mixed feeding.[51] This was attributed to influences from extended families and the community members. Similarly, Omari et al. reported in Zambia that HIV-positive women changed to mixed feeding although having started out with ERF. Once again, reasons included socio-cultural and expectations of family members (partners and mothers-in-law, extended families) and community members.[52] In Tanzania, HIV-positive mothers who were not able to do exclusively replacement feeding continued mixed feeding since they believed their milk was not enough to make the baby grow ‘fat and shiny’ as expected by kin and neighbors.[53] A study which investigated infant feeding choices and experiences of HIV-positive mothers from two Ghanaian Districts, found social pressure and local norms as factors that influenced mothers decisions to mixed feed their children.[54] From the review, it is clear that in all cultures there are a number of factors that affect women’s decisions on how to feed their children.


From this review, it is clear that in many African settings breastfeeding initiation is near universal, and early mixed feeding patterns are deeply entrenched. Adopting either EBF or ERF represents departures from the social norms. While counseling is important and a necessary condition for improved feeding choices for HIV-positive mothers, the impact of counseling about breastfeeding risks and alternative feeding methods has also not been adequate. Furthermore, the influence of socio-economic factors, family and community members often result in women not being able to adhere to the recommended infant feeding options.[49, 53]

Infant feeding represents a great challenge in the prevention of MTCT of HIV in Sub-Sahara Africa. Based on the review of the literature, we hypothesized that decisions by HIV-positive mothers with regards to infant feeding is influenced by three important sets of factors. These include knowledge of the feeding guidelines for infants born to HIV-positive mothers, socio-economic status of HIV-positive mothers and cultural norms and practices. Not only that, but also influences by their spouses/partners, family members and the community at large. These factors are linked to the issues of affordability, availability, acceptability, and sustainability of different feeding options and finally the decision by the mother to adopt a particular option or combination thereof.

Socio-economic status of HIV-positive mothers more specifically is determined by a range of factors including the mothers’ and their spouses’ professional status, Socio-economic status of her family[37-39] and educational levels.[41] Education also impacts positively on employment and income with implications for issues of affordability.[24, 55] Mothers with higher educational levels are more likely to be socio-economically better off, are more likely to adopt healthy infant feeding practices.[56] It is not surprising then that infant feeding options which often include financial considerations (e.g. cost of formula) and require access to clean water and sanitation need to be considered as important influences on the decision-making process of HIV-positive mothers. It is obvious that the socio-economic position of HIV-positive women is an important factor which influences the infant feeding decision-making process and can often explain why women who indicate their intention to replacement feed, change their decisions postpartum because of the financial challenges they face. This underscores the importance of counseling and support which extends beyond the antenatal period. In a global context of widespread impoverishment especially in developing countries, there is the need for countries to re-examine their infant-feeding policies in relation to broader socioeconomic issues and realities facing women and families.[57]

From this review, it is clear that infant feeding counseling is an important intervention for the prevention of PMTCT of HIV. PMTCT interventions include HIV testing and counseling, antiretroviral prophylaxis or treatment for mother and infant, modified obstetric practices, and support for infant-feeding practices.[5] The World Health Organization advises that HIV-positive mothers should be offered nondirective counseling on various infant feeding options that are feasible, affordable, safe, sustainable, and effective in the local context. Comprehensive PMTCT of HIV programs have nearly eliminated MTCT in developed countries.[58] However, progress in implementing PMTCT interventions in resource-limited countries has been slow.[59] It is against this background that Coutsoudis and colleagues recommend investments in high-quality, widely available HIV counseling support for choice of feeding methods for HIV-positive mothers.[60]

Clearly, counseling in the context of MTCT calls for adequate training of health workers and lay counsellors in infant feeding counseling skills, followed by monitoring and supervision which can lead to effective support to mothers in areas of high HIV prevalence. Such efforts have resulted in reduced mixed feeding and increased EBF and ERF. Counseling approaches need to effectively guide women to informed choices with support available to make these choices viable and sustainable. Reducing transmission of HIV through breast milk is dependent on the knowledge and understanding of these mothers and the quality of counseling information given to them by PMTCT counsellors or health workers. Poor quality of counseling is likely to reduce the effectiveness of these programs on infant feeding interventions in the context of HIV/AIDS. Therefore it is important that HIV-positive mothers are provided with correct information during counseling on infant feeding options to enable them choose a feeding option and adhere to it. To support counseling on HIV and infant feeding as a routine part of Maternal and Child Health, health workers and PMTCT counsellors need to be trained to provide culturally compatible counseling support that improves self-esteem and confidence and corresponds with the social norms and perceptions of mothers.

As noted earlier in this review, mixed-feeding and not exclusive breast-feeding is the norm in many cultures across the sub-Saharan Africa region. These practices are also embedded within cultural norms where communities, husbands and other significant family members play a decisive role in infant feeding decisions. Understanding and addressing local beliefs and customs can help counsellors to provide more culturally appropriate counseling about breastfeeding. Therefore, unless local beliefs and customs surrounding infant feeding and the socio-cultural aspects of HIV/AIDS is understood by policy makers and program implementers, PMTCT programs will only be partially successful in influencing feeding practices of HIV-positive women.

Conclusion and Global Health Implication

In conclusion, guidelines for infant feeding options among HIV-positive mothers are changing with informative research. Cultural factors, socialization processes, gender dimensions and socio-economic status within communities and families should be considered in recommending feasible and sustainable options. Hence, the need to take into account the social, cultural and psychological complexity of infant feeding practices when advocating appropriate infant feeding options. The need for further research into infant feeding in the context of HIV to ascertain the safety of using animal’s milk (cow’s milk), expressed heat-treated human milk and wet-nursing as infant feeding options. Finally, development of appropriate, locally produced, feasible, sustainable and affordable local nutritive foods for children in Sub-Saharan Africa.

Acknowledgements: The authors wish to express their sincere gratitude to Swedish International Development Agency (SIDA) for the scholarship granted to the corresponding author to pursue the masters’ program.


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Original Article

International Journal of MCH and AIDS
Volume 2, Issue 1, 2013, Pages 139 – 152
Has the Rate of Reduction in Infant Mortality Increased in India Since the Launch of National Rural Health Mission? Analysis of Time Trends 2000-2009 with Projection to 2015
Rajesh Narwal, MD, MPH; Lu Gram, MSc
International Journal of MCH and AIDS
Volume 2, Issue 1, 2013, Pages 139 – 152
Has the Rate of Reduction in Infant Mortality Increased in India Since the Launch of National Rural Health Mission? Analysis of Time Trends 2000-2009 with Projection to 2015
Rajesh Narwal, MD, MPH1 , Lu Gram, MSc2
1 Merlin, 207 Old Street, London EC1V 9NR, United Kingdom
2 London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
Corresponding author e-mail:;


Objectives: National Rural Health Mission (NRHM) – India was launched in 2005 to tackle urban-rural health inequalities, especially in maternal and child health. We examined national and state level trends in Infant Mortality Rates (IMR) from 2000 through 2009 to: 1) assess whether the NRHM had increased the average annual reduction rate (AARR) of IMR 2) evaluate state-wise progress towards Millennium Development Goals (MDG4) and estimate required AARRs for ‘off track’ states.

Methods: Log-linear regression models were applied to national and state IMR data collated from the Sample Registration System (SRS)-India to estimate average annual reduction rates and compare AAARs before and after introduction of NRHM. The log-linear trend of infant mortality rates was also projected forward to 2015.

Results: The infant mortality rate in rural India declined from 74 to 55/1000 live births between 2000 and 2009, with AARR of 3.0% (95% CI=2.6%-3.4%) and the urban-rural gap in infant mortality narrowed (p =0.036). However there was no evidence (p=0.49) that AARR in rural India increased post NRHM (3.4%, 95% CI 2.0-4.7%) compared to pre NRHM (2.8%, 95% CI 2.1%-3.5%). States varied widely in rates of infant mortality reduction. Projections of infant mortality rates suggested that only eight states might be on track to help India achieve MDG4 by 2015.

Conclusions and Public Health Implications: Despite a narrowing urban-rural gap and high AARRs in some states, there was no evidence that the rate of reduction in infant mortality has increased in rural India post NRHM introduction. India appears unlikely to achieve child survival-related NRHM and millennium development goals. Government should revisit the child survival related NRHM strategies and ensure equitable access to health services. More robust monitoring and evaluation mechanisms must be inbuilt for following years.

Key Words: India • National Rural Health Mission • Infant Mortality Rate • Millennium Development Goals • Health Systems

Copyright © 2013 Narwal et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


India’s under-five mortality rate (U5MR) has declined by 32%; from 116 in 1990 to 66 per 1000 live births in 2009, placing it 48th globally[1]. However, the highest number (1.69 million) of under-five deaths globally continue to occur in India[2]. Nearly two thirds of these deaths are preventable with available interventions that can be implemented in low-income countries[3, 4].India’s progress has huge strategic importance in the global quest for Millennium Development Goals (MDG4). This largely depends on tackling infant mortality (forming >70% of all under five deaths[5-7]) in rural areas where >70% population lives and where the infant mortality rate (IMR) historically has stayed twice as high as urban areas (Figure 1).

National Rural Health Mission (2005-2012)

To address the striking urban-rural health inequalities[8], National Rural Health Mission (NRHM) was launched by the Government of India in April 2005.

Eighteen states with weak health infrastructure and indicators were categorized as High Focus states[9] (Fig 2). The key aim of NRHM is to reduce India’s IMR from 58 in 2005 to 30/1000 live births by 2012, in order to reach MDG4[10].

Since the launch of NRHM, government reports[9, 11] and independent reviews[12-14] show a visible increase in the supply (increased 24 x 7 functioning health facilities-3- to 6-fold, drugs, consumables and flexible finances, additional 9,000 doctors, 60,000 nurses/ANMs and 690,000 ASHAs) and demand side (increased attendance to in-door and out-patients’ departments and institutional deliveries) of health services. Going by the components of the health program (Figure 3), these NRHM reports and reviews provide useful insight into the input & pocess, output and outcome measures. However, despite the approaching NRHM deadline (2012), and considerable resource mobilization for improving childs, little is known about the extent to which these interventions have had an impact on infant mortality rates. The objectives of our study were to 1) describe time trends in infant mortality at national and state level between 2000 and 2009, 2) establish whether there was an increase in the annual average reduction rate (AARR) of IMR in rural areas, after the launch of NRHM and 3) to assess whether India and its states are likely to achieve the NRHM goal (national IMR of 30/1000 live births by 2012) or MDG4 (2/3rd reduction in baseline U5MR of 1990, by 2015). Since there is insufficient state-level U5MR information, we used IMR as an indicator.


NRHM was implemented in all states of India, so we were limited to performing a before- and after-comparison due to the lack of control areas. Infant mortality rate (IMR) was the dependent variable defined as number of deaths in children under one year of age per 1000 live births in that year.


National and state level IMR data was derived from the Sample Registration System (SRS)[15]. Under SRS, panel household surveys are conducted for 1.5 million households with 7.1 million people living in 7,597 (as of year 2004) randomly selectedvillages (60%) and urban blocks (40%) spread across all states. The data collection involves continuous enumeration of births and deaths, which is cross verified and matched biannually (for detailed methods refer to: The figures obtained from SRS are widely used by national and international development agencies and its U5MR data has been found particularly reliable[16]. Besides, SRS became an obvious choice since it is the only source providing yearly IMR estimates at the state level; including separate urban-rural figures. All of the data was compiled from online sources in the public domain. Please note, throughout this article we refer to aggregate urban and rural IMR figures as total IMR.


Our analysis focused on average annual reduction rates (AARRs) which measure the average percent reduction in IMR per year. A positive value of AARR suggests average annual decrease in IMR and conversely negative AARR suggests an average annual increase. At both the national and state level, the analyses involved:


Figure 1. Spatial IMR Trends and Various Health Programs in India: 1980-2009. CSSM=Child Survival and Safe Motherhood; RCH-1=Reproductive and Child Health phase 1; NRHM=National Rural Health Mission.


Figure 2. Categorization of States as per National Rural Health Mission (NRHM) and state-wise burden of infant deaths.


Figure 3. Basic Health Systems Framework

1)   Descriptive analysis of AARRs for the period 2000-2009 using urban, rural and total IMRs;

2)   Estimates of the absolute change in rate of IMR reduction in rural India using the separate AARRs for pre- and post-NRHM;

3)   Forecasting total IMR up until 2015; estimating the required AARR in order to reach MDG4.

