Barriers to maternal retention in HIV care in Ghana: key differences during pregnancy and the postpartum period

Kwame S Sakyi,Pamela J Surkan,Margaret Y Lartey,Emma Sacks,Emily A Hurley,Prince G Owusu,Caitlin E Kennedy,Julie A Dension,Luke C Mullany

doi:10.1186/s12884-020-03067-8

Abstract

BackgroundMaternal retention in HIV care is lower for women in the postpartum period than during pregnancy, but the reasons are poorly understood. We examined key differences in barriers to retention in HIV care during and after pregnancy.MethodsWe conducted semi-structured, in-depth interviews with 30 postpartum women living with HIV. Participants were recruited from two tertiary facilities implementing Option B+ for prevention of mother-to-child HIV transmission in Accra, Ghana. We collected data from mothers who had disengaged from HIV care and those who were still engaged in care. The interviews were analyzed using principles adapted from grounded theory.ResultsParticipants’ experiences and narratives showed that retention in HIV care was more challenging during the postpartum period than during pregnancy. Poor maternal physical health (from birth complications and cesarean section), socio-cultural factors (norms about newborn health and pregnancy), and economic difficulties linked to childbirth (such as unemployment, under-employment, and debt) made the costs of retention in HIV care more economically and socially expensive in the postpartum period than during pregnancy. Some participants also shared that transportation costs and resulting dependence on a partner to pay increased during the postpartum period because of a strong shift in maternal preference for private modes of transportation due to HIV stigma and the desire to protect the newborn. These factors played a larger role in the postpartum period than during pregnancy and created a significant barrier to retention. A conceptual model of how these factors interrelate, the synergy between them, and how they affect retention in the postpartum period is presented.ConclusionsIn Ghana, lower retention in HIV care in the postpartum period compared to in pregnancy may be primarily driven by social, economic, and newborn health factors. Multifaceted economic-based and stigma-reduction interventions are needed to increase retention in maternal HIV care after childbirth.

Highlights

Maternal retention in Human Immunodeficiency virus (HIV) care is lower for women in the postpartum period than during pregnancy, but the reasons are poorly understood
In Ghana, only 66% of postpartum women are retained in HIV care [6], compared to 75% among pregnant women [7] and 86% among the general population of adults living with HIV [8]
We describe critical barriers to retention in HIV care by examining how maternal physical health, socio-economic factors, and cultural forces linked to pregnancy and childbirth interact to negatively impact retention

Summary

Introduction

Maternal retention in HIV care is lower for women in the postpartum period than during pregnancy, but the reasons are poorly understood. Some countries like Ghana have reduced several key barriers to ART access, including providing ART at no cost and implementing Option B+, where pregnant women are put on lifelong ART, regardless of their CD4 cell counts [3]. Despite these advancements, recent studies demonstrate that after ART initiation, women living with HIV have difficulty remaining in HIV care during the first year after childbirth (referred to as the postpartum year) [4, 5]. In South Africa, one study found that about 50% of pregnant women living with HIV dropped out of care in the postpartum year [9]

Methods

Results

Conclusion