HIV-related stigma keeps Kenyan pregnant women from having babies in health-care facilities

PLOS MedicineAug 22 2012

The fear of being labeled HIV-positive is strong enough to keep mothers in one Kenyan province from having babies in health-care facilities, according to a study published online today in the journal PLOS Medicine. Communities there have come to see clinics and skilled care as mostly for HIV-positive women.

Specifically, researchers from the University of Alabama at Birmingham found a close link between HIV-related stigma and the fact that just 44.2 percent of mothers deliver their babies in facilities with skilled caregivers in Nyanza Province, Kenya. About 16 percent of women ages 15-49 in the province are HIV-positive.

Professional help greatly increases the chances that any mother, HIV-positive or not, will survive childbirth, which takes the lives of more than 250,000 women in developing nations each year. In Nyanza, Kenya, a region where one in five pregnant women is HIV-positive, skilled care during pregnancy and birth also increases the likelihood that those infected will receive antiretroviral drugs that prevent the passing of HIV from mother to child.

Past studies in the region have reported that being labeled HIV-positive links women with promiscuity in the eyes of their families, often causing them to be abused by male partners who are less likely to visit clinics or be tested for HIV themselves. What was less well understood going into the current study was the degree to which stigma kept pregnant women from accessing skilled care for childbirth.

"Our work shows that women in Kenya are deeply afraid of the HIV label, so stigma-reduction programs would increase the use of HIV services and of skilled attendance at delivery for all women," says Janet Turan, Ph.D., associate professor in the Department of Health Care Organization and Policy at the UAB School of Public Health. "It's also essential that these facilities warmly welcome the poorest, least-educated women, because they deliver their babies without skilled care most often."

Traditional birth attendants assist in about 26 percent of births in Nyanza, most of them without formal training and despite discouragement from the Kenyan authorities. According to the current study, many Kenyans think the region's clinics are the best place to give birth for women with pregnancy complications, but women who choose clinics over home births with traditional attendants run the risk of being labeled HIV-positive.

The stigma is so strong that many people have adopted a low opinion of anyone living with HIV, and not without cost. The team found that women with such opinions were about half as likely to deliver their baby in a health facility as those without them.

Based on their findings, the study authors conclude that government campaigns seeking to halt mother-to-child transmission by urging HIV-positive mothers to give birth in health facilities may be inadvertently promoting the idea that childbirth there is mainly for women who are HIV-positive. Public health messages should be adjusted to stress that delivery in a facility with a skilled health-care provider is vital for all women, not just those with HIV or pregnancy complications.

Preventing avoidable deaths

The Maternity in Migori and AIDS Stigma (MAMAS) Study involved 1,777 pregnant women with unknown HIV status in Nyanza Province between 2007 and 2009. The women completed a questionnaire on their perceptions of HIV-related stigma during their first antenatal care visit and before being offered HIV testing. A subset completed another questionnaire after giving birth. The team measured the women's perceptions of HIV-related stigma using a 22-item scale developed and validated in Africa.

Along with Turan, UAB study authors included her husband Bulent Turan, Ph.D., assistant professor in the Department of Psychology. Also making important contributions were Abigail Hatcher, Suellen Miller and Craig Cohen in the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of California, San Francisco; José Medema-Wijnveen, at the University of Groningen, Groningen, The Netherlands; and Maricianah Onono and Elizabeth Bukusi in the Centre for Microbiology Research at the Kenya Medical Research Institute, Nairobi, Kenya. The project was funded by the U.S. National Institute of Mental Health.

Turan's effort in Kenya is part of a wide-ranging UAB research effort to address the HIV epidemic at home and in Africa. The UAB Center for AIDS Research (CFAR) is one of the seven original centers established in 1988 by the federal government to drive research advances. It supports prevention and HIV-patient care at the 1917 Clinic in Birmingham and in Zambia through a partnership with the Center for Infectious Disease Research. Turan also leads the CFAR-funded Interdisciplinary Research Group at UAB, which works to reduce HIV-related stigma and promote testing in Alabama. The group is currently conducting the Finding Respect and Ending Stigma around HIV (FRESH) Study.

"Kenya has made only limited progress towards reaching the 2015 United Nations Millennium Development Goals, which include lowering the maternal death rate in developing countries by 75 percent," says Turan. "In this context, understanding women's use of skilled delivery and HIV-related health services is an urgent priority, since skilled care during childbirth prevents most avoidable deaths."