To compare IMR trends before and after NRHM, we used piecewise linear regression on log IMRs. This model assumes a single underlying linear trend during the pre-NRHM era up until the cut-off point followed by a different trend during the post-NRHM era. For pragmatic reasons, we prespecified the cut-off point as exactly 6 months after the initiation date of NRHM for each state. For nation-wide analyses, we chose the launch date for NRHM as a whole, April 2005. 95% CIs for absolute differences and tests for no difference between AARRs before and after NRHM were calculated using the delta method[17]. Overall AARRs for the whole period from 2000 to 2009 were computed using simple linear regression on the log (rural) IMRs. Similar methods have been used earlier in Brazil and US[18-20]. We considered interrupted time series analysis and generalized linear mixed models (GLMM) as alternative analysis methods. However, it is difficult to estimate autocorrelation accurately with 9 observations per state and a Box-Ljung Q test[21] for auto-correlated errors indicated no reason for detailed time series modeling. The GLMM methods provided unacceptably large shrinkage in preliminary results wiping out between-state differences completely.

For forecasting we used simple instead of piecewise linear regression in order to limit the number of parameters. The extrapolated IMRs assume constant proportionate changes in trend for the annual IMRs from 2000 through to 2015. Since the actual IMR in 2015 is a random variable rather than a parameter, we obtain 95% reference ranges (RRs) in place of 95% CIs. We then assessed whether or not that state was ‘on track’; i.e. likely to achieve 2/3 reduction in its 1990’s baseline IMR, by 2015. Where the upper end of the projected RR fell below the 2015 target IMR, we took it as a clear evidence for that state being ‘on track’. Where the lower end excluded the target IMR, we had clear evidence for the state being ‘off track’. Where the RR included the target IMR, the state was ‘potentially on track’.

Our projections were based purely on the assumption that the current IMR trends continue into the future. Given the scope of this research, no provisions were made for likely extrinsic shocks or influences of medical technology, demographic or radical behavioral or socioeconomic changes on future mortality. All statistical analyses were carried out in Stata11 and maps were created using Arc GIS 9.2

Average Annual Reduction Rate of IMR in Rural Areas of Indian States; 2000- 2009


Figure 4. Map of India Showing Annual Average Reduction Rates in Infant Mortality Between 2000 and 2009. The color of state represents the AARR whereas the bars represent IMR for the period

Table 1. Overall Average Annual Reduction Rates (AARRs) in Infant Mortality Between 2000 and 2009; for India Total, Rural and Urban, as well as AARR for Rural Areas of the States



Figure 5. Absolute Differences in AARR Pre- and Post-NRHM Introduction by State.

Table 2. Average Annual Reduction Rates (AARRs) of Rural IMR Before and After the Implementation of NRHM, Along with Absolute Differences in AARR



Table 3. Projected and Target National and State-level IMRs for 2015. All reported state-level IMRs are total IMRs. Current and required AARRs are shown for states unlikely to achieve 2/3 reduction in IMR by 2015 as compared to the 1990 baseline. States are sorted in order of projected IMR



1990 IMRs for states with figures in brown were extrapolated using 1992-1994 figures as 1990 figures were unavailable.
Baseline IMRs for Madhya Pradesh, Bihar and Uttar Pradesh were used for Chhattisgarh, Jharkhand and Uttarakhand respectively as the latter states were carved out of the former.
* No projections done for Nagaland due to insufficient data.


Figure 6. Statewise Projected Total IMRs and Reference Ranges (Brown lines for High Focus, Blue dotted lines for Non-Focus states) in 2015 against the Baseline IMR of 1990. The irregular diagonal line represents Two-third reduction cutoff and states with Reference ranges falling on or below this cutoff line are likely to achieve MDG4.


India total

The total IMR in India decreased from 68 to 50 per 1000 live births between 2000 and 2009, with an AARR of 3.1% (95% CI=2.6% to 3.5%). The IMR declined with an AARR of 3.0% (95% CI =2.2% to 3.8%) during pre-NRHM era and 3.3% (95% CI=1.8% to 4.8%) in the post-NRHM era. There was no evidence that the rate of IMR reduction had increased in India after launch of NRHM (absolute difference 0.3%; p=0.71).

Rural and Urban India

Between 2000 and 2009, the IMR in urban areas declined by 21% from 43 to 34 per 1000 live births with an AARR of 2.1%, whereas in rural India it declined by 26% from 74 to 55 with an AARR of 3.0%. There is evidence that the urban-rural gap in IMR narrowed (p=0.036) with AARR in rural areas being nearly 1½ times higher than urban areas. However, there was no evidence that the rate of IMR reduction in rural India post-NRHM (3.4%, 95% CI=2.0%-4.7%) was larger than the pre-NRHM rate (2.8%, 95% CI=2.1%-3.5%, p=0.71 for a difference in rates).

Overall state trends for rural IMR 2000-2009

Table 1 showsAARR figures over the ten-year period between 2000 and 2009 for total, rural and urban India, as well as for rural areas of all states in descending order of AARR. A declining IMR trend was observed in most Indian states (see web appendix). Relative declines in IMR were highest in Goa (AARR 9.1%; 95% CI=7.4 to 10.8%) and Tamil Nadu (AARR 6.5%; 95% CI =5.7% to 7.3%) for Non Focus States; Chhattisgarh (AARR 5.7%; 95% CI=4.1% to 7.2%) and Uttarakhand (AARR 5.0%; 95% CI=4.3% to 5.6%) for High Focus States. Nine states showed no clear evidence of change in IMR: Manipur, Sikkim, Arunachal Pradesh, Tripura, Meghalaya, Jammu & Kashmir, Lakshadweep, Puducherry and Kerala. There was evidence for negative AARRs in 4 states suggesting the underlying trend in IMR increased rather than decreased; by 10.4% per year (95% CI=3.1% to 18.3%) in Nagaland, 9.8% per year (95% CI=3.3% to 16.8%) in Mizoram, 6.8% (95% CI 1.4% to 12.5%) in Andaman and Nicobar islands and 3.2% (95% CI=0.0% to 6.6%) in Delhi.

There was no clear evidence for a change in trend in all except two states; for Bihar AARR increased by 4.7% from 0.2% pre-NRHM to 4.8% post-NRHM (p<0.001; 95% CI=3.6% to 5.7%) and for Manipur AARR reversed from an annual reduction of 9.3% to an annual increase in IMR of 26.3% post-NRHM (p=0.004; 95% CI=13.2% to 58.0%). For three states, we found weak evidence for a difference; the estimated trend in IMR in Meghalaya was an annual decrease of 2.3% during the pre-NRHM era and -6.3% post-NRHM (p=0.016; 95% CI for difference = -15.2% to -2.0%), for Puducherry the AARR changed from -2.1% during the pre-NRHM era to 8.2% post-NRHM (p=0.023; 95% CI=2.1% to 18.5%), for Daman and Diu from 3.5% to 13.6% (p=0.048; 95% CI=0.4% to 19.8%) and for Dadra & Nagar Haveli from 8.1% to -1.4% (p=0.025; 95% CI=-17.6% to -1.4%).


Table 3/Figure 6 shows projected national and state-level IMR figures for 2015. India appears unlikely to achieve either the NRHM goal of reducing IMR to 30 by 2012 or MDG4 of reducing IMR to 27/1000 live births by 2015. The predicted total IMR for 2015 is 47 (95% RR=40 to 46) – 74% higher than the target. In order to achieve MDG4, an AARR of 9.9% is needed between 2009 and 2015, which is more than triple the AARR of 3.1% between 2000 and 2009.

At the state-level, no state was clearly `on track’ for 2/3 reduction in IMR compared to the 1990 baseline by 2015; Dadra & Nagar Haveli, Tamil Nadu, Maharashtra, Chhattisgarh, Uttarakhand, Jharkhand, Manipur and Daman & Diu are `potentially on track’. The remaining states were `off track’. For detailed figures, please refer to Table 3.


Our analysis showed that India’s IMR in rural areas declined with an AARR of 3.0% between 2000 and 2009, significantly higher than theAARR of 2.1% in urban India. There was evidence suggesting that the nation-wide urban-rural gap in IMR has narrowedover this period. However, we found no evidence to suggest that the AARR at both the rural or national level had increased after the launch of NRHM in comparison to the AARR of the pre-NRHM era. Our projections of IMR suggested that despite good progress in some states, India is unlikely to achieve child health related NRHM or Millennium Development Goals.

A recent multinational study[22] suggested similar findings for India’s country level child mortality trends. The persistent decline in infant mortality rates over the past decade may be attributed to economic growth, better living standards, improved drinking water sources and sanitation facilities[23], increased maternal literacy rates and availability and utilization of healthcare services[24-26]. However, there were considerable variations at state level. The increasing IMR trends in Mizoram and Nagaland and stagnation in Jammu and Kashmir may be explained by ongoing political instability, which could haveled to disruption of healthcare and other public services. Kerala on the other hand already had low IMR and further decline would need substantial efforts. However, there was no clear explanation for other states, for example, the increasing IMR trends in Andaman & Nicobar and Delhi.

Claeson et al.quoted a narrowing urban-rural gap in IMR for 1990-2000[27]; we found strong evidence that this trend continued in the following years. This tapering might be explained by greater proportionate increase in standards of living, literacy rates, and utilization of MCH services in rural areas[24-26]; whereas, owing to high migration, the number of urban poor living under unhygienic and crowded conditions has grown[28, 29]. The higher IMR in these populations might be diluting the overall AARR for urban India. The AARR in IMR at state level did not show clear evidence of change except in Bihar, where it increased by 4.7 percentage points and Manipur where it decreased by 35.6 percentage points. However, it would be premature to attribute this to NRHM and will require further analysis of contributing factors. Note that Manipur had already achieved quite low IMRs and hence small absolute changes in IMR could have resulted in large relative shifts.

Web Appendix-1

Infant Mortality Rates (IMR), India and its states; 2000 to 2009


* Data Source: Sample Registration System, India
* IMR data seggregared byurban-rural not available for Nagaland from yrs 2000-03
* IMR data is expressed per 1000 live births

Despite apparent increases in service provision, delivery and utilization since launch of NRHM, we found no evidence for an increase in the rate of IMR reduction. A few possible explanations:

Firstly, healthcare alone does not exclusively determine infant mortality[30]. At the same time, access to and utilization of healthcare does not guarantee quality and equity[31]. The utilization of reproductive and child health services historically has stayed at a low level amongst the poorest wealth quintile[23, 32], which has the highest infant mortality[23, 33]. There is a possibility of continuing inadequate access and utilization by these groups, even post NRHM. Lim et al.’s evaluation of the NRHM’s JSY (conditional cash transfer scheme) also suggested that the poorest and the least educated women had the lowest odds of receiving payments[35]. Secondly, problems were reported with regards to scale-up of NRHM across states, inadequacies in human resources & infrastructure, poor convergence, lack of community participation and funds flow mismanagement[14]. Gaps in the health budget[34], operational issues[35, 36] and lack of public health capacity in India[37, 38] could have had detrimental effects on roll out, implementation and management of this huge program. Finally, a longer time lag may be required to observe the effects of NRHM; however, cluster randomized control trials in high burden states of India using community based approaches analogous to NRHM strategies, have shown large reductions in infant and neonatal mortality over a period of two-three years[39-41].

Our projections for India’s likelihood of achieving MDG4 were similar to WHO’s reportwhich suggests ‘insufficient progress’[42]. Another study made similar projections for 2003 to 2015[43]. The projections showed a clear need to increase AARR in all except eight states. The High Focus States of UP, Bihar, Madhya Pradesh, Rajasthan and Orissa will have to increase AARRs by 2 to 7-fold. Pregress in these states will play a crucial role in India’s endeavor to achieve MDG4, since they share two thirds of all infant deaths.


We only used data from India’s Sample Registration System (SRS). However, validity assessments have shown that surveys may underestimate neonatal deaths[44]. Any errors in SRS data could have led to over- or underestimation of AARRs and IMR projections. For evaluating progress towards MDG4, IMR was used as a proxy for U5MR. Hence, we advise interpreting the figures for ‘required AARR’ with care; U5MR may not decline at proportionate rates to IMR, between 2010 and 2015. In addition, we note a few statistical points. Large numbers of tests have inflated type I error; p-values near 0.05 should be considered weak, suggestive evidence. Bonferroni correction suggests p<0.0014 provides strong evidence, butthis is not a strict law. Further, we assumed a piecewise linear dependency of log IMR on time correctly modeled the underlying trend of IMRs. For states with complex trend patterns (Andaman and Nicobar, Delhi, Jammu and Kashmir, Kerala, Lakshadweep and Mizoram) lower significance provided an adjustment for the lack of fit, but this adjustment was not rigorous. Finally, for some of the states, we got wide CIs/RRs. We believe this reflected genuine uncertainty due to measurement error and large state-level variability in IMR across time.

