SWAZILAND: Poor health services hamper PMTCT progress
Swaziland has made remarkable progress in reducing HIV transmission from infected mothers to their babies, but health activists worry that this may be stalled or even reversed if lapses in basic health services are not addressed.
Since prevention of mother-to-child transmission (PMTCT) services became available in 2003, HIV transmission has almost halved, from 40 percent of children becoming infected by their HIV-positive mothers to 21 percent.
"This is very positive news, and it makes me proud of our efforts in Swaziland," said Khanya Mabuza, Assistant Director of Programmes at the National Emergency Response Committee on HIV/AIDS (NERCHA), which coordinates efforts to combat the disease.
The number of teenage pregnancies has also fallen; teen mothers are less likely to use antenatal care and PMTCT services, so fewer teens giving birth means fewer HIV-positive babies.
But the news is not all good. A significant proportion of pregnant women are giving birth at home, and so are not using PMTCT services.
A rise in home deliveries appears to be a direct result of appalling conditions at underfunded clinics and hospitals: leaking roofs, unreliable water supplies and a lack of beds at clinics are contributing to the problem of "burnout" among nurses.
"Women are refusing to come to some clinics and hospitals because of the poor environment and the attitude of the health workers," said Sophia Mukasa Monico, Country Coordinator for UNAIDS in Swaziland.
She recounted the story of a woman who gave birth on the floor of a waiting room in a clinic in the capital, Mbabane, without any assistance from overworked, unmotivated staff, who ordered her to clean up afterwards.
"Pregnant women think: 'Why should I go to a hospital where I expect to have a safe birth and end up writhing on the floor in pain? I should stay at home.'"
Zodwa Mthetfwa, an HIV testing and counselling officer at Swazis for Positive Living, a local support NGO, confirmed that many Swazi women avoided going to clinics to have their babies.
"If you go to a place and have a bad experience, you don't go back, particularly if you are a pregnant woman whose ... needs are not met," she said. "Word gets around, and I get more requests from pregnant women for midwives' contact details than for clinics."
Pregnant women think: 'Why should I go to a hospital where I expect to have a safe birth and end up writhing on the floor in pain? I should stay at home'
Most of the more than one in four Swazi women who give birth at home do not use PMTCT services. "The rise in home deliveries is quite alarming," said Dr Mahdi Mohammed of the Elizabeth Glaser Paediatrics AIDS Foundation. "The trend counters all our PMTCT efforts."
At a recent conference hosted by the health ministry in the central commercial town of Manzini, delegates from a number of local health groups said insufficient funding was the root cause of deteriorating standards and conditions at clinics.
"From shortages of drugs to broken equipment and discouraged [and thus underperforming] staff, it all comes down to money," said one participant. "This is a perennial problem in a poor country like Swaziland, but it also has to do with government spending priorities."
New and old
Ingrained cultural practices have also proved difficult to change, limiting the success of PMTCT programmes and contributing to a stubbornly high infant mortality rate of 85 deaths per 1,000 live births.
"In Swaziland ... the child is raised by the entire homestead. We instruct [HIV-positive] mothers on the importance of exclusive breastfeeding for the first six months, but a granny will say, 'Our boys always eat other foods from birth; that's the way we do it'," said Percy Chipepera of the Swaziland Infant Nutrition Action Network.
Mixed feeding has been proven to increase the likelihood of infants contracting HIV from their mothers and is also detrimental to HIV-positive babies on antiretroviral (ARV) medication.
According to the latest World Health Organization (WHO) guidelines, a pregnant woman's HIV status should be determined in her first trimester so as to provide optimal PMTCT services, but Swazi tradition discourages women from talking about a pregnancy during the first 14 weeks, let alone going to a clinic, for fear of inviting bad luck that could result in a miscarriage.
"Social and personal behaviour change doesn't take a second, it is complex, but it is key to our PMTCT success," commented Dr Fabio Mwanumba, HIV Specialist at the UN Children's Fund (UNICEF) and UNAIDS in Swaziland.
Experts agree that a more holistic approach is needed to integrate PMTCT services with strengthened maternal, newborn and child health programmes, but Dr Mwanumba said the success of behaviour change efforts should also be monitored.
PMTCT services were now quite widespread, "But what is the depth of these services? What is the quality?" he said. "It is easy to monitor commodities - the quantity of drugs available, the distribution of materials - but harder to quantify soft services, like the effect of counselling and behaviour change."
source: IRIN
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