When the time came for 24-year-old Jane Atieno to deliver her second child, she sought the services of a traditional birth attendant rather than the local clinic so she wouldn't have to be tested for HIV or agonize over how to tell her husband that health workers wanted him to attend her antenatal check-ups.
"At home, nobody will bother to test your HIV status, but when I go to the clinic, they tell me they want to test for [HIV]. And they want my husband to come with me, yet I can't convince him to do so," she told IRIN/PlusNews from her home in Kisumu, a city in western Kenya's Nyanza Province.
Atieno is too afraid of being stigmatized to get tested for HIV, and has never taken her child, now one year old, for testing. "When I go to the clinic, I just lie to them [that] I was tested where I gave birth," she said.
According to a University of Alabama at Birmingham study recently published in the journal PLoS Medicine, HIV-related stigma could be keeping Kenyan mothers away from crucial skilled childbirth services. The study found that "health facility birth is commonly viewed as most appropriate for women with pregnancy complications, such as HIV".
"The belief that childbirth in a health facility is only necessary for women who have problems and complications and is not needed for a 'normal' birth seems to be very widespread in the region," Janet Turan, the study's lead researcher, told IRIN/PlusNews.
The study examined factors associated with anticipating and experiencing HIV-related stigma among pregnant women and their subsequent utilization of maternity services. It was conducted in Migori, a rural district in Nyanza Province where the HIV prevalence of 13.9 percent is more than twice the national average. Some 35 percent of respondents reported giving birth at a health facility; 78 percent of those who did not said they delivered with the help of a traditional birth attendant.
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According to the Kenya Demographic and Health Survey 2008-09, 92 percent of expectant mothers attend antenatal clinics, but only 44 percent receive delivery care from a skilled provider.
The authors said widespread public communications campaigns to boost the prevention of mother-to-child HIV transmission (PMTCT) may be partly responsible for the perception that skilled childbirth services were more suitable for HIV-positive women.
"Community mobilization efforts aimed at increasing the use of PMTCT services...may have inadvertently strengthened the perception that women who give birth in such facilities are likely to be HIV-positive," the authors stated.
According to Turan, health messaging is key to correcting misconceptions about health facility delivery.
"Health messaging should emphasize that childbirth in a health facility with a skilled healthcare provider is important for all women," Turan said.
The study found that women with more negative attitudes about people living with HIV were less likely to deliver at a health facility than those with more positive attitudes towards HIV-positive people. Women who had higher levels of education, had discussions with their male partners on the place of birth and attended more than four antenatal visits were also more like to give birth at a health facility.
"Combining known HIV stigma-reduction strategies with maternal health and PMTCT interventions has the potential to reduce some of the most pressing health problems for women and children throughout sub-Saharan Africa," the authors concluded.
Health workers say the government must also address the other barriers to the utilization of skilled childbirth services. "Distance from a health facility, the cost of delivering there, and the perception health workers will abuse or force you to undergo certain surgical procedures are some of them," Nicholas Okeyo, a clinical officer at the Maseno health center, told IRIN/PlusNews.