Conclusions and Public Health Implications

There were wide differences in the AARRs of various states underpinning varied levels of progress. However, there was clear evidence of increasing IMR trends in some states and UTs; the central and governments of high Focus North Eastern states need to closely monitor the program implementation while maintaining high levels of commitment and ownership. We specifically recommend assessing the equity of access and utilization of NRHM services. This needs to be followed up by strengthening of the mechanisms to ensure that quality services are available and accessible to the most needy and vulnerable groups. In general, we note that Manipur, Goa, Dadra and Nagar Haveli, Tamil Nadu and Maharashtra are likely on target to help India achieve MDG4. While socioeconomic and political factors probably played an important role in the progress of these states, it would also be worth exploring the role ofgovernance, specific strategies and health delivery systems in these states. Best practices and lessons learnt can be extrapolated to other states after assessing local capacity and needs. Similarly, it would be pertinent to investigate the reasons contributing to Bihar’s success in accelerating child survival post-NRHM introduction. This study provides insight into state level IMR trends for recent years. Similarly, it explores the effectiveness of NRHM in terms of impact rather than output indicators which were previously unavailable. It will enable policy makers and health care providers to allocate resources efficiently and fine-tune prioritization of states. The study provides a basis for hypothesis formulation that may subsequently be tested in future evaluations thus improving operationalization of NRHM and eventually child survival.


The authors acknowledge the technical insights and suggestions provided by Drs. Betty Kirkwood (LSHTM), David Osrin (UCL) and Simon Cousens (LSHTM) in conducting and writing of this research


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33. Moser, K.A., D.A. Leon, and D.R. Gwatkin, How does progress towards the child mortality millennium development goal affect inequalities between the poorest and least poor? Analysis of Demographic and Health Survey data. British Medical Journal, 2005. 331(7526): p. 1180-2.

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41. Tripathy P, Nair N, Barnett S, Mahapatra R, Borghi J et al., Effect of a participatory intervention with women’s groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial. The Lancet, 2010. 375(9721): p. 1182-92.

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Original Article

International Journal of MCH and AIDS
Volume 2, Issue 1, 2013, Pages 129 – 138
Does Pre-Survey Training Impact Knowledge of Survey Administrators and Survey Outcomes in Developing Countries? Evaluation Findings of a Training of Trainers Workshop for National AIDS and Reproductive Health Survey-Plus in Nigeria
Kolawole Solomon Oyedeji, PhD; Adeniyi Francis Fagbamigbe, PhD; Johnbull Sonny Ogboi, MSc; Adebobola Toluwalashe Bashorun, MPH; Kawu Bolakale Issa, MPH; Perpetua Amida, MSc; Adeniyi Ogundiran, DrPH; Onoriode Ezire, MSc

International Journal of MCH and AIDS
Volume 2, Issue 1, 2013, Pages 129 – 138
Does Pre-Survey Training Impact Knowledge of Survey Administrators and Survey Outcomes in Developing Countries? Evaluation Findings of a Training of Trainers Workshop for National AIDS and Reproductive Health Survey-Plus in Nigeria
Solomon Kolawole Oyedeji PhD1; Adeniyi Francis Fagbamigbe PhD2; Johnbull Sonny Ogboi MSc3 ; Adebobola Toluwalashe Bashorun MPH4; Kawu Bolakale Issa MPH4; Perpetua Amida MSc4; Adeniyi Ogundiran DrPH5; Ezire Onoriode MSc6.1 Department of Medical Laboratory Sciences, College of Medicine, University of Lagos, Idi-Araba, Lagos.2 Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Nigeria.3 Malaria & Human Development, Department of Life Sciences and Public Health, University of Camerino, 62032 Camerino (MC), Italy.4 HIV/AIDS Division, Department of Public Health, Federal Ministry of Health, Abuja, Nigeria5 World Health Organization Country Office, Abuja, Nigeria.6 Research and Evaluation Division, Society for Family Health, Abuja Nigeria
Corresponding author e-mail:


Background: Although, Nigeria had conducted various national surveys followed by central and state level trainings for survey administrators, prior pre-survey trainings have not been systematically evaluated to assess their impact on knowledge gain and final outcome of the survey. A central training of trainers’ session was organized for master trainers on the conduct of the 2012 National AIDS and Reproductive Health Survey.

Objectives: To evaluate the impact of training on the quality of conduct of a national research survey in the 36 states and the Federal Capital Territory in Nigeria.

Method: A total of 185 participants consisting of State AIDS Program Coordinators, Reproductive Health Coordinators, State Laboratory Scientists, Lead Supervisors and Counselor Testers were invited from the 36 states in Nigeria and the FCT for the central training of trainers in Abuja. The training lasted 5 days and the trainees were grouped into two on the basis of behavioral epidemiology and laboratory components. Training tools such as the developed protocol, training power point slides, practical sessions such as role plays, and usage of HIV rapid test kits were utilized during the training. The facilitators were drawn from Federal Ministry of Health (FMoH), universities and research Institutions as well as Non-Governmental Organizations (NGOs). The facilitators prepared and administered 25 structured questions for the behavioral group and 28 questions for the laboratory group at the beginning of the training to assess the participants’ knowledge of HIV and the survey. The same questions answered by Trainees responded to the same questions prior to the commencement and at the end of the trainings. Scores were aggregated to 100 for each test. We conducted paired t-test to determine statistically significant differences between pre-test and post-test results at 0.05 significance level and ANOVA to determine if there were differences in knowledge level among different groups.

Result: The overall mean pre-test and post-test scores were 64.0% and 77.4% respectively indicating a 13.4% knowledge gain above what it was at the beginning of the training. The mean pre-test score and post-test score for the Southern states (SN) were 64.7% and 80.3% while that of the Northern states (NN) were 63.5% and 75.3% representing a knowledge gain of 15.6% and 11.8% respectively. There was statistical significant difference in the post-test scores between the two regions (p=0.001) and in knowledge gained after the training (p=0.017).

Conclusions and Public Health Implications: Comparison between the pre test and post test scores at the 5-day training showed a significant gain in knowledge of participants. The survey training contributed positively to the preparation and building of knowledge needed for the conduct of 2012 NARHS-plus.

Keywords: Training • Survey • NARHS-Plus • State AIDS Program Coordinators • Reproductive Health Coordinators • State Laboratory Scientists • Lead Supervisors and Counselor Testers • Abuja • Nigeria

Copyright © 2013 Oyedeji et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Any organization determined to survive and prosper in the current challenging economy, must understand the imperative to invest in training and professional development in order to improve efficiencies in production as well as to acquire the greatest return in investment of human capital[1]. Furthermore, several authors have suggested that training is most extensive and important in any organization or establishment [2, 3]. Training is becoming increasingly complex, and tools to determine the proficiency of training programs and trainees are needed. Although emphasis has been placed recently on expanding assessment and demonstrating outcomes in proficiencies other than knowledge, evaluation of the depth and breadth of trainings’ knowledge base remains critically important, because this constitutes the foundation on which competence is built, and is an essential requisite for the development of sound reasoning skills [4, 5]. Therefore, training as a tool to acquire best practices in the proficient conduct of services cannot be over emphasized.

National AIDS and Reproductive Health Survey (NARHS) had been conducted three times in Nigeria (2003, 2005, and 2007)[6, 7, 8]. After 2005 NARHS survey, there was a need to include biomarker-HIV testing (biological) components into the survey and it captures ages 15-64 years, hence the nomenclature of NARHS-plus was therefore adopted in 2007[8]. The 2012 NARHS was the fourth since its inception. In the past, NARHS and NARHS-plus data collection started with central level training of States AIDS Program Coordinator (SAPC), Reproductive Health Coordinator (RHC), State Laboratory Scientists (SLS), HIV Counselor-testers (CTs), and Lead supervisors but the impact of the trainings on the participants have not been evaluated to assess whether there is need for such trainings or not, during the survey. The training of trainers (TOTs) workshop was aimed at teaching selected survey administrators on how to conduct and supervise the NARHS plus survey based on the complexity and enormity of the study especially the ‘plus’ component. The goal was to replicate same training at the state level to other supervisors, interviewers, and counselor-testers who served as research assistants in the collection of data on the field during the survey exercise.

The training was conducted using the engagement of participants in plenary discussions, presentations, group discussions, role plays, and question and answer sessions. The various sessions exposed the participants to issues of community engagement and participation in research, basics of HIV and AIDS, challenges of ensuring informed consent, reproductive health indices in Nigeria, good clinical and laboratory practice and management, data monitoring and management in research. The group interactions afforded participants the opportunity to learn from one another’s experience while the role plays simulated actual practical experiences in the field. The trainees were expected to give same training in their respective states. Based on the above, this evaluation study set out to assess the impact of five-day training on the quality of conduct of research survey, namely, NARHS-plus. The overall evaluation research questions were: does training of trainers at the central level have any impact on the level of knowledge that could predicate a successful conduct of NARHS-plus survey in Nigeria, and are there variations in the level of knowledge among participants from different states or different regions of the country?


Study Design:

This study was an evaluation of training using a cross sectional design with structured questionnaire pre and post training.

Target population:

The target populations were all state AIDS Program Coordinator (SAPC), State Reproductive Health Coordinator (SRH), State Laboratory Scientist (SLS) from all 36 states and the Federal Capital Territory (FCT) in Nigeria. In addition there were one Lead Supervisor (LS) and one Counselor Tester (CT) from each state and FCT.

Sampling technique

Total sampling of the target population was done giving 185 trainees invited for the central training. They were divided into two regions- North and South for convenience. Seventeen states from southern Nigeria had their training for 5 days followed by that for the FCT and 19 states from northern Nigeria for another 5 days.

Training methods

The training was conducted for 5 days. The five days training of trainers (TOTs) workshop for NARHS –Plus 2012 survey for SAPCs, RHCs, SLS, CTs and lead supervisors from the 36 states of Nigeria and FCT was conducted between 27th September to 7th October, 2012. The training sessions took place in Maraba, Nassarawa State for the Southern States and in Abuja for the Northern States

The training methods were didactic, role plays and hands-on. Training included the use of training tools such as the training protocol, training slides, and engagement in practical sessions on the use of HIV rapid test kits. The training lasted 5 days each. At the venue of training, the trainees were grouped into two on the basis of behavioral epidemiology (SAPC, SRH and LS) and laboratory components (SLS and CT). The facilitators were drawn from the Federal Ministry of Health (FMOH), academic institutions as well as supporting organizations. Facilitators prepared 25 and 28 structured questions on knowledge of HIV and the survey for the behavioral and laboratory tract respectively, scores were aggregated to 100. Trainees answered the same set of questions before (pre-test) and after (post-test) the trainings.

Data analysis

We conducted descriptive analysis, used summary statistics, paired t-test at 0.05 significance level to determine statistically significant difference between pre-test and post-test performances of the trainees while ANOVA was used to determine the differences in knowledge level among different groups.


One hundred and seventy (91.9 %) trainees participated in the pre-test while 177 (95.6 %) attempted the post-test, 158 attempted both pre and post-test. Also, the number of trainees that participated in the pre-test, post-test and took both during the training for the Southern Nigeria (SN) were 72, 82 & 68 and Northern Nigeria (NN) were 98, 95 & 90 respectively. Combining all the respondents irrespective of their zones, the overall pre-test and post-test score were 64.0% and 77.4% respectively indicating a 13.4% gain in knowledge over the baseline knowledge level (Table 1). The pre-test score and post-test score for the SN and NN were 64.7% and 80.3% respectively, and 63.5% and 75.3%. The knowledge gain was 15.6% and 11.8% for SN and NN respectively (Table 1).

Table 1.   Attendees’ Performances in the Pre-test, Post-test and Differences between the tests[EA1]


n = number of participants/zone SEM= standard error of error

Comparing the performances in the two sets of training, Table 2 shows that the baseline knowledge was not statistically different among trainees from SN and NN (p=0.44), however there was statistical significance in the posttest scores between the two regions (p=0.001) and in knowledge gained (p=0.017).

