Birth Preparedness Plans and Status Disclosure Among Pregnant Women Living with HIV Who are Receiving Antiretroviral Therapy in Ibadan, Southwest, Nigeria

1. Background and Introduction

The human immunodeficiency virus (HIV) can be transmitted from an HIV-positive woman to her child during pregnancy, childbirth, and breastfeeding. This mother-to-child transmission accounts for most infections in children.1 If a pregnant woman is living with HIV without treatment, the likelihood of the virus passing from mother to child is 15% to 45%. However, antiretroviral treatment (ART) and other interventions can reduce the risk to below 5%.2 Meanwhile, HIV continues to be a major cause of maternal and infant mortality and morbidity in sub-Saharan Africa.3,4,5 However, prevention of mother-to-child transmission (PMTCT) of HIV strategies has proven to be effective in decreasing the number of children infected in utero, intrapartum, and during the breastfeeding period, with significant potential for improving maternal and child health.6

Nigeria, along with 22 other countries around the world (the vast majority of which are in sub-Saharan Africa), contributes 73% of the global women infected with HIV. Hence, the prevalence of HIV infection among pregnant women in these countries could rise. Thus, Nigeria is classified as a high priority for PMTCT.7 Therefore, adequate PMTCT services are needed in Nigeria to prevent HIV infections among pregnant women and children.8 These PMTCT services include access to antiretroviral therapy (ART) by PWLH, an adequate birth preparedness plan, institutional delivery, and counseling on HIV status disclosure.

The birth preparedness plan was recommended by the WHO as part of the package of essential services for high-quality care for PWLH.9 The birth preparedness plan encompasses an adequate birth plan, post-partum follow-up plan, breastfeeding plan, family planning plan, and breastfeeding plan. This birth preparedness plan is expected to be documented and discussed between the skilled care providers and the client. It also ensures institutional delivery, which eventually can be used to promote PMTCT and improve maternal health. However, several barriers to PMTCT have been observed in sub-Saharan Africa. These barriers commonly relate to the implementation of the recommended package of essential services for high-quality care for PWLH. Individual, social, and structural factors are all important determinants of PMTCT success, with stigma, difficulties with partner disclosure, perceived compulsory testing, confidentiality issues, and inadequate counseling being considered as major themes in recent studies.10

Studies have shown that disclosure of one’s HIV status is important in the prevention of HIV transmission, the early treatment and care of partners, and improved retention in PMTCT and ART programs.11 Also, it is acknowledged that the disclosure of one’s HIV status is complex, and therefore, healthcare providers who are working with PWLH need to give appropriate counseling, support, and skills that will enable PWLH to share results with their partners or significant others.12 The prevalence of HIV disclosure to partners varies between settings and populations.11 Studies from developed countries reported a very high level of HIV status disclosure,13 while the level is lower in sub-Saharan Africa.14,15 However, women reported fear of disclosure due to fear of being rejected and abandoned, fear of being blamed, fear of being considered unfaithful, fear of physical abuse, fear of divorce, stigma, and fear of violence from partners as barriers to disclosure.11

Therefore, the researchers sought to identify information on the prevalence of HIV infection among pregnant women, as well as status disclosure among PWLH, considering that many interventions which have been implemented to improve status disclosure to reduce the spread of the infection and to improve PMTCT. Also, there is a dearth of information on the level of birth preparedness plans among PWLH. Hence, there is a need to have such information to be able to plan interventional programs that will further ensure PMTCT in Nigeria.

2. Methods

3. Results

3.3. HIV Disclosure Status

The study found that 40.0% of the participants tested for HIV because it was compulsory for antenatal registration. However, 14.3% reported that they voluntarily tested for HIV and were aware of their status before antenatal registration (Figure 1). We found that 61.4% of the participants disclosed their HIV status to either their mothers or siblings, while 7.1% of them disclosed their status to their husbands/partners (Figure 2).

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Figure 1

Reasons for HIV screening/testing among participants

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Figure 2

HIV status disclosure among participants

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4. Discussion

This study reported that one-tenth of the participants who participated in this study proposed to have their childbirth outside of a healthcare facility. However, one-fifth of the participants did not disclose their HIV status at their proposed place of birth. The results are worrisome because most non-institutional deliveries in Nigeria do not have skilled birth attendants.18 Hence, this factor may contribute to increases in the spread of HIV infection and mother-to-child transmission. More so, this category of women who proposed to deliver outside the hospital did not disclose their HIV status at their proposed place of birth. HIV testing is not guaranteed in almost all non-institutional deliveries in Nigeria. Hence, both the birth attendants and newborns could be infected with HIV in the process of childbirth. Therefore, interventions, programs, counseling, and other efforts that ensure institutional delivery for all PWLH in Nigeria and other developing countries are recommended.

