Many Domiciliary deliveries conducted by traditional birth attendants are

Many women in need of PMTCT
are not being reached by current programmes and this can be attributed to
socio-cultural, economic, systemic and programmatic factors. Domiciliary
deliveries conducted by traditional birth attendants are commonplace in rural
Zimbabwe and are on the rise (Macro International , 2007). Moreover; PMTCT
programmes insist on corresponding methodologies to avoid missed opportunities
in this evolving context. This report is among the several attempts that have
been made towards evaluating the practicability as well as the appropriateness
of the involvement of TBAs in PMTCT initiatives.

Some of the attributes of the TBAs in this
rural perspective included being elderly, married or widowed, with the lowest
level of education. Such socio-demographic qualities are comparable to those of
TBAs in other locations (Itina, 1997.). Untrained TBAs who
were not trained in most cases were younger, possessed less experience than TBAs
who had been trained. These TBAs had learned to assist on their own or by assisting
another TBA. The reduction in training programmes targeted for TBAs in Zimbabwe
could provide an explanation as to why younger cadres fall within the untrained
TBAs group.

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In order to realize valuable gains to
community-based public health interventions and chart ways for a number of
activities connected to prevention and care there is need for there to be
existing links between community health workers such as TBAs and the formal
health services. Corresponding approaches, through which community-based mediations
are paired with the reinforcement and/or spreading out of services at the health
facility level, also possess the ability to tackle a variety of other health
challenges, such as the limited acceptance to HIV testing and compliance to PMTCT

Studies that have been carried out in the
recent past have suggested some problems associated with home deliveries with
reference to uptake of PMTCT interventions (Albrecht, et al., 2006). Studies have
demonstrated that outside the TBAs’ current activities which include but are
not limited to assisting women during delivery and in the post-delivery stage,
they are also willing to broaden the range of their work in mother-and-child
activities to encompass PMTCT with some restrictions identified such as escorting
the child to the health centre to be given medication as well as assisting staff
at the health centre to document ANC services rendered to the women. This data hints
on the need to reinforce the health care network system between the recognized
health services and the rural populations including TBAs. For this, incorporating
the services of TBAs into the conventional health care delivery system is therefore
of utmost importance and should be implemented. The health care system that is
in existence has to build-up collaboration with TBAs who provide services in
the informal sector and assist in expanding communication skills in the
referral process. Moreover, authorities mandated to provide health care and
health personnel need to identify the cultural and practical involvement of
TBAs to the health system.

The role played by and
status accorded to TBAs in any given community determine the achievement
realised from community-based interventions that underscore the contribution of
TBAs. In India, a reduction of more than 60% in neonatal deaths was realised as
a result of community-targeted approach that encompassed training of TBAs as
well as women in the communities to recognize and treat sick new-born babies in
the community (Bang, et al., 1999). Additionally, significant
gains in the decrease of peri-natal deaths and maternal deaths were documented in
a pilot training of and incorporating TBAs in the conventional health-care system
in Pakistan (Jokhio, et al., 2005 ).

The results of our
survey reveal that TBAs interviewed in this location have inadequate information
with regards to issues pertaining to HIV/AIDS overall, also PMTCT to be
specific. However this situation can be enhanced through prioritizing educating
these cadres that are at present available and operating in these communities.
Selected trainings have to be specifically designed to match the duties that
the TBAs are expected to carry out, the education and proficiencies that are essential
as well as modifying the training syllabuses to the TBAs’ level of education.

The current study reinforces
the need to strengthen TBA’s level of appreciation on MTCT reduction interventions
before they could play a part in the delivery of PMTCT packages. Currently, in
a rural district setting as this one, TBA cadres’ guidance provided to women
with regards to issues of HIV/AIDS (not excluding PMTCT) is somehow not a
priority for them. It is therefore of utmost importance to, at national level,
review the TBA training manual and include sections which look at simple, easy
to understand concepts of HIV infection (Choguya, 2015). Studies conducted in Tanzania
concluded that if TBAs are motivated enough and as well provided with  supplementary proficiencies, they can
effectively function in the implementation of such programmes, contributing to accessing
women who do not give birth at health-care facilities where PMTCT interventions
are made available (such as counselling, as well as administering single-dose
nevirapine sdNVP) (Busza, et al., 2012). It was also
concluded in studies carried out in Uganda that when selection is conducted carefully,
complemented by proper training and regular and uninterrupted follow-up
support, TBAs provided an integral part in championing and referring expecting
women for health centre-based PMTCT services (Barigye, et al., 2010).

Conducting blood test for
HIV was one activity that TBAs were reluctant to perform in the study. Applying
this intervention using community health cadres such as TBAs is directly linked
to the national policy framework of each particular country and if it were ever
going to be adopted it would require uninterrupted and vigilant observation and
follow-up. The first known PMTCT programme to utilize TBAs in the provision of  private  and confidential counselling and testing for HIV
using a fluid rapid test applied orally was in Cameroon (Nkenfou, et al., 2013 Aug 9). This method was implemented
by way of community involvement, training and accompanied with assistance from nurses
who provide supervisory visits to the rural communities on monthly schedules.