Figure 1 shows the mean scores of the attendees from each state in the two tests as well as the differences between the scores. The highest mean scores for the pretest, posttest and their differences were recorded in Delta (87.9%), Akwa Ibom (74.0%), and Lagos (72.4%) states respectively while the lowest mean scores were from Kwara (54.1%) -pretest, Sokoto (66.4%) – posttest and Sokoto (3.4%) knowledge gain. In Table 3, the scores in the pretest and the posttest were compared, the analysis of variability of the scores showed that the mean scores for the states were statistically significantly different (p<0.05) in both tests but there was no significant difference in knowledge gain of the attendees across all the states in the area of knowledge of HIV epidemiology, HIV counseling, AIDS- related issues, survey administration etc.

Table 2.   Comparison of mean scores in pre-test and posttest across the two regions using ANOVA



Figure 1. Distribution of scores in the pre-test, post-test and knowledge gained across the states[EA3]

While the highest mean scores for the pre-test was in the Counselor Testers’ group (67.2%); post-test- Supervisors’ group (79.1%); and knowledge gain was recorded in SAPCs’ group (17.6%). The lowest mean scores for the pre-test was SRHCs’ group (60.4%), post test was the Laboratory Scientists’ group (73.1%), and knowledge gain was also the Laboratory Scientists’ group (8.0%). The highest knowledge gain was recorded among the SAPC (17.6%), followed by the SRHC (16.7%). The overall mean pre-test and post-test scores were 64.0% and 77.4% respectively indicating a 13.4% gain in knowledge above baseline knowledge. (See Figure 2 and Table 4).

Table 3.   Variability in performances of attendees across their states



Table 4.   Distribution of Pre-test and Posttest Scores and Knowledge gain across the categories of the attendees.


Although there was no statistically significant difference in the pretest and posttest mean scores of the five groups of attendees, the mean scores of knowledge gained across the five groups were statistically significantly different (p<0.05) (see Table 5).


Figure 2. Performance of attendees by their designations and regions

Table 5.   Variability in performances of attendees across the various groups


In an attempt to explore the details of the significant knowledge gain obtained in Table 5, we carried out the dependent sample t-test on the post-test and pre-test scores across different characteristics were as shown in Table 6. The differences between post-test and pre-test scores were statistically significant within the Southern attendees, North Attendees, the two zones combined, various designation groups irrespective of their zones.

Table 6.   Analysis of Knowledge Gained (differences between the paired Posttest and Pretest scores) by the attendees


Table 7.   Evaluation of the training by the participants


Similar to the analysis shown in Table 6, we analyzed the paired (post-test and pre-test) differences among attendees from each state. The differences between post-test and pre-test scores were statistically significant (p<0.005) among the attendees from Abia, Adamawa, Bayelsa, Edo,Ekiti, Katsina, Lagos, Nassarawa, Niger, Ogun, Ondo, Oyo, Plateau, Taraba and Yobe states only. As shown in Table 7, most participants (51.5%) believed that the training sessions were very good.


This study was aimed at evaluating the impact of five-day training on the quality of conduct of research survey of NARHS plus in order to answer the research question; does training of trainers at the central level have any impact on the level of knowledge and successful conduct of NARHS survey in Nigeria since there has been no recent systematic analyses of the quality and comprehensiveness of training received in any national survey in Nigeria.

The study revealed that the participants have positive attitudes about training (training attitudes), since the training afforded them the opportunity to acquire additional knowledge in basic issues concerning HIV/AIDS and its counseling and testing, and build data collection skills to be able to be comported to conduct interviews as well as manage a research study of this magnitude. It also afforded them the opportunity to learn about national requirements and regulations. It is clear from the training results that recent trainees feel very well prepared (well trained and competent) in many areas, particularly in HIV survey. Pre-test level of knowledge, supported by the improved post-test scores (North and South) is reasonable and indicates a right selection of methods and training participants.

For participants, the training afforded them the opportunity to acquire new knowledge and build skills to be able to conduct interviews as well as manage a research study of this magnitude. It also afforded them the opportunity to learn about national health survey requirements and regulations. Despite the relatively small number of respondents, this training provides the only current and detailed assessment of training of HIV survey in Nigeria across a wide spectrum of learning and content areas. Nevertheless, the results have potentially important implications for HIV surveillance and education in Nigeria. The train-the-trainer program was effective in developing sustainable quality NARHS plus in Nigeria as demonstrated by the fact that there is increase in knowledge base of the participants. In addition, the central training helped build a cadre of trainers who will be able to do an effective step down training throughout the states of the federation as seen in the result.

The recent evaluation of learning strategies used by United Nations Children’s Fund (UNICEF) in resource-limited settings noted that training local professionals to train their colleagues is generally less expensive than sending national or international experts to conduct trainings[9]. In addition, the use of local trainers to train their peers has the advantages of building local capacity as well as ensuring the trainings have cultural relevance and application which will help to enhance learning. Thus, it is likely that this central training model will continue to be applied to assist in ensuring that there is uniformity in knowledge impartation at the state levels. However, efforts will be made to mitigate differences in quality through use of competency-based curricula, well-designed training programs and, when needed, implementation of performance and quality improvement methodologies.

In another study[10] on the effect of co-presenting training items during supervised classification learning of novel relational categories, in a test phase measuring learning and transfer, the comparison group significantly outperformed a control group receiving an equivalent training session of single-item classification learning. In a similar study on Family Physician (trainers and non-trainers) and their practices to see whether there were differences in trainers and non-trainers and in how their practices were organized and their services were delivered, Trainers scored higher on all but one of the items, and significantly higher on 47 items, of which 13 remained significant after correcting for covariates. Trainers (and training practices) provided more diagnostic and therapeutic services, made better use of team skills and scored higher on practice organization, chronic care services and quality management than non-training practices.[11].


The qualities of training at the state levels were not evaluated, to ascertain the same level of delivery as the one at the central training. The result was only based on increase knowledge base of the participants after the central training. Further evaluations needed to be done whether the people trained at the various states acquire same level of improvements as seen at the central training. The paper has demonstrated that the trainees need training as indicated by the knowledge gained noted to be significant. However, the paper did not demonstrate how the knowledge gained has improved the conduct of the survey or the quality of data collected during the survey because the survey itself is yet to be concluded. For same reason, it could not relate the knowledge acquired during the trainings to the quality of data generated on the field from the southern and northern zones. This will be assessed after the conclusion and dissemination of survey findings nationwide.

Conclusions and Public Health Implications

This is the first report on the effect of a central training of trainers on the effective conduct of NARHS plus survey in Nigeria. However, it is important to follow-up on the training at the state level to see the impact of the knowledge gained at the central training and using the skills they have acquired. This information allows the organizers to determine future training needs, either by zones or otherwise. Results on the increase in knowledge base of this central training program in developing trainers are also significant, providing a basis of comparison for future programs. This finding is comparable to similar evaluations of TOT models, such as that conducted by UNICEF which found the TOT trainees going on to provide step down training to their colleagues. [9]. Although this was a central program, the lessons learned – in terms of factors contributing to program success and the ways in which challenges were addressed – may be applicable in the implementation of any such training program in the future.

In conclusion, our evaluation of this central training program demonstrates that a TOT-based central training program can be successfully endorsed for an effective conduct of surveys in Nigeria, with the ability to rapidly scale-up human capacity for both service delivery and training in a sustainable fashion.


1.   Knoke, D., & Kalleberg, A. L. Job training in U.S. organizations 1994. American Sociological Review, 59, 537-546.

2.   Rowden, R. W., & Conine, C. T.. The impact of workplace learning on job satisfaction in small US commercial banks. Journal of Workplace Learning, 2005 (17), 216-230. doi:10.1108/13665620510597176. Accessed 15th January, 2013

3.   Sahinidis, A. G., & Bouris, J. Employee perceived training effectiveness relationship to employee attitudes 2008. Journal of European Industrial Training 32, 63-76

4.   Accreditation Council for Graduate Medical Education: Outcome Project.   Accessed 15th January, 2013

5.   Hawkins RE, Swanson DB: Using written examinations to assess medical knowledge and its application, in Holmboe ES, Hawkins RE (eds): Practical Guide to the Evaluation of Clinical Competence 2008. Philadelphia, PA, Elsevier Health Sciences, pp 42-59

6.   Federal Ministry of Health (FMoH).: National HIV/AIDS and Reproductive Health survey Technical Reports, 2003 FMoH, Nigeria.

7.   Federal Ministry of Health (FMoH).: National HIV/AIDS and Reproductive Health survey Technical Reports, 2005 FMoH, Nigeria..

8.   Federal Ministry of Health (FMoH).: National HIV/AIDS and Reproductive Health survey Technical Reports, 2007 FMoH, Nigeria.

9.   United Nations Children’s Emergency Fund (UNICEF): Evaluation of UNICEF learning strategy to strengthen staff competencies for humanitarian response, 2000–2004. UNICEF; 2005.

10. Kurtz KJ, Boukrina O, Gentner D. Comparison Promotes Learning and Transfer of Relational Categories. J Exp Psychol Learn Mem Cogn. 2013 Feb 18. [Epub ahead of print]

11. Van den Hombergh P, Schalk-Soekar S, Kramer A, Bottema B, Campbell S, Braspenning J.: Are family practice trainers and their host practices any better? Comparing practice trainers and nontrainers and their practices. BioMed Central ltd Family Practice. 2013 Feb. 21; 14(1):23. [Epub ahead of print]. Accessed March 16th 2013

Original Article

International Journal of MCH and AIDS
Volume 2, Issue 1, 2013, Pages 121 – 128
Evaluating Birth Preparedness and Pregnancy Complications Readiness Knowledge and Skills of Accredited Social Health Activists in India
Smitha Kochukuttan, BDS, MPH; TK Sundari Ravindran, PhD; Suneeta Krishnan, PhD
International Journal of MCH and AIDS
Volume 2, Issue 1, 2013, Pages 121 – 128
Evaluating Birth Preparedness and Pregnancy Complications Readiness Knowledge and Skills of Accredited Social Health Activists in India
Smitha Kochukuttan, BDS, MPH 1; TK Sundari Ravindran, PhD1; Suneeta Krishnan, PhD2
1Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
2RTI International, San Francisco Office, 114 Sansome Street, Suite 500, San Francisco, CA-94104-3812, USA
Corresponding author e-mail:


Background: The National Rural Health Mission (NRHM) in India relies on Accredited Social Health Activists (ASHAs) to act as a link between pregnant women and health facilities. All ASHAs are required to have a birth preparedness plan and be aware of danger signs of complications to initiate appropriate and timely referral to obstetric care.

Objectives: To examine the extent to which Accredited Social Health Activists (ASHAs) are equipped with necessary knowledge and skills and the adequacy of support they get from supervisors to carry out their assigned tasks in a rural district in Karnataka, (South) India.

Methods: A cross-sectional descriptive study was carried out among 225 ASHAs between June -July 2011. Quantitative and qualitative data were collected using pre-tested semi-structured interview schedule. The data were analyzed using SPSS version 17. Chi-square test was used to determine associations between categorical variables.

Results: The response rate was 207(92%). In terms of knowledge of all key danger signs (Complication Readiness), 2(1%), 10(4.8%), and 15(7.2%) ASHAs were aware of key danger signs for labor and child birth, postpartum period and pregnancy period, respectively. Knowledge of key danger signs was associated with repeated, recent and practical training (p <0.05). A majority (71%) scored 4-7 of the maximum score out of 8 for knowledge regarding Birth Preparedness.

Conclusion and Public health implications: ASHAs in rural Karnataka, India, are poorly equipped to identify obstetric complications and to help expectant mothers prepare a birth preparedness plan. There is critical need for the implementation of appropriate training and follow-up supervision of ASHAs within a supportive, functioning and responsive health care system.

Key Words: Birth preparedness and complication Readiness • National Rural Health Mission • Accredited Social Health Activists

Copyright © 2013 Kochukuttan et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


As a country, India has made some progress towards achieving the Millennium Development Goals (MDGs), especially in the rural areas. However, with the MDG deadline just two years away, much remains to be done. The shortage of skilled health workers in remote rural areas of the country remains a key challenge to achieving the goals related to maternal and child health as laid out in MDGs 4 and 5. Although Community Health Workers (CHWs)[1] do not replace the need for health workers with greater training, they certainly play an important role in increasing access to and utilization of health care services. Around the world, CHWs have been found to play a crucial role in promoting behavior change by addressing socio-cultural factors such as traditional beliefs, dependence on local healers and delays in care-seeking that contribute to maternal and child deaths.

