4.3 Focus Group Discussion One focus group

4.3 Focus
Group Discussion

One focus group discussion (FGD) was carried
out, with the comprising of the following contributors: Seven TBAs with no
training; 5 TBAs who were trained; four women who gave birth at a health care
facility and; four women who had given birth at home. Data from FGDs comprising
of untrained TBAs suggested that their daily operations were mostly influenced
by their religious beliefs. Most of the women who approached
them for services were women with whom they shared the same religion. The
TBAs said that they mostly assisted those women that had not had not had
difficult births previously, also those women who faced challenges with
transport and money to go and deliver at formal health centres. As confirmed by
all participants, high cost of living has forced a lot of women to seek
assistance during delivery outside health care facilities, as conveyed by the statement

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life is difficult. Who can give the United States Dollars that are being
charged at the clinics when one wants to give birth?”


was sighted by TBAs as one of the reason why women come to them for deliveries.


It is during emergencies only when trained
TBAs have confirmed that they double up as delivery assistants at the health care
centres, when the woman fails to get to the health facility that provides
maternity services.

In a lot of instances,
TBAs would rather encourage women to register their pregnancies at a health
care facility so as to receive ANC services, rather than providing assistance
to these women before delivery. This was alluded to by one TBA who explained:


“If and when a
pregnant woman comes to me and there is still time till delivery, and there
exist no distress related to pregnancy, I will encourage her to visit a health
centre, in most cases I even accompany them.”

That was one TBA
explaining some of the duties she carries out with expectant mothers.


Previous complications
during pregnancy, including women who are pregnant for the first time were
indicated as contraindication for a TBA to deliver such women. Booking
pregnancies early was a way that TBAs felt women could better prepare
themselves for any problems that may arise during pregnancies and at delivery
time. With regards to knowledge related to basic HIV/AIDS issues, TBAs that
were interviewed expressed enlightenment on the existence of HIV, even though
not all of them had heard about PMTCT. In most cases they would never suspect
if a woman was HIV-positive, they would only know about it later after the
woman fell sick and had died. They indicated that their attitude towards
assisting HIV-positive women would not change and they would welcome and
appreciate any assistance rendered to them by health centres with such sundries
as gloves for their optimum protection during deliveries.

These community health cadres expressed
their readiness to be involved in PMTCT interventions but were quick to pick
the importance of training, so that an agreement on what services would be dispensed
and the requirement to be somehow acknowledged by the health workforce to
counteract any difficulties when delivering PMTCT services.

Deliberations with women who had delivered
at a health facility brought out an idea that they had probably done so as a
result of their choice to receive antenatal care at a health facility since medication
is supplied there. Such women would go back to health facilities for their children
to be immunized, they are also aware of the PMTCT services available to them at
the health centres, however, discrimination and stigmatization presented a
source fear of being tested for HIV. When it comes to the involvement of TBAs
in PMTCT, these women are of the idea that not all TBAs would be able to effectively
conduct the services, even if training was provided to them, a negative factor
being old age in most of the TBAs.

In the group of women
who were assisted to deliver by a TBA, qualitative data indicates that the main
the reason for doing so was lack of transport means to the health centres
during an emergency delivery. Most of these women would have received ANC at the
health centres but somehow felt that the relationship that existed between the
health personnel and themselves was not conducive enough for them to go back
there for maternal services. One of the women expressed:

personnel do not have time listen to our concerns as they may be too busy to do
so during our visits to the health centre, whereas TBA always have time to
discuss our issues”


When it comes to the TBAs’
involvement in PMTCT endeavours, these women are of the idea that TBAs are
talented enough to conduct these services only if they receive training,
however they also doubted the TBAs’ capability to perform blood test for HIV.
Furthermore, the women’s concern lay on the ability of the TBA to withhold
women’s HIV-sero-status classified. A woman who was assisted to deliver by a
TBA alluded:


“It therefore
relies on the TBA’s ability to keep a secret if I reveal to them my HIV-positive
status. I would not be comfortable with a situation where every-one in the
community is aware of my HIV-positive status. “At the clinic, in most
cases the nurse does not know you so she is not tempted to tell anyone, that
way my status stays a secret,”




Many women in need of PMTCT
are not being reached by current programmes and this can be attributed to
socio-cultural, economic, systemic and programmatic factors. Domiciliary
deliveries conducted by traditional birth attendants are commonplace in rural
Zimbabwe and are on the rise (Macro International , 2007). Moreover; PMTCT
programmes insist on corresponding methodologies to avoid missed opportunities
in this evolving context. This report is among the several attempts that have
been made towards evaluating the practicability as well as the appropriateness
of the involvement of TBAs in PMTCT initiatives.

