Impediments to facility delivery among HIV positive women in a Kenyan Setting: Insights from women's accounts and the service delivery context

Abstract

In sub-Saharan Africa, where over 85% of pregnancies among HIV positive women occur, many countries report low rates of uptake of the widely available and virtually free services to prevent mother-to-child transmission of HIV (PMTCT), such as facility delivery and infant prophylactic antiretroviral drugs. A small but growing body of scholarship that has examined the reasons why women might fail to take advantage of PMTCT services has primarily documented structural and resource factors such as long distance or inability to pay for transportation to a health care facility as key barriers to service uptake. The influence of service delivery dynamics (for example, the nature of provider-patient interactions and the quality of counseling) demonstrated in other health literatures to be salient in service utilization is a perspective that is largely ignored in the assessment of PMTCT service use. Thus, to understand the influence of service delivery dynamics on women's uptake of PMTCT services, this study utilized ethnographic methods to examine how i) the bureaucratic organization of services, ii) patients' experience of the care environment, iii) patient-provider relations, and iv) providers' experience of their work affected facility delivery among HIV positive women attending Mathare North Health Center, a community health facility in Nairobi, Kenya. Findings revealed that guarding against inadvertent disclosure of HIV positive status to a partner or relations accompanying a woman to the facility during childbirth was an important motivation for participants' non-delivery at Mathare or other public sector health care facilities. In understanding how the inadvertent disclosure of a woman's HIV status could occur during childbirth at Mathare, Michael Lipsky's (1980) theory of street-level bureaucracy provided an analytical point of departure. Specifically, several patterns of practice elucidated by Lipsky were mapped out in ANC service delivery with pregnant HIV positive women. Because of the work practices that providers at Mathare adopted to cope with the mismatch between limited resources in the work environment and patients' needs, women did not receive the care necessary to support childbirth at the health center. Insights from this research offer useful directions for modifying care practices to boost facility delivery among HIV positive women.

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