Accredited Social Health Activists (ASHAs), a national variant of CHWs are a key part of the rural health system in India. Over half a million ASHAs have been employed by India’s National Rural Health Mission (NRHM). The Janani Suraksha Yojana[2] (JSY) which aims to reduce maternal and neonatal mortality by promoting institutional deliveries relies on ASHAs to raise awareness and promote health care accessibility and utilization, especially among relatively poor and marginalized groups. ASHAs play important roles such as counseling women on issues such as birth preparedness and importance of safe delivery, arranging escort services to accompany pregnant women, mobilizing funds, arranging transport and blood donor, all of which would ensure better outcomes of pregnancy and child birth.[2] “Birth Preparedness and Complication Readiness” (BPCR) is a strategy which promotes timely use of skilled maternal and neonatal care especially during child birth, based on theory that preparing for child birth and being ready for any complication reduces delays in obtaining this care.[3]

Despite the reliance on the role of ASHAs in preparing pregnant mothers for child birth in India, few assessments have been conducted on the maternal, neonatal and child health (MNCH)-related knowledge, competencies and performance of ASHAs. To provide baseline information and generate areas for further research, we conducted an assessment of the MNCH-related knowledge of ASHAs in rural district of Karnataka state, India.


Study area

The state of Karnataka has a population of 62 million.[4]Though it remains one among the developed southern states, its social and health indicators are only just above the national average, and it trails behind its more advanced southern neighbors, Kerala and Tamil Nadu. The Karnataka Human Development Report ranks Koppal, the site of our study, at the bottom of all districts. The experiences of pregnant women in Koppal present a more complex reality.[5] The situation is grim in terms of addressing the three delays: in recognizing complications and seeking care, in reaching appropriate health facilities and delays in receiving appropriate care after admission to a health facility.[6]

Study design

A cross sectional descriptive study was conducted using both quantitative and qualitative methods. The inclusion criterion was ASHAs who have been working for at least 6 months, who were willing to participate in the study and provide written informed consent.

Sample size and sampling technique

Based on a prior study at Madhya Pradesh, India [7]assuming that 46% of the ASHAs have 60-70% knowledge level related to BPCR and to get 95% confidence interval + 6% the sample size was calculated to be 204 using Statcalc (EPI info 3.5.1)and adjusting for non-response rate of 10% it was calculated to be 225. Multistage random sampling was employed. There are a total of 888 ASHAs working at 39 Primary Health Centers (PHC) in the four sub districts of Koppal. Two of the four sub districts were randomly selected, by the lottery method. These two sub districts together have a total of 18 PHCs. All the 18 PHCs were included in the study. The calculated sample size of 225 was proportionally allocated according to the population of ASHAs in the respective PHCs.

Data Collection

Data collection was carried out over a six -week period between June and July 2011. The interview schedule was translated and back translated; English to Kannada to English to improve validity and reliability. The instrument was piloted in 5% of the estimated sample size in a similar setting in a different district. The interviews were evaluated and relevant modifications were carried out.

The semi-structured interview schedule was predominately adapted from the “Monitoring Birth Preparedness and Complication Readiness tools and indicators for maternal and newborn health” developed by the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO).[3] The schedule was modified according to the training curriculum of the ASHAs and the operational guidelines on maternal and newborn health of the NRHM, in consultation with an expert in the field of Reproductive Health Research. The BPCR outlines key knowledge areas for ASHAs to include all danger signs during pregnancy, delivery, post-partum period and making a birth preparedness plan with the pregnant woman.

To avoid data contamination ASHAs working under the same PHC and Sub-center were interviewed within a span of two days so as to avoid discussions among those interviewed and those yet to be interviewed regarding the type of questions asked. Spontaneous and unprompted responses were expected of ASHAs. Spontaneous knowledge here refers to the ASHAs naming a sign or response without being asked about that sign by name. Care was taken not to inadvertently change the meaning or interpretation of the danger sign or other responses when translated to English from the local terminology. All respondents were asked to give an account of the experiences they have had while working as ASHAs. A total of 37 ASHAs narrated their experiences.

Ethical considerations

Ethical clearance was obtained from the Institute Ethics Committee (IEC) of Sree Chitra Tirunal Institute for Medical Sciences and Technology. A letter of support was obtained from NRHM, Karnataka. Written informed consent was obtained from individuals eligible according to the inclusion criteria and who were willing to participate in the study. Interviews were conducted in locations that ensured privacy and participant convenience and with minimal interruptions. No information about the ASHAs’ scores on knowledge was shared with their supervisor or colleagues. Data were securely handled by the principal investigator using a password on the computer. After all the data had been entered in the computer, the hard copy of the questionnaires was stored in a locker and locked for safe keeping.

Data analysis

All questionnaires were coded before administration. Completed questionnaires were sorted out, collated and cleaned. The collected data were analyzed using SPSS for windows version 17. Cross validation and consistency checks were done. The results were presented in tables showing proportions of the distribution of the characteristics. Cross tabulations were used to compare the characteristics of chi square and p-value. The qualitative data were organized and analyzed with the help of ATLAS. ti software (version 6.2).


Socio-demographic and work related characteristics

The overall response rate for the study was 92% (207). The median age of the ASHAs interviewed was 30 years. Almost all the ASHAs (97%) were currently married, and 18.8% had children below 5 years of age. Sixteen (7.2%) ASHAs had had four or fewer years of schooling. A majority (78.7%) of the ASHAs had been employed for between 25- 36 months. Nearly two-thirds of the ASHAs (65.7%) had received one round of training, 33.3% had received 3-4 rounds of training and an insignificant proportion (1%) had received two rounds of training. The majority (83.1%) had not received any form of practical training, and the content of practical training, for those who had received some, was home based newborn care, with little or no emphasis on issues during pregnancy and child birth.

Birth preparedness and complication readiness: knowledge and practice

Birth Preparedness

We assessed whether ASHAs were aware of the key components of birth preparedness and rated them using a score. Only 3 (1.4%) of the respondents scored an excellent score 8 – demonstrating knowledge as per their training curriculum, while the vast majority (71%) had a good score between 4 and 7. The table below describes the components and the resulting scores.

Table 1.    Distribution of Knowledge on Birth Preparedness Information for the ASHAs, Primary Survey, 2011

Birth Preparedness Information to be provided by the ASHAs (N=207) Frequency
Percentage (%)
Identify health facility 174 (84.1)
Identify skilled provider 43 (20.8)
Identify mode of transport 157 (75.8)
Save money for delivery 173 (83.6)
Save money for transportation 86 (41.5)
Identify blood donor 7 (3.4)
Identify the person who will escort to skilled care 10 (4.8)
Prepare clean items for birth 171 (82.6)
Birth Preparedness Information Score N (%)
Excellent – Score 8 3 (1.4)
Good – Score 4-7 14 (71.0)
Poor – Score 0-3 57 (27.5)

Notably, ASHAs’ key activity related to birth preparedness was supporting institutional deliveries (99%), which included helping with cash assistance (98%) and identifying a functional health center before delivery. However, only 1% identified an institution for referral and less than 1% had identified a blood donor. Birth preparedness service provision was seen to be significantly associated with the knowledge score of Birth preparedness plan. Work characteristics such as experience, training, practical training, recent training had a significant association with birth preparedness service provision (P value <.05).

Complication Readiness

Based on the ASHA training curriculum, we selected common and easy to recognize indicators of a severe problem during pregnancy as given in the table below.

We assessed knowledge regarding other signs that should also result in referrals, such as severe abdominal pain at any time during pregnancy, loss of consciousness, severe weakness, accelerated/reduced fetal movement, water breaks to these other danger signs such as breathlessness, swelling of feet, severe headaches, and excessive weight gain without labor.

Table 2.    Key danger signs during Pregnancy, Labor and child birth and Post-partum periods

Pregnancy Labor and child birth Post-partum
Severe vaginal bleeding
Swollen hands/face
Blurred vision
Severe vaginal bleeding
Prolonged labor (> 12 hours)
Retained placenta
Severe vaginal bleeding
Foul-smelling vaginal discharge
High fever

Source: JHPIEGO/Material and Neonatal Health Program, Knowledge of key danger Signs, Indicators 1.1 to 1.3.

Overall, ASHAs’ knowledge of danger signs was very poor – a substantial minority had no knowledge of any danger signs. However, a majority (>80%) of ASHAs knew that post-partum hemorrhage is a life threatening danger sign. Of those who knew all key danger signs, 2(1%), 10(4.8%) and 15(7.2%) were aware of key danger signs for labor and child birth, postpartum period and pregnancy period, respectively. A composite knowledge score of the key danger signs was computed by summing up the responses obtained in all the three periods for each respondent. The maximum score would be 10 and the minimum zero. None of the respondents scored above 8. The majority 114(55.1%) scored very poor (0-3), 78(37.7%) scored 4-5 and 7.2% score 6-7.

We examined the association of the score for knowledge of key danger signs with socio-demographic and work-related characteristics of ASHAs. Various dimensions of training emerged as the single most important factor associated with knowledge of key danger signs (Table.4).

Family, Community and Health Systems Influences

Responses to the open-ended questions identified a number of family, and community and health systems factors that influence ASHAs’ performance in narratives of 37 ASHAs. Tensions in the family due to lack of regular payment were a major deterrent to their provision of services. Lack of awareness about blood donation, poverty and traditional beliefs operated at the community level and hindered community utilization of services. Irrational and multiple referrals, poor hospital conditions, lack of blood bank facility, delays in treatment during an obstetric emergency, and informal payments operated at health systems level. ASHAs also underscored shortages of doctors and nurses and the subsequent overloading of existing staff as affecting the morale and motivation of all health care workers.

Table 3.    Distribution of Knowledge of danger signs during Pregnancy, Labor and child birth and Postpartum periods for the ASHAs, Primary Survey, 2011


Table 4.    Work-related characteristics of ASHAs and their knowledge of key danger signs of pregnancy, labor and childbirth and postpartum period


The following are a few examples of the experiences, which ASHAs shared with the researcher.

There is no facility to for us to stay overnight with the pregnant woman in the hospital. We are shooed off by the nurses and the doctors. We take a bed sheet and sleep on the corridors and wait till the woman delivers.”

It is very difficult for me to arrange blood if required. The zilla hospital does not have blood. The doctors ask me to arrange blood from Hospet which is very far, (it costs) Rupees 35/- by bus. They also ask me to sign a paper saying if by the time blood comes the lady dies it is my responsibility. I feel very confused and scared during these times.”

Doctors need to cooperate and understand a poor woman’s condition; instead they ask for bribes, so the patients don’t like coming to the hospital. The nurses too want half of the money we get or else they do not cooperate with us in helping the pregnant woman.”


According to the study findings the knowledge level regarding key danger signs in all the three stages very extremely poor, i.e. pregnancy (7.2%), labor and child birth (1%) and post-partum period (4.8%). This survey suggests a condition that is worse than the study conducted in the Rewa district of Madhya Pradesh in 2009 among pregnant woman which suggested that the knowledge level regarding the danger signs was around 18.6%.[7]This study highlights several weaknesses in the current effort to promote safe motherhood in rural Karnataka and reveals challenges that may potentially be evident in other rural, resource constrained settings across India. ASHAs’ potential to promote MNCH is limited by number of barriers including inadequate hands-on training, supervision and back-up support, and poor infrastructure. However, these barriers also suggest opportunities for further strengthening efforts to address MNCH in Karnataka – including greater emphasis on hands-on training, supportive supervision, and increased community engagement especially with regards to complication readiness.

Out of 207 ASHAs surveyed none of them had score above 7 out of 10 for knowledge scores regarding key danger signs. This clearly indicates that more rounds of training would definitely affect their knowledge competencies.

Though 65.7% of the ASHAs helped to raise funds for delivery of the pregnant women they attended to their births, a quarter of the ASHAs were not aware of the presence or lack thereof of blood donors or blood provision.

This study provides baseline data for further research. This study presents what could be considered as a worst case scenario; meaning it was conducted in a district which is placed at the bottom of human development index in Karnataka. The findings may be identical to what is prevalent in other areas with identical human development index across India. The study has been conducted in the right context and time; six years since the launch of JSY, providing valuable data on some of the outcomes of the JSY. In addition, the qualitative component illuminated information presented from the quantitative survey.

