DEBRE BIRHAN UNIVERSITY

FACULTY OF MEDICINE
DEPARTMENT OF MEDICINE
KNOWLEDGE & ATTITUDE TOWARDS THE PREVENTION
OF MOTHER TO CHILD TRANSMISSION OF HIV AMONG
POST NATAL MOTHERS IN DEBRE BIRHAN REFERAL
HOSPITAL, DEBRE BIRHAN.

BY

AUGUST
2008
DEBRE BIRHAN

INTRODUCTION
BACKGROUND
The Acquired Immune Deficiency Syndrome (AIDS) epidemic is the greatest challenge to
human kind in the 21st century. AIDS was first recognized in 1981 and is caused by human
Immunodeficiency virus (HIV) which was isolated in USA by the end of 1983. There are two
types, namely HIV-1 and HIV-2. HIV-1 is more common, infects people worldwide and
Causes AIDS. HIV-2 though less aggressive and found mainly in West Africa causes a similar
illness.1
The HIV pandemic still remains an issue of major concern on a global scale.
A total of 35.3 million people are living with HIV; of these, an estimated 2.3
million are newly infected.2 Sub-Saharan Africa contributes more than twothirds (69%) of the global infected population. Children under the age of 15
accounts for 3.4 million of the global number of infected, while sub-Saharan
Africa alone contributes to 90% of this burden.3
The most significant source of HIV infection in children and infants is
transmission of HIV from mother to child during pregnancy, childbirth, or
breastfeeding. Without intervention, the risk of transmission varies ranging
from 5% to 10% during pregnancy, 10% to 15% during labor/delivery, and
5% to 20% through breastfeeding.3,5 More than 90% of children were infected
through MTCT of which nearly 90% occurred in sub Saharan Africa. Approximately half of them
die before their second birth day if there is no appropriate treatment. 4
Ethiopia is also one of the largest epidemic countries in sub-Saharan Africa.
The national HIV prevalence estimate was 1.5%, but the prevalence in
women was 1.9% in 2011.6 Increased incidence of HIV in pregnant women
would ultimately lead to increased incidence of HIV in children. Among the
total 137,494 new HIV infections, 10% were children infected mainly due to
vertical mother-to-child transmission of HIV (MTCT).7, 8
Vertical transmission from mother-to-child accounts for more than 90% of pediatric AIDS.
Particularly in developing countries including Ethiopia, MTCT has become a critical child health
problem and created enormous social and economic problems [9].
The reasons for an increasing MTCT of HIV might include lack of knowledge of mothers on the
risk of MTCT, benefits of preventive interventions, such as prophylactic ARV drugs and infant
feeding options [10].
According to calibrated single point estimates (2007), the national adult HIV
prevalence is reported to be 2.1% (7.7% in urban and 0.9% in rural areas).
977,394 Ethiopians are living with HIV/AIDS (41% males, 59% females); an
estimated 75,420 HIV-positive pregnant women are anticipated in 2007.
Highest prevalence occurs in the 15-24 age groups and prevalence is higher

among females than males in both urban and rural areas. Prevalence
appears to have levelled off in urban areas but continues to rise in rural
areas, where 85% of the population lives. 9
According to the Ethiopian Demographic and Health Survey of 2011, only
34% and 9.9% of mothers received antenatal care from health professionals,
and delivered at health institutions, respectively.6 To cope with the
challenges, the Federal Ministry of Health planned to rapidly increase
antiretroviral (ARV) service utilization to 77% of eligible pregnant women by
2015 as an intervention to PMTCT.8, 9 But only 9.3% of pregnant women
received ARVs in 2011. This also limits access to mothers and their babies
who might require PMTCT intervention.7, 8
Nowadays, for the phase of elimination of MTCT of HIV, a combination of
ARVs, elective cesarean section, and abstinence from breastfeeding is
recommended, through which it is possible to reduce MTCT of HIV to < 2% in
developed countries. This is still not possible in resource-limited countries.
Primary prevention is considered the most important way to decrease MTCT
of HIV.9 So, strengthening the integration of PMTCT services with maternal,
sexual, reproductive health, and family planning services in health facilities is
the most critical priority outlined for achieving the PMTCT targets.8 One of
the pillars of PMTCT and the most cost-effective way is increasing the
knowledge of pregnant and lactating mothers.
In sub-Saharan Africa, antiretroviral (ARVs) coverage increased from 17% to 28%. Yet, despite
recent progress, much work remains to be done. For instance, in 2008 an estimated 430,000
children were newly infected with HIV, nearly all of them through MTCT. Even in countries that
are rapidly scaling-up PMTCT services, the major challenge is to provide more effective ARV
interventions, including the provision of antiretroviral treatment (ART) for pregnant women and
mothers eligible for treatment and to demonstrate the impact of these interventions by a decrease
in pediatric infections, HIV-free survival and improved maternal and child health [11].
To prevent the transmission of HIV from mother to baby, World Health Organization (WHO)
promotes a comprehensive strategic approach that includes four components: the prevention of
new infections in parents, avoiding unwanted pregnancies in HIV infected women, preventing
transmission of HIV from an infected mother to her infant and care, treatment & support for
mothers living with HIV, their children and families. It primarily includes the provision of
antiretroviral prophylaxis to the mother to reduce the risk of MTCT through rigorous PMTCT
program [7].
The prevention of MTCT plays a major role in limiting the number of children being infected by
HIV. Without any intervention, 20-50% of infant would be infected; 5-10% during pregnancy,
10-20% during labor and delivery and 5-20% through breast feeding. By implementing PMTCT
program, the overall risk can be reduced to less than 2% [12].

