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Cutting HIV transmissions for home birth

Swazi women who give birth to their babies at home undergo this traditional manner of childbirth may do so because it is a familiar and customary way for them and their families to welcome a new life into their homestead.
At-home births may also be due to a desire actually to have a child delivered in a clinic or hospital but a reality that the mother may live too far from a clinic or hospital for this to be practical.
Women do not go into labour on schedule. As we know from many a scene in the movies and from real-life experience, labour can begin at odd hours, unpredictably. In the absence of public transport in the evenings, or long distances to travel if a woman lives in a rural area, making it to the hospital in time for delivery because of a dangerous wager. Better to be safe, the family feels and deliver the baby at home.
Healthcare is improving in Swaziland incrementally, and both infant mortality and deaths of women during childbirth are decreasing. This is true even for at-home childbirths. However, HIV and AIDS have introduced a dangerous new element to the equation. Preventing a mother’s HIV (if she is HIV-positive) from infecting her newborn baby is a challenge that Swaziland has taken seriously during the past decade.
The success of PMTCT (prevention of mother-to-child transmission) is made more complicated, though not made impossible by any means, if a baby’s birth happen away from the medical care and medications available at a hospital.
It is a dilemma. Unless a woman is able to reside near a hospital in the final stages of a pregnancy in order to ensure a quick trip to receive professional medical care during the birth of her child, transportation and logistical issues will continue to ensure that many a Swazi child is born at homes far away from professional medical help.
The issue was raised this past week in Manzini at the Info Centre, which was transformed for a day into the ‘2012 International AIDS Conference Hub.’ Speakers from several nations contributed presentations on best practices, new data and AIDS-related developments.
Karen Webb led a presentation entitled ‘Where do women who deliver at home fall through the cracks in the PMTCT Continuum of Care?  Descriptive evidence from Zimbabwe.’
‘Continuum’ in this case means  the entire process of preventing HIV transmission from an HIV-positive mother to her baby. Home childbirth can disturb this process if measures are not taken to ensure the “continuum” is not broken. Interesting examples from Zimbabwe were presented.
As for Swaziland’s experiences, the subject is not new to AIDS Lifeline.  Back in 2010 this column noted, “A significant proportion of pregnant women are giving birth at home, and so are not using PMTCT services.”
There was much good news about the record of prevention of mother-to-child transmission services since these became available in 2003.
HIV transmission was almost halved, from 40 percent of children becoming infected by their HIV-positive mothers in 2003 to 21 percent in 2010.
Khanya Mabuza, Assistant Director of Programmes at the time at NERCHA, told AIDS LIFELINE, “This is very positive news, and it makes me proud of our efforts in Swaziland.”
However, 2010 also saw the beginning of a rise in home childbirths that continued in the last couple of years.
The rise in home deliveries appeared to be a result of conditions at underfunded clinics and hospitals: leaking roofs, unreliable water supplies and a lack of beds for patients, all of which contributed to low morale amongst nurses and staff.  Sophia Mukasa Monico, Country Coordinator for UNAIDS in Swaziland at the time told AIDS LIFELINE, “Women are refusing to come to some clinics and hospitals because of the poor environment and the attitude of the health workers.”
The UNAIDS Country Coordinator related 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 then ordered her to clean up after herself.
“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,” she said.
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.” This then is another reason to proritise the restoration of our clinics and hospitals: as an inducement for mothers to give birth there is lessened and PMTCT efforts are compromised.

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