It must be acknowledged that this study may present some inherent bias in the responses as the respondents were approached through the health system. The presence of a research assistant during the time of interview to help the principal investigator in translating to the local dialect might also have brought in bias in the responses.

Conclusion and Public Health Implications

Our findings suggest the need for key actions at the District and Facility levels to improve ASHAs’ performance. These include provision of hands-on training on how to identify danger signs and symptoms of complications during pregnancy, childbirth and post-partum and the appropriate referral pathways; supportive supervision with attention to contextual issues that affect MNCH. e.g., a checklist that help supervisors identify areas that need to be stressed during periodic review meetings and trainings; community engagement by using posters, street theatre and other community outreach methods to improve community awareness and understanding of MNCH. Additional strategies to improve MNCH outcomes also include offering resources to women with high risk pregnancies living in remote communities. E.g., support their stay close to a referral hospital 10-15 days prior to the expected delivery date will also make a difference.

In conclusion, ASHAs are envisioned as change agents at the forefront of efforts to reduce maternal, neonatal and child mortality in India. Further improvements in training, supervision and support for ASHAs are needed in order to maximize on the potential they represent. The need of the hour is the implementation of appropriate training and supervision of ASHAs within a supportive, functioning and responsive health care system.


We thank NRHM, Karnataka for cooperating with the study. Our deepest gratitude goes to the ASHAs at Koppal who have cooperated by providing the required information.


1. Campbell OM, Graham WJ. Lancet Maternal Survival Series Steering Group. Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006; 368:1284-1299.

2. National Rural Health Mission. Mission document. New Delhi, Government of India. (2005): 2005-2012.

3. Monitoring birth preparedness and complication readiness. Tools and indicators for maternal and newborn health. Baltimore, JHPIEGO, 2004.

4. Office of the Registrar General. Census of India, New Delhi: Office of the Registrar General, Government of India, 2011.

5. George A, Iyer A and Sen Gendered health systems biased against maternal survival: preliminary findings from Koppal, Karnataka. Brighton, Institute of Development Studies, Working paper 253, September, 2005.

6. Thaddeus, A. and Maine. Too far to walk: maternal mortality in context. Social Science and Medicine. 1994; 38(8): 1091–110.

7. Nandan D, Kushwah SS and Dubey DK. A study for assessing birth preparedness and complication readiness intervention in Rewa district of Madhya Pradesh. New Delhi, National Institute of Health and Family Welfare and United Nations Population Fund (UNFPA), 2009.

8. United Nations Children’s Fund. Surviving childbirth and pregnancy in South Asia, New Delhi, UNICEF, Working paper, 2004.

Original Article

International Journal of MCH and AIDS
Volume 2, Issue 1, 2013, Pages 111-120
Contraceptive Characteristics of Women Living with HIV in the Kumasi Metropolis, Ghana
Akosua A. Gyimah, MB ChB; Emmanuel K. Nakua, MSc; Ellis Owusu-Dabo, PhD; Easmon Otupiri, PhD
International Journal of MCH and AIDS
Volume 2, Issue 1, 2013, Pages 111-120
Contraceptive Characteristics of Women Living with HIV in the Kumasi Metropolis, Ghana
Akosua A. Gyimah, MB ChB1 ; Emmanuel K. Nakua, MSc2; Ellis Owusu-Dabo, PhD3; Easmon Otupiri, PhD2
1 Kumasi South Hospital, Ghana Health Service, Kumasi, Ghana.
2 Department of Community Health and School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
3 Kumasi Collaborative Centre for Research in Tropical Medicine, Kumasi, Ghana
Corresponding author e-mail:


Objectives: Contraceptive use among women living with HIV is important to prevent the transmission of the infection to their partners, prevent unintended pregnancies and prevent the mother-to-child transmission of the infection. The study sought to determine the contraceptive characteristics of women living with HIV in the Kumasi metropolis.

Methods: A cross-sectional study was conducted from July to August 2012 at two HIV/AIDS clinics in the Kumasi Metropolis in the Ashanti Region, Ghana. Interviewer- administered questionnaires were used to collect data from two hundred and ninety five women. Data from one hundred and eighty three women living with HIV and who were sexually active were analsed. Factors associated with contraceptive use were examined using logistic regression.

Results: The overall contraceptive use was high; 84.7% were using a modern contraceptive method. The male condom was the commonest contraceptive method (77.0%) used and this was the main contraceptive method promoted at the HIV/AIDS clinic. Dual method usage was low (4.4%). Multivariate analysis showed that the significant predictor of contraceptive use was HIV status disclosure to partner (AOR 0.25; 95% CI = 0.07-0.87;p = 0.03).

Conclusion and Public Health Implications: The integration of family planning and HIV/AIDS services could stress dual method use and encourage HIV status disclosure to partner.

Key words: Contraceptives • Condom • Women Living with HIV/AIDS • Ghana

Copyright © 2013 Gyimah et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Human Immunodeficiency Virus prevalence in the world has levelled-off in most regions in the world. Women are known to be the most affected with HIV. In 2010, women formed about 50% of the adult population (15 years or older) infected with HIV/AIDS in the world[1]. In Sub-Saharan Africa, women living with HIV make up 59% of the adult population living with the infection[1]. Sub –Saharan Africa accounts for about 70% of new HIV infections[1]. HIV/AIDS is known to affect the sexual desire of most women initially. Some might be able to resume normal sexual activity others might not[2]. In Ghana, the estimated HIV prevalence is 1.5 with about 226,000 people living with HIV/AIDS[3]. Contraceptive use among women living with HIV is important to prevent unintended pregnancies. This is a prong of preventing mother – to – child transmission (PMTCT). Most HIV infections in children are transmitted through mother-to-child during pregnancy, labor and breastfeeding. Condom use among women living with HIV is also important to prevent the transmission of HIV/STI to the partner. Even for those who desire to have a child, condom use is important especially in serodiscordant relationships. In Ghana, the current contraceptive use of any method among married women (15- 49 years) in the general population is 23.5% and modern contraceptive use is 23.0%[4]. Condom use among married women aged 15 –49 years is 2.4% in the general population in Ghana[5]. The sexual behaviour and contraceptive use among women living with HIV are important in reducing the transmission of HIV. It was projected that about 10,300 mothers need prevention of mother-to-child transmission services and there would be 1,100 new HIV infections in children in 2012 in Ghana[3]. Condoms have been the main contraceptive that has been promoted for people living with HIV/AIDS because of its dual purpose of preventing the transmission of HIV/STI and preventing pregnancies. It is therefore important to study the contraceptive use and the factors associated with contraceptive uptake in women living with HIV in order to inform programs designed to reduce the transmission of HIV and prevent unintended pregnancies among this sub-population.


Study Area and Design

This was a hospital-based cross-sectional descriptive study conducted from the 10th of July 2012 to the 15th of August 2012. The study was conducted in the Kumasi Metropolitan Area which has a total population of 2,035,064; females constitute 52.2% of the population[6]. For health purposes, the metropolis is divided into five sub-metropolitan areas: Bantama, Asokwa, Manhyia North, Manhyia South and Subin. Two public health institutions in the metropolis with HIV/AIDS clinics, namely the Kumasi South Hospital in the Asokwa sub-metropolitan health area and the Suntreso Government Hospital in the Bantama sub-metropolitan health area were used for this study. The HIV/AIDS clinics at the Kumasi South Hospital and the Suntreso Government Hospital are the largest HIV/AIDS clinics of the Ghana Health Service facilities in the metropolis and they have about 4000 and 2000 clients respectively. The HIV/AIDS clinics offer counselling and testing, care and treatment, and provision of antiretroviral drugs. They also serve as referral centres for other clinics that do not provide antiretroviral drugs in the metropolis.

Study Population and Study Sample

Women living with HIV/AIDS within the reproductive age 18 to 49 years attending clinics at the above mentioned facilities were recruited for the study. The estimated sample size for the study was 300. To be eligible for the study, the respondent should have attended the clinic for at least six months. Newly diagnosed HIV/AIDS clients were excluded in the study since they are usually emotionally unstable and not sexually active or had lost interest in sex. Individuals in the WHO clinical stage IV and the very sick were also excluded

Three hundred women living with HIV/AIDS were approached to be interviewed. Two hundred clients were sampled from the Kumasi South Hospital while one hundred clients were selected from the Suntreso Government Hospital. We aimed to recruit all eligible HIV/AIDS clients presenting at the clinic within the study period. Therefore a consecutive sampling method was used till the desired sample size was attained. If the client agreed to participate in the study, a consent form was signed and interviewed conducted. In all two hundred and ninety five women living with HIV agreed and questionnaires were administered to them.


The questionnaire covered socio-demographic characteristics, contraceptive use, HAART use, reproductive history, partner’s characteristics and desire for children, knowledge of PMTCT and contraceptive methods discussed at the HIV/AIDS clinic. Hospital records were reviewed to collect information on WHO clinical stage and date of diagnosis of HIV of the study participant. Questions on contraceptive knowledge and use were adopted from the 2008 Ghana Demographic Health Survey. Interviews were conducted in English or translated into Twi (local dialect) depending on preference of the participant, and it lasted between 10 to 15 minutes.

Statistical Analysis

Data analysis was done using STATA version eleven (Stata Corp., College Station, Texas: StataCorp LP, USA). Analysis was performed on 183 study participants who were sexually active; frequencies, percentages and odds ratio were calculated. Pearson chi-square and Fisher exact test were used for categorical data. The outcome variable was contraceptive use. Univariate logistic regression was conducted to determine associations between independent variables and contraceptive use. Multivariate logistic regression model was fitted to simultaneously adjust for the effect of other covariates. Statistical significance level was set at an alpha value of 0.05 with 95% confidence interval. For inclusion of variables into the model a significance level of 0.25 was considered using the likelihood ratio test.

Ethical Consideration

Ethical clearance was obtained from the Committee on Human Research, Publications and Ethics, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.


Out of the 295 clients who were responsive, 183 were sexually active. The response rate was 98.3%. The mean age of the respondents was 34.5 years with standard deviation of 5.2. About 79% of the respondents were married and of those who were using a contraceptive 82.2% were married. Majority of the respondents were Christians with 6.6% being Catholics. About 13% of the respondents had no formal education. Twenty percent of the respondents were unemployed whilst majority (70.5%) were self employed. About 86.0% of those who use contraceptives were self employed. The average monthly income of most of the respondents who were employed was below US$ 53 (GHCedi (¢) 1.90 is equivalent to US$ 1.00) (See Table 1).

Reproductive characteristics and intention of respondents

Most of the respondents (80.3%) were menstruating regularly and 94% had ever had children. Majority of the women and their partners desire to have children and about 85% of the respondents had disclosed their HIV status to their partners. About one – third of the respondents did not know the HIV status of their partners. Among the women currently using contraceptive 61.2% desire to have children in the future and 59.2% of their partners also desire to have children (Table 2).

Factors associated with contraceptive usage

In the univariate analysis, age group and educational status were not associated with the use of contraceptives. However, women who were cohabitating were less likely to use contraceptives (unadjusted odds ratio [OR] =0.32; 95% CI = 0.12-0.88, p = 0.03) compared with those who were married. Participants who did not have children were significantly less likely to use a contraceptive (unadjusted 0R = 0.17; 95% CI = 0.05-0.60, p = 0.02) compared with women with children. The HIV status of the partner was associated with contraceptive use; partners whose HIV status were unknown compared with those who were HIV positive were less likely to use a contraceptive (unadjusted OR = 0.27; 95% CI = 0.08-0.86, p = 0.03). Multivariate analysis showed that, disclosure of HIV status to partner was the only variable that significantly predicted contraceptive use, suggesting that women who have not disclosed their status to their partners were less likely to use contraceptive (AOR = 0.25; 95% CI = 0.07-0.87, p = 0.03) (Table 3).

Table 1. Socio-demographic and health characteristics of women living with HIV


*Other Christian= All Christian organisations (Methodist, Presbyterian, Pentecost, Charismatic) except Catholic,

**Basic education=Primary

***High Education= Middle/Junior High School, Secondary/Senior High School and Tertiary,

Among those who use contraceptive (n=125) and those who do not use contraceptive (n=21)

Table 2: Reproductive characteristics and intentions of women living with HIV by contraceptive use


Current Contraceptive use among women living with HIV

Eighty – five percent of the respondents were using a modern contraceptive method. Dual method use which is the condom and another method was 4.4%. Eighty -eight percent of the respondents were using any contraceptive method. The distribution of the various contraceptive methods are male condom(77.0%), injectables(5.5%), female sterilisation(1.1%), female condom(0.5%), implants(0.5) and other non modern methods which is the rhythm(1.1%). None of the partners of the respondents had had vasectomy.