Some of the attributes of the TBAs in this
rural perspective included being elderly, married or widowed, with the lowest
level of education. Such socio-demographic qualities are comparable to those of
TBAs in other locations (Itina, 1997.). Untrained TBAs who
were not trained in most cases were younger, possessed less experience than TBAs
who had been trained. These TBAs had learned to assist on their own or by assisting
another TBA. The reduction in training programmes targeted for TBAs in Zimbabwe
could provide an explanation as to why younger cadres fall within the untrained
TBAs group.

In order to realize valuable gains to
community-based public health interventions and chart ways for a number of
activities connected to prevention and care there is need for there to be
existing links between community health workers such as TBAs and the formal
health services. Corresponding approaches, through which community-based mediations
are paired with the reinforcement and/or spreading out of services at the health
facility level, also possess the ability to tackle a variety of other health
challenges, such as the limited acceptance to HIV testing and compliance to PMTCT

Studies that have been carried out in the
recent past have suggested some problems associated with home deliveries with
reference to uptake of PMTCT interventions (Albrecht, et al., 2006). Studies have
demonstrated that outside the TBAs’ current activities which include but are
not limited to assisting women during delivery and in the post-delivery stage,
they are also willing to broaden the range of their work in mother-and-child
activities to encompass PMTCT with some restrictions identified such as escorting
the child to the health centre to be given medication as well as assisting staff
at the health centre to document ANC services rendered to the women. This data hints
on the need to reinforce the health care network system between the recognized
health services and the rural populations including TBAs. For this, incorporating
the services of TBAs into the conventional health care delivery system is therefore
of utmost importance and should be implemented. The health care system that is
in existence has to build-up collaboration with TBAs who provide services in
the informal sector and assist in expanding communication skills in the
referral process. Moreover, authorities mandated to provide health care and
health personnel need to identify the cultural and practical involvement of
TBAs to the health system.

The role played by and
status accorded to TBAs in any given community determine the achievement
realised from community-based interventions that underscore the contribution of
TBAs. In India, a reduction of more than 60% in neonatal deaths was realised as
a result of community-targeted approach that encompassed training of TBAs as
well as women in the communities to recognize and treat sick new-born babies in
the community (Bang, et al., 1999). Additionally, significant
gains in the decrease of peri-natal deaths and maternal deaths were documented in
a pilot training of and incorporating TBAs in the conventional health-care system
in Pakistan (Jokhio, et al., 2005 ).

The results of our
survey reveal that TBAs interviewed in this location have inadequate information
with regards to issues pertaining to HIV/AIDS overall, also PMTCT to be
specific. However this situation can be enhanced through prioritizing educating
these cadres that are at present available and operating in these communities.
Selected trainings have to be specifically designed to match the duties that
the TBAs are expected to carry out, the education and proficiencies that are essential
as well as modifying the training syllabuses to the TBAs’ level of education.

The current study reinforces
the need to strengthen TBA’s level of appreciation on MTCT reduction interventions
before they could play a part in the delivery of PMTCT packages. Currently, in
a rural district setting as this one, TBA cadres’ guidance provided to women
with regards to issues of HIV/AIDS (not excluding PMTCT) is somehow not a
priority for them. It is therefore of utmost importance to, at national level,
review the TBA training manual and include sections which look at simple, easy
to understand concepts of HIV infection (Choguya, 2015). Studies conducted in Tanzania
concluded that if TBAs are motivated enough and as well provided with  supplementary proficiencies, they can
effectively function in the implementation of such programmes, contributing to accessing
women who do not give birth at health-care facilities where PMTCT interventions
are made available (such as counselling, as well as administering single-dose
nevirapine sdNVP) (Busza, et al., 2012). It was also
concluded in studies carried out in Uganda that when selection is conducted carefully,
complemented by proper training and regular and uninterrupted follow-up
support, TBAs provided an integral part in championing and referring expecting
women for health centre-based PMTCT services (Barigye, et al., 2010).

Conducting blood test for
HIV was one activity that TBAs were reluctant to perform in the study. Applying
this intervention using community health cadres such as TBAs is directly linked
to the national policy framework of each particular country and if it were ever
going to be adopted it would require uninterrupted and vigilant observation and
follow-up. The first known PMTCT programme to utilize TBAs in the provision of  private  and confidential counselling and testing for HIV
using a fluid rapid test applied orally was in Cameroon (Nkenfou, et al., 2013 Aug 9). This method was implemented
by way of community involvement, training and accompanied with assistance from nurses
who provide supervisory visits to the rural communities on monthly schedules.