After assessing the overall birth preparedness plan of the participants who received ART, the result showed that most of the participants had poor birth preparedness plans, which implies that many of the participants may have unplanned home delivery. Unplanned home delivery has been linked to inadequate birth preparedness.20 Unplanned home delivery could further increase the spread of HIV through mother-to-child transmission, and PMTCT may not be achieved. Also, less than half of the participants had good birth preparedness, which could be due to poor knowledge and low income, since most of the participants were petty traders and artisans who could not afford to adequately prepare for birth. Although there is limited information in the literature about birth preparedness plans among PWLH, studies20,21 conducted among pregnant women in Nigeria reported low birth preparedness. Hence, there is a need for integrating BPCR education into routine prenatal education, especially counseling of PWLH. More importantly, documentation of birth preparedness plans among PWLH could yield a better pregnancy outcome and further strengthen PMTCT.

The study findings show that a higher percentage of the participants tested for HIV because testing was compulsory for antenatal registration. However, the least percentage was recorded by those who did voluntarily test for HIV; they were aware of their status before antenatal registration. In this study, antenatal registration was the most influential factor regarding the decision for HIV testing during pregnancy, since testing was a criterion for antenatal registration. This finding implies the importance of antenatal registration with a skilled care provider in healthcare facilities to conduct PMTCT. This finding is also supported by Ejigu et al.22 who described HIV testing at antenatal registration as an entry point to PMTCT and therefore recommended integrating HIV testing into antenatal care services. This finding is also consistent with findings in a previous qualitative study in Sudan.23 Thus, training and sensitizing antenatal care providers to promote HIV testing at antenatal registration will facilitate care provider-initiated HIV testing among pregnant women, thereby promoting PMTCT.

Disclosure of HIV status promotes access to care, PMTCT, and ART adherence, especially among pregnant women.11 The methods are entry points for successful ART treatment. In this study, more than half of the participants had disclosed their HIV status to either their mothers or siblings. However, less than one-tenth of the participants disclosed their status to their spouses. Spousal disclosure is associated with increased support, including support for regular clinic attendance and ART adherence.24,25 Although relatively uncommon, lack of disclosure and fear of stigma were major barriers to ART adherence. Some women may not disclose their status for fear of losing support from their partners. This finding corresponds with a qualitative study in a similar setting where the fear of disclosure among HIV-positive women was influenced by their economic dependency on men, among other factors.26

A previous study identified the largest barrier to spousal disclosure, which was fear of negative outcomes, especially divorce. Disclosure is a process that requires preparedness and time, as described in the process-oriented framework or disclosure processes model.27 It is thus, not surprising that disclosure increased over time.28 Similar to previous studies performed in the general population, women in this study had better disclosure to their spouses, mothers, and sisters as opposed to their fathers and brothers.28 The spousal disclosure in this study was low when compared to disclosure to mothers and sisters or other family members. This finding is contrary to another study in Nigeria, which showed that two third of the participants disclosed their HIV status to their partners following antenatal HIV testing.29,30 Therefore, disclosure of HIV status to partners will promote spousal support. This finding is also supported by Chirambo et al.31 Spousal support could be in the form of transportation and ART reminders, which may enhance medication adherence.

Similarly, having a sexual partner who has been tested makes it easier for women to disclose their HIV status.30, 32 Interventions to enhance HIV status disclosure and partner support should address women’s fears and support for partner testing. These interventions may include efforts to foster family support groups. Batte et al.30 reported that women made various attempts to disclose and encourage their partners for testing, with varying levels of success. A spousal test could be a point of intervention for PMTCT services, as spousal disclosure increases women’s participation in PMTCT programs.33 In addition to improving PMTCT programs, disclosure, and partner testing at antenatal registration may support care for HIV-infected partners.

This study showed a low prevalence of HIV among pregnant women who received skilled antenatal care. The finding further stresses the importance of receiving skilled care during pregnancy. Antenatal care visits strengthen data collection that will be used for informing necessary interventions for positive pregnancy outcomes. The low prevalence of HIV among participants in this study is similar to what was found in meta-analysis data from 19 African studies.34 However, the prevalence in this current study was approximately one-third compared to what was found in another study in Nigeria, which was 13 years before this current study.35 The finding implies that the prevalence is decreasing with increasing years in Nigeria. Nonetheless, the identified prevalence in this study was higher and even double the prevalence in another study36 conducted in Lesotho, despite Lesotho being a country with a high burden of HIV infection among women of reproductive age. Therefore, much needs to be done to reduce HIV infection among pregnant women in Nigeria.

5. Conclusion and Global Health Implications

The main reason for HIV testing among the participants was antenatal registration, which was one of the successes of the integration of HIV screening into antenatal care. The HIV prevalence among the participants was low, and efforts should be made to sustain this. However, the birth preparedness plan among the participants was low, the level of status disclosure to partners was low, and not all the participants proposed to deliver their babies to the hospital where their HIV status was known. These decisions may potentially militate against PMTCT and HIV transmission. Therefore, interventions to improve PMTCT among PWLH are recommended at all levels of healthcare institutions.