This cross-sectional study serves as a pilot study on the contraceptive characteristics of women living with HIV in the Kumasi Metropolis, Ghana. The results showed that disclosure of HIV sero-status to one’s partner was a significant predictor of contraceptive use; women who had not disclosed their status to their partners were significantly less likely to use contraceptive. Similarly, a study in Zambia[7] also reported disclosure of HIV status as a predictor of contraceptive use. In Uganda[8] disclosure of HIV status was a predictor of modern contraceptive use in women living with HIV. Disclosure of one’s HIV status to partner would ensure that both parties would understand the importance of using the condom and other modern contraceptives to prevent unintended pregnancies. It would be easier for couples who have completed childbearing to decide to go for a permanent contraceptive method as well as use the condom. Women living with HIV could therefore be counselled and encouraged to disclose their HIV status to their partners since it may improve their contraceptive use to prevent unintended pregnancies and the transmission of HIV/STI. Disclosure of HIV status to partner is a dilemma because of the stigma and discrimination[9, 10] associated with the infection and more so if the woman is the first to know of her status it sometimes presupposes that she is the one who got the infection first. Women in many places in Africa are expected to be modest and chaste, and be with only one partner. Most HIV infection is transmitted through heterosexual intercourse in Africa and if a woman is tested positive it presupposes that she is promiscuous that is why she has the infection. .Interventions that promote HIV status disclosure and issues relating to non-disclosure could be assessed[11, 12] since it may improve uptake of contraceptives.

Table 3. Univariate and adjusted analysis of factors associated with contraceptive use among women living with HIV


*Reference group

Contraceptive use among women living with HIV is generally higher than the general population[8, 13]. This is mainly because of the high use of the condom which has a dual purpose of preventing the transmission of HIV and preventing unintended pregnancies. The use of modern contraceptive among respondents was high (84.7%). This compares with a study done in Soweto, South Africa were 84% women living with HIV were currently using at least one contraceptive method[14]. Other studies however reported lower contraceptive use among women living with HIV. A cross-sectional study in Kenya[13] reported 44.2% of respondents currently using a contraceptive method. A study in Uganda[15], even reported as low as 25.2% of women currently using a contraceptive method and this could be due to the fact that the study was conducted in a post conflict era. Another study in Uganda[8] conducted at twelve HIV clinics reported current contraceptive use of 61.8% . In Lusaka, Zambia[7], 59.2% of women living with HIV reported current use of a modern contraceptive and this is due to the fact that more than half of the respondents had not disclosed their HIV status to their partners. The differences in the level of contraceptive use can be explained by the differences in the characteristics of the populations sampled.

In the current study, more than three-out-of-four women were using the male condom. This is mainly because of its dual purpose in preventing the transmission of STI/HIV and pregnancy, and this is the main contraceptive promoted at HIV/AIDS clinics in Kumasi. Similarly in other African countries the commonest contraceptive used by women living with HIV is the male condom[7, 8, 13]. Condom is the main contraceptive promoted among people living with HIV. The female condom which has the advantage of being female controlled and can be used if the man is reluctant to use the male condom was however very low (0.5%). Similarly in the general population in Ghana female condom use is very low[5]. It can be argued that the female condom has not been well promoted; it was recently re-launched by the Ghana Health Service in October 2012 with the aim that it will help with its integration into sector wide policies as well as within HIV/AIDS programming[16]. Similarly in Uganda[8], female condom use was low (0.8%). Female condom use in Kenya[13] was higher (10.5%) unlike that in Kumasi, Ghana but this is still low when compared with male condom use. Further research into the low use of female condom among women living with HIV will help clarify the barriers to its use and probably improve its uptake.

Dual contraceptive method use which is the male condom and any other method was low (4.4%) in the sexually active women living with HIV. Other studies however reported higher dual contraceptive use[7, (8, 13, 14]. This study recorded lower dual contraceptive method use and it may be due to the fact that much attention has not been given to the other modern contraceptive methods among women living with HIV. Dual contraceptive method use has the additional advantage of being an effective method of preventing unintended pregnancies and this is important especially for couples who have completed their families or who do not desire children. The integration of family planning services into HIV/AIDS clinics creates an ideal opportunity to promote dual method use and this will go a long way in the prevention of mother to child transmission and the transmission of HIV. Female sterilisation was very low and compares to other African studies[7, 8, 13]. In the United States[17] however sterilisation was one of the commonest contraceptives (44.4%) used among women living with HIV/AIDS. It must however be stated that about a third of the women had sterilisation regret[17]. In counselling women on contraceptive methods, care must be taken so as not to coerce women living with HIV to accept permanent contraceptive methods. Women living with HIV have reproductive rights to decide freely on the number of children and spacing of their children and counselling on contraceptive methods should be done in a supportive environment. Couple counselling is also another method that may improve use of other contraceptive methods in addition to condom use but further research in this area has to be done. In Kumasi, about one tenth of sexually active women living with HIV used other family planning methods without condom. This was slightly lower than the 13% reported in a study in Uganda[8]. Since the condom is the only contraceptive that has the additional benefit of preventing HIV/STI transmission, its continuous promotion at HIV/AIDS clinics may still be warranted.

Study Limitations

In interpreting the results caution must however be taken. The clients attending the clinic may be compliant clients who adhere to treatment and counselling. Potential information bias has to be considered in the interpretation of this data. Since these clinics are specialised, the potential to elicit high response rate for use of condoms is high. Women who were very sick or in WHO Clinical Stage IV were excluded from the study. This will affect assessing the health status and contraceptive use of all women living with HIV in general. These limitations notwithstanding the findings from this study provide a good source of information for improving the services to women living with HIV.

Conclusion and Public Health Implications

Overall, the use of contraceptives among women living with HIV in the Kumasi Metropolis, Ghana is high. Condom is the main contraceptive used because of its dual purpose in preventing the transmission of HIV/STI and preventing unintended pregnancy. Factors associated with contraceptive use at univariate analysis: are ever had children, desire for a child, HIV status of partner and HIV disclosure to partner. Women who have not disclosed their HIV status to their partners were less likely to use contraceptive. Women living with HIV could be encouraged to disclose their HIV status to their partners and encourage their partners to also go for HIV testing. Issues relating to non-disclosure may be assessed and interventions that promote disclosure of HIV status may be implemented. Women who had not disclosed their HIV status could be as a result of stigma and discrimination associated with the infection and they could also be lacking condom negotiation skills. There may be the need of improving the condom negotiation skills of women living with HIV. As part of the integration of family planning services into HIV/AIDS services in Ghana, attention could be given to temporary long term and permanent contraceptives whilst emphasising condom use as well. There is however the need for much larger and longer follow-up studies in this area to be conducted in Ghana.

Conflicts of Interests: None declared


We acknowledge the support and technical assistance by the Kumasi Metropolitan Health Directorate. We also thank the staff of Kumasi South and Suntreso Government hospitals, and the interviewers. We also appreciate all the respondents who were part of the study.


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Original Article

International Journal of MCH and AIDS
Volume 2, Issue 1, 2013, Pages 102-110
Reproductive Tract Infections and Treatment Seeking Behavior among Married Adolescent Women 15-19 Years in India
Ranjan Kumar Prusty, MPS; Sayeed Unisa, PhD

International Journal of MCH and AIDS
Volume 2, Issue 1, 2013, Pages 102-110
Reproductive Tract Infections and Treatment Seeking Behavior among Married Adolescent Women 15-19 Years in India
Ranjan Kumar Prusty, MPS1 ; Sayeed Unisa, PhD1
1International Institute for Population Sciences, Deonar, Mumbai- 400088, India.

Corresponding author


Background: India is home to the highest number of adolescents in the world. Adolescents in India suffer from lack of knowledge and empowerment to make informed sexual and reproductive health decisions. This paper analyses the prevalence of reproductive tract infections and sexually transmitted infections (RTI/STI) and treatment seeking behavior among married adolescent women in India aged 15-19 years.

Methods: Data from the District Level Household Survey (DLHS, 2007-08) of India were used. The prevalence of RTIs symptoms and treatment seeking behavior among women by different socio-demographic characteristics was analyzed. Factor analysis was utilized to create an index using information about 11 symptoms of RTI/STI collected in the survey. Linear and binary logistic regressions were used to know the association between infections and treatment seeking behavior with socio-demographic factors.

Results: About 15 percent of adolescent women reported having any symptoms of RTI/STI. The main symptoms reported were low backache, pain in the lower abdomen, pain during intercourse and itching or irritation around the vulvar region. Factor analysis showed the concentration of diseases in three clusters – infection in around the vulva, other reproductive infection and abnormal discharge; and intercourse related problems. Major predictors of both symptoms of reproductive infections and treatment seeking behavior from multivariate analysis are age, education, wealth, region and awareness about RTI/STI.

Conclusion and Public Health Implications: Knowledge and treatment seeking behavior is poor among adolescent women in India. There is need for programmatic and policy emphasis on increasing knowledge and awareness through family life education including in educational curriculum at school level.

Key Words: Married Adolescents • Reproductive tract infections • Health Behavior • Treatment • India

Copyright © 2013 Prusty et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Owing largely to early marriage, adolescent women in India become sexually active at an early age and face tremendous social and familial pressure for child bearing soon after marriage, a situation that leads to multiple reproductive health problems[1]. Many of them lack knowledge about proper use of family planning methods and safe abortions. The improper use of contraception, intrauterine devices (IUD) insertion in the presence of infections, female sterilization in unsterile condition, and unsafe abortion also increases the risks of RTIs[2-4]. These infections are often asymptomatic, or the symptoms are not recognizable. Therefore, RTIs are generally seen as a ‘silent’ epidemic and are among the leading public health problems significantly contributing to gynecological morbidity and maternal mortality in India and other developing countries[5].Moreover, in India, women with self- reported symptoms of reproductive morbidity do not seek treatment due to existing taboos and inhibitions regarding sexual and reproductive health. They hesitate to discuss their reproductive health problems especially, due to shame and embarrassment[6-7].

Untreated infections are among the underlying causes of Pelvic Inflammatory Diseases (PID), ectopic pregnancy, infertility, cervical cancer, fetal loss, health problems of new born, and increased risk of HIV transmission. In addition to health consequences, women experience social consequences in terms of emotional distress related to gynecological morbidity[8]. As most of these illnesses progresses to a chronic state and remain with women for the rest of their lives, the importance of early detection and management becomes much more evident.

The prevalence of RTI infections is low in India[9]; however, the number of adolescent affected by infections is a real concern due to the large adolescent population. India has the largest proportion of adolescents (more than 243 million) in the world, accounting for almost 20 per cent of the country’s population.[10] Around 340 million incidences of curable STIs are diagnosed each year, out of which 151 million are from South and Southeast Asia[11]. Furthermore, two third of all STIs occur among young and adolescent people who are in their early twenties[12].

Until now, very few studies have focused on reproductive tract infections (RTI) or sexually transmitted diseases (STIs) among adolescent women in developing countries such as India. A study conducted in southern Indian state of Tamil Nadu on young married women aged 16-22 years in a rural community reported a very high level of morbidity[14]. The study showed that more than half of the women were suffering from at least one or more RTIs[14]. Similarly, very few attempts have been made to study the health seeking behavior for reproductive morbidity of adolescent women in India[1, 13-14]. One of the studies explained the familial influence in treatment seeking behavior of married adolescents in Maharashtra, a western state of India[1]. However, most of the studies are micro-level data collected from districts or regions. Therefore, the present study focuses on knowledge and prevalence of reproductive tract infection among married adolescent women using a national level large scale data with a special attention on different categories of infection and treatment seeking behavior. More importantly, this study attempts to group the symptoms by factor analysis and to examine the factors associated with symptomatic clusters. .


The study uses data from third round of the India District Level Household Survey (DLHS)[15], which provides district level information about reproductive and health care of women aged 15-49. The survey was conducted during December 2007 to December 2008. The survey used multistage stratified systematic sampling design and 50 census villages in rural areas and wards from urban areas were selected from each district based on probability proportional size (PPS) sampling[15].In this paper, ever married women aged 15-19 consisting of 39, 164 are considered. Although this age group does not cover the complete gamut of adolescents, this age-group is more suitable for examining the prevalence of RTI and knowledge as most of the adolescents get married and starts active sexual life at this age.