Engaging TBAs in PMTCT issues is backed by a
number of exclusive reports that have shown enhancement of TBAs’ efficiency in
the delivery of public health services. In one systematic review that was
produced it was revealed that training TBAs seems to enhance attendance of antenatal
care by women by rates exceeding 38% (Sibley, et al., 2004).

In this particular district of Zimbabwe, achievements
derived from  MTCT prevention programmes
may be enhanced by intensifying community-based interventions, as well as involve
TBAs who then could: bring about linkages between communities and health
service providers and, make available health education to promote improved
utilization of ANC services, consequently access to PMTCT; sensitize
communities targeting a family-aligned PMTCT approach (Abrams, et al., September
2007). This
also encompasses informing and communicating the basic knowledge pieces
concerning  PMTCT as well as the significance
of  being tested for HIV to the expecting
mothers  and their spouses; deliver
community-aligned HIV counselling and testing (Shetty, et al., 2005).

One more significant
conclusion was the unquestionable relationship between women who gave birth at
home and the chance they had to pick their desired location for delivery. The
power to make decisions, gender imbalances as well as collective  insistence from the society particularly from
spouses including other kinfolks has been reported to considerably affect
utilization of maternal and child health care (Beckera, et al., 2014). It is well acknowledged
that in Africa women do not possess the authority to make decisions on their
own, decisions pertaining to their own and their children’s health care (Acharya, et al., 2010).

As this study reveals,
most of the women who were assisted to deliver by a TBA, as well as the TBAs
themselves mentioned that cost fees were a chief determining factor when
choosing a place to deliver, a point that is coherent with other conclusions
derived in similar settings (Tebekaw, et al., 2015). Such an element, coupled
with the standard of care articulated in this research as unfavourable
experiences women meet when they interact with health personnel in earlier
pregnancies, have been recognized as imperative justifications for the women
not to utilize maternal services as well as PMTCT services and choosing other
places for them to deliver, other than the conventional health service (Belay & EndalewGemechu, 2016). With regards to
circumstances like this one encountered here in which women mix TBAs and specialized
care and where TBAs urge women to make use of ANC service, reinforcement of established
basic antenatal service delivery overall and prior introduction of extra
interventions which also include PMTCT packages in particular is of paramount
importance (Sarker, et al., January 5, 2016).

Fear of being judged
and branded, and even or violation of privacy was at the forefront as the
leading causes for women to shun HIV testing and knowing their status.  Being terrified of knowing one’s HIV status
has been elucidated before as a very significant reason why women may drop out
of taking PMTCT services and low levels of HIV status revelation (Both & van Roosmalen, 2010). Being attended at
healthcare centres in the presence of TBAs dissuaded
women from taking the medication for fear of revealing their HIV status. It is therefore
imperative to extend and strengthen collaborations between various stakeholders
at health centre and community level to reinforce education and health
information access for each and every woman specifically and the public in
general so that stigma and discrimination may then be prevented. Furthermore, teaching,
placement and regulation of community health cadres TBAs included, must highlight
the importance of keeping client health information confidential, also the need
to encourage women when they disclose their HIV sero-status (Kadowa & Nuwaha, 2009
Increase in access to HIV and treatment programmes can be attributed to HIV
status disclosure, a rise in prospects for risk decline and consciousness of
HIV risk to partners that have not been tested for HIV, which can in turn result
in much improved uptake of voluntary HIV counselling and testing, and devotion
to the guidance provided to prevent postnatal and sexual HIV transmission (Hart, 2010).

TBAs expressed
willingness to be involved in PMTCT work, as confirmed by the qualitative
results shown in the focus group discussions. However, as was found out in the
community study, women who gave birth at a health centre or assisted by a TBA concurred
that for TBAs to be taken aboard in PMTCT programmes they have to undergo
training first.

There exist numerous possible shortcomings
that have to be attended combined to the results of this study. The first thing
being that the study was conducted in just one district in the whole of
Zimbabwe, therefore the results may not may not show the true picture of the
situation of the whole of the country. However, the socio-economic traits of ladies
of child bearing age who were selected in this survey are similar to those of
Zimbabwe as well as several other African locations (Solanke, 2017). Furthermore, interviewees’
versions of independent events around gestation and giving birth could have
been liable to recollection bias. Another issue that could be up for consideration
was the possibility that there could have been inconsistences with regards to
where interviewees did not possess understanding of the approved Shona expressions
because this could have had a bearing on the perception of some queries by the interviewees.

This was somehow averted
from the training that data enumerators received with regards to terms to be
utilized for the Shona languages interpretations to reduce mistakes and by way
of piloting of the tools.