Engaging TBAs in PMTCT issues is backed by a
number of exclusive reports that have shown enhancement of TBAs’ efficiency in
the delivery of public health services. In one systematic review that was
produced it was revealed that training TBAs seems to enhance attendance of antenatal
care by women by rates exceeding 38% (Sibley, et al., 2004).

In this particular district of Zimbabwe, achievements
derived from  MTCT prevention programmes
may be enhanced by intensifying community-based interventions, as well as involve
TBAs who then could: bring about linkages between communities and health
service providers and, make available health education to promote improved
utilization of ANC services, consequently access to PMTCT; sensitize
communities targeting a family-aligned PMTCT approach (Abrams, et al., September
2007). This
also encompasses informing and communicating the basic knowledge pieces
concerning  PMTCT as well as the significance
of  being tested for HIV to the expecting
mothers  and their spouses; deliver
community-aligned HIV counselling and testing (Shetty, et al., 2005).

One more significant
conclusion was the unquestionable relationship between women who gave birth at
home and the chance they had to pick their desired location for delivery. The
power to make decisions, gender imbalances as well as collective  insistence from the society particularly from
spouses including other kinfolks has been reported to considerably affect
utilization of maternal and child health care (Beckera, et al., 2014). It is well acknowledged
that in Africa women do not possess the authority to make decisions on their
own, decisions pertaining to their own and their children’s health care (Acharya, et al., 2010).

As this study reveals,
most of the women who were assisted to deliver by a TBA, as well as the TBAs
themselves mentioned that cost fees were a chief determining factor when
choosing a place to deliver, a point that is coherent with other conclusions
derived in similar settings (Tebekaw, et al., 2015). Such an element, coupled
with the standard of care articulated in this research as unfavourable
experiences women meet when they interact with health personnel in earlier
pregnancies, have been recognized as imperative justifications for the women
not to utilize maternal services as well as PMTCT services and choosing other
places for them to deliver, other than the conventional health service (Belay & EndalewGemechu, 2016). With regards to
circumstances like this one encountered here in which women mix TBAs and specialized
care and where TBAs urge women to make use of ANC service, reinforcement of established
basic antenatal service delivery overall and prior introduction of extra
interventions which also include PMTCT packages in particular is of paramount
importance (Sarker, et al., January 5, 2016).

Fear of being judged
and branded, and even or violation of privacy was at the forefront as the
leading causes for women to shun HIV testing and knowing their status.  Being terrified of knowing one’s HIV status
has been elucidated before as a very significant reason why women may drop out
of taking PMTCT services and low levels of HIV status revelation (Both & van Roosmalen, 2010). Being attended at
healthcare centres in the presence of TBAs dissuaded
women from taking the medication for fear of revealing their HIV status. It is therefore
imperative to extend and strengthen collaborations between various stakeholders
at health centre and community level to reinforce education and health
information access for each and every woman specifically and the public in
general so that stigma and discrimination may then be prevented. Furthermore, teaching,
placement and regulation of community health cadres TBAs included, must highlight
the importance of keeping client health information confidential, also the need
to encourage women when they disclose their HIV sero-status (Kadowa & Nuwaha, 2009
Increase in access to HIV and treatment programmes can be attributed to HIV
status disclosure, a rise in prospects for risk decline and consciousness of
HIV risk to partners that have not been tested for HIV, which can in turn result
in much improved uptake of voluntary HIV counselling and testing, and devotion
to the guidance provided to prevent postnatal and sexual HIV transmission (Hart, 2010).

TBAs expressed
willingness to be involved in PMTCT work, as confirmed by the qualitative
results shown in the focus group discussions. However, as was found out in the
community study, women who gave birth at a health centre or assisted by a TBA concurred
that for TBAs to be taken aboard in PMTCT programmes they have to undergo
training first.

There exist numerous possible shortcomings
that have to be attended combined to the results of this study. The first thing
being that the study was conducted in just one district in the whole of
Zimbabwe, therefore the results may not may not show the true picture of the
situation of the whole of the country. However, the socio-economic traits of ladies
of child bearing age who were selected in this survey are similar to those of
Zimbabwe as well as several other African locations (Solanke, 2017). Furthermore, interviewees’
versions of independent events around gestation and giving birth could have
been liable to recollection bias. Another issue that could be up for consideration
was the possibility that there could have been inconsistences with regards to
where interviewees did not possess understanding of the approved Shona expressions
because this could have had a bearing on the perception of some queries by the interviewees.

This was somehow averted
from the training that data enumerators received with regards to terms to be
utilized for the Shona languages interpretations to reduce mistakes and by way
of piloting of the tools.


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