Multiple statistical techniques are used for analysis. Factor analysis was used to create an index using all the 11 symptoms of RTI/STI reported in the survey. Factor analysis is generally used for the determination of a small number of factors based on a particular number of inter-related quantitative variables. Cross tabulation were used to explore the prevalence of RTIs symptoms and treatment seeking behavior among women by different socio-demographic, medical and behavioral characteristics. In this study, we tried to find statistical association between different type of symptoms of RTI/STI among adolescents married women in India and reduced the numbers of factors using principal component analysis method of factor analysis. Simple linear regression was used to know the relation between different types of infections and socio-demographic medical and behavioral characteristics. The explanatory variables are: religion, caste, educational levels, type of house, age of women, age at marriage, abortion, children ever born, contraceptive users, aware of RTI/STI. In order to estimate the net effect of each variable on the probability of seeking treatment or consultation, binary logistic regression model was used.

Ethical Statement

This study used District Level Household Survey dataset which is conducted by International Institute for Population Sciences (IIPS) and funded by Ministry of Health and Family Welfare (MoHFW), Government of India (GoI). The questions in the survey were approved by both IIPS and MoHFW. Informed consent was obtained from the respondents before the interviews were conducted. The authors have no role in data collection.


Awareness of Reproductive Tract Infections among Adolescent Women

In the present study, we found that awareness among married adolescent women is very low with only one-fourth (25%) of them are aware of any symptoms of RTI/STI. The awareness among older women is better than the adolescent women (table 1). Unsafe sex with persons having many partners (60%) is the most perceived mode of transmission among women in India. Knowledge of other modes of transmission like unsafe delivery, unsafe abortion, unsafe IUD insertion and unsafe sex with homosexuals is low among adolescent women than their adult counterparts. The awareness of any RTIs’/STIs’ symptoms is low among married adolescent women in rural areas (24%) than in the urban areas. However, only 31 percent of the urban adolescent women in India are aware of any RTIs’/STIs’ symptoms. Less percentage of younger, illiterate and women from poorest wealth quintiles are aware of RTI/STI as compared to older, higher educated and women from richest wealth quintile respectively (table not shown).

Prevalence and Duration of Symptoms

Among the adolescent women, around 15 percent reported having any symptoms of RTIs/STIs and 11 percent reported having abnormal vaginal discharge in the last three months of the survey. Low backache (8 %), pain during sexual intercourse (5 %), pain in the lower abdomen not related to menstruation (5%), itching or irritation over the vulva (4%), pain on urination or defecation (2.5 %) and boils/ulcers/warts around the vulva (1.6%) are the major problems reported by married adolescents. The result shows that more than half of the adolescent women have at least one reproductive infections for more than three months. The proportion of other morbidities varied from 46 to 60 percent. Low backache, and swelling in the groin is most neglected by more than 60 percent of women reporting the symptoms exist for more than 3 months.

Factor Analysis

Some of the infections may exist due to other type of infections or may simultaneously exist together. In order to understand the association between different symptoms, we used factor analysis using all eleven symptoms of RTIs/STIs reported by adolescent women. Using principal component analysis method, we found three factors with factor score of above 0.4. The factors are a) Infections in and around the vulva i.e. boils/ulcers/warts around the vulva, painful blister like lesions in and around the vagina, itching or irritation over the vulva and swelling in the groin. All the symptoms in the first factor are in around the vulva and mostly lower track infections. b) Other reproductive infection related to the upper tract of the vagina like pain in the lower abdomen not related to menses, pain during urination and defecation and low backache. Abnormal vaginal discharge which is a lower tract infection is also found to be associated with the second factor c) Sexual intercourse related problem of pain and spotting among women.

Table 1.   Knowledge of different mode of transmission of RTI/STI of ever married women by their age groups, India, 2007-08


Table 2.    Percentage of adolescent married women reporting different symptoms of RTIs/STIs and the duration of the illness, India, 2007-08


aexcluding abnormal discharge. bTotal duration is not 100% because of don’t know and missing cases. LA=Lower Abdomen

Determinants of RTIs/STIs

We used linear regression to understand different socioeconomic and demographic factors affecting these three variables which are in continuous form. Dummy variables were created from categorical socioeconomic variables and age was used as a continuous variable. The result of linear regression shows that following variables have a significant and positive association with lower tract infections, ‘use of modern contraception (ß=0.36), abortion (ß=0.4), poorest (ß=0.6) and middle (ß=0.19) quintiles of wealth index; and North-East (ß=0.51), West (ß=0.25), and central (ß=0.13) regions’. Other infections related to the upper tract shows positive and significant association with age (ß=0.04), education, region, the use of modern contraception, abortion, wealth index and regions. The ? value for use of modern contraception and abortion is 0.18 and 0.67 respectively. While caste status shows a negative association with other infections related to upper tract. The value of scheduled tribes and other backward classes are -0.12 and -0.06 respectively.

Table 3.   Linear regression showing beta values Infection in and around the vulva and other Infection in upper tract problems among women 15-19 years

Background Infection in and around vulva (β) Other Infection in Upper Tract (β)
Age -0.05 0.04**
No education 0.08 0.13**
Primary 0.01 0.13**
Secondary 0.00 0.05**
Hindu 0.32 0.19**
Muslim 0.17 0.24**
Scheduled castes -0.01 -0.04
Scheduled tribes -0.1 -0.12**
Other backward Class -0.01 -0.06**
Modern contraception 0.36** 0.18**
Abortion 0.40** 0.67**
Poorest 0.60** 0.24**
Poorer 0.18 0.14**
Middle 0.19** 0.09**
Richer 0.09 0.07**
North 0.08 0.30**
North-east 0.51** 0.23**
East 0.1 0.12**
West 0.25** 0.03
Central 0.13** 0.09**

The β of sexual intercourse related problem is not given as none of the covariates are significant in the model. *p<0.1 **p<0.05

Treatment seeking behavior of RTIs/STIs among married adolescent women in India

Although premarital sexual relationship is not as prevalent in India as in other countries, early induction into marriage compels women into early and long sexual lives with their husbands at a young age when they are not accustomed to the use of family planning practices and other sexual health education. In this study, we found that treatment seeking among adolescent women is poor. Only 62 percent of the adolescent women discuss the infections with their husbands/partner whereas only one out of four of them go for treatment. Comparing different age groups, the treatment seeking behavior is much higher among older women (25+ years) as compared to the adolescents. This may be due to the fact that older women enjoy better status in households than younger and newly married women. More than three-fifths of the women preferred private hospitals/clinics as compared to only a little more than one-fourth going to government hospitals for treatment. This may be attributed to privacy, better quality of care, as well as lack of special treatment division for RTIs in government hospitals. More than half the poorest and poorer section of the control prefers to private hospitals or clinics. This shows that going to private hospitals might well be a compulsion rather than choice.

Factors Affecting Treatment Seeking Behaviour of Adolescents

In order to understand the adjusted effect of different socioeconomic and demographic determinants, a binary logistic regression was performed taking “care sought” (No/Yes) as an outcome variable. The result shows that adolescent age, education, religion, caste, wealth index categories, and awareness about RTIs/STIs are significant determinants of her care seeking behavior (table 4). Age, religion, residence, education and wealth are positively associated with treatment seeking of RTIs/STIs of women. The older adolescent women (age 19 years) are two times more likely to seek treatment than the younger adolescent (age 15 years). Muslims (OR=1.45, p<0.05) and other (OR=1.29, p<0.1) religious adolescent women are more likely to seek treatment than the Hindu adolescents. Husband’s education also shows significant association and women of higher educated husbands (OR=1.18, p<0.1) have higher odds of seeking care than women of illiterate husbands. The adolescent women with secondary education (OR=1.28, p<0.05) and women in richest quintile of the households (OR=1.39, p<0.05) have a higher chance of seeking treatment than women with no education and women belonging to the poorest households. In comparison to adolescent from the north, the southern adolescent women have a higher odd (OR=1.25, p<0.05) and North-eastern adolescent have a lower odd (OR=0.54, p<0.1) of seeking treatment. Those who are not aware (OR=0.72, p<0.05) of any RTIs/STIs are less likely to seek treatment than those married adolescent aware about the infections.

Table 4.   Logistic regression showing odds ratio the treatment seeking behavior among married adolescents in India

Background Characteristics Sought
Number of Women with any RTI/STI symptoms
15® 352
16 1.46* 713
17 1.56** 1155
18 1.65** 2794
19 1.97** 2781
Hindu® 2622
Muslim 1.45** 655
Other 1.29* 2266
Rural® 1877
Urban 1.13* 1542
Wealth index
Poorest® 2062
Second 1.13 4570
Middle 1.26** 2426
Fourth 1.22* 686
Richest 1.39** 113
North® 6236
North-east 0.84* 1220
East 0.92 339
West 1.02 7218
South 1.25** 577
Aware of RTI/STI
Yes® 2320
No 0.72** 5475

Note: Education of women and their husbands, Children ever born, and Caste are used as control variable in the regression model. *p<0.1 **p<0.05 and ***p<0.01


In this study, we highlight the state of knowledge, prevalence and treatment seeking behavior among married adolescents in India. Awareness of RTIs/STIs among married is very low in India and level of knowledge of RTI is even lower than in other developing countries including many African countries[16-17].Only one-fourth of the adolescent married women of are aware about any mode of transmission considered in the study and this is little higher among the older women. Due to low education and low age at marriage adolescent women are mostly not accustomed to RTIs. Many studies in south-east Asia had also reported low understanding of RTI/STIs among women. For instance, a study in rural Bangladesh reported that only 12% of the study population had the basic understanding of RTIs[18]. The study explained this great disparity in the proportion of the various populations who were aware of RTIs could be explained from the rural nature of India and Bangladesh where most of the respondents were illiterates, when compared to the urban settings of Nigeria and Kenya where the literacy level is higher[16]. However, we found that only 31 percent of the urban adolescent women in India are aware of any RTIs’/STIs’ symptoms.

We found around 15% of adolescents have any symptoms of reproductive tract infections. Earlier studies on South Asia found the prevalence of reproductive varies in between 22-92%[3,6,19-21]. However, most of these studies included all three types of reproductive morbidities including gynecological morbidities. Most of these infections stayed for more than three months. The factor analysis shows the concentration of diseases in three clusters – infection in around the vulva, other reproductive infection and abnormal discharge; and intercourse-related problems. Multivariate results show that the use of modern contraception and abortion were significantly associated with both infection in around the vulva and other reproductive infection and abnormal discharge. This corroborates the findings from prior studies[2-4].

The treatment seeking for any RTI/STI infections is found to be low in our study. Three-fifths of women discuss RTIs with their husbands/partner but only a little more than one-fourth of them prefers going to seek treatment. This finding is consistent with some of the earlier studies in India which accentuates that the country’s health programs which has been special importance to adolescents and youths has failed to reach them[13, 22-23].Our multivariate results shows younger adolescents, rural and poor women are less likely to seek treatment than older urban and rich adolescent women respectively. With respect to geography, women from northern region and north-eastern women have less probability to seek treatment than their southern counterparts. Those who are not aware of RTI/STI symptoms are less likely to seek treatment. Thus, here is need to focus on rural and poor adolescents with a special focus on strengthening their knowledge about RTI/STI infections.


The result of this study shows that awareness of life threatening reproductive infections still remains low despite several government efforts in Reproductive and Child health (RCH) programs and the current national rural health mission (NRHM). The awareness remains dismal among adolescent women who have very low knowledge of these infections. Not many of the women are aware that RTIs/STIs can be transmitted through unsafe delivery, unsafe abortion or IUD insertion in the presence of infections. The study found although the prevalence is not very high many of the women ignore these infections for long duration. There exists a strong association between the morbidities which was confirmed by factor analysis.

Furthermore, the number of unqualified and illegal private medical practitioners practicing allopathic medicine and doing abortions has remained the priority among people in the rural areas and small towns of India. People willingly pay for their services rather than availing themselves of free services at the government health facilities. Women rarely use the government health centers than private ones. This underutilization has been described in many other studies. [24-26]


The authors would like to thank the Editor-in-Chief and the two anonymous reviewers for their comments and suggestions to improve the paper.


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