Statement of the problem

PMTCT advocated by UNAIDS entail 1.keeping women of reproductive age and their partners
through reproductive health and HIV prevention services, 2. avoiding unwanted pregnancies
among HIV-infected women and women at risk of HIV, through family planning and HIV testing
and counseling services, 3. ensuring HIV testing of pregnant women and timely access to
effective antiretroviral therapy, both for the health of HIV-infected mothers and for PMTCT,
during pregnancy, delivery and breastfeeding and 4. Treatment, care and support of HIV
infected women, their infants and their families. (9) Adherence to these practices is
highly variable with better results obtained in developed countries than in the developing
countries. Not surprisingly, inadequate continuum of care, magnitude of PMTCT and associated
services including HIV testing and counseling and ARV prophylaxis are still very low in
developing countries [9].
Virtual elimination of HIV MTCT has been achieved in most industrialized countries, with
declines of over 80%-90% in the number of cases of perinatally acquired HIV infection, and
MTCT rates of under 2%-3% [12-14]. Moreover, MTCT, in the context of antiretroviral
prophylaxis is below 1% in Europe and the USA. However it exceeds 30% in many poorly
resourced countries, with sub-Saharan Africa carrying the highest burden [14, 15].
Various factors contribute to the high burden of pediatric HIV infection in Ethiopia and other
sub-Saharan African countries. These include the high prevalence of HIV infection amongst
women of reproductive age, large populations of women, high birth rates, and lack of access to
effective interventions aimed at preventing mother to child transmission of HIV [12].
According to Mini Ethiopian Demographic Health Survey (EDHS) 2014 only 41% of mothers
had Antenatal Care (ANC) follow up, 16% had delivery care by health professional and
Percentage of women with a postnatal checkup in the first two days after birth was 13.2% in
Ethiopia. Thus having a negative contribution on under-utilization of PMTCT services.

Significance of the study

Basic knowledge about HIV and its prevention strategies as well as the attitude of mothers in
accessing PMTCT services are vital to the success of the programme. Thus the study provided
baseline information about the knowledge, and attitude of PMTCT services among post natal
mothers. It would also be a significant venture in promoting effective relationship between the
healthcare team and the client thereby facilitating quality and efficient healthcare services to
reduce mortality and morbidity of children as well as mothers.
Moreover, the results of this study would help healthcare institutions to recognize mothers
knowledge, and attitude of PMTCT services and hence benefit them by providing accurate
information on risk of MTCT, availability of prevention options, effect of HIV on pregnancy
outcomes and involvement and screening of partner to improve quality care and utility of the
services.

Objective
General objective
To assess the knowledge and attitude of Mother -to -child transmission of HIV/AIDS
among post natal mothers (PNC) of Debre Birhan Referal Hospital.

Specific objective

To determine the knowledge of prevention of mother-to-child transmission of HIV/AIDS

among post natal mothers attending PNC clinic.
To examine the attitude towards Voluntary Counseling and testing and prevention of
mother-to-child transmission of HIV/AIDS among post natal mothers attending PNC
clinic.
To determine Post natal mothers knowledge on when to start prophylaxis for PMTCT.
To assess knowledge of post natal mothers on risk factors that increase MTCT during
breastfeeding.

METHODOLOGY
Study area
The study will be conducted in PNC clinic of Debre Birhan Referal Hospital which is located at
North Shoa zone, Amhara regional state, and 130 km away from Addis Ababa. The hospital
renders various services with its departments: surgery, internal medicine, gynecology and
obstetrics, pediatric, ophthalmology, emergence service, laboratory, radiology, dental and
pharmacy. The hospital has also ART clinic.

Study design
A Hospital-based cross-sectional study will be conducted.

Study period
The study will be conducted from August 1- December 30, 2016.

Study population
All post natal mothers who attended the Gynecology & obstetrics .

Inclusion and Exclusion criteria

Inclusion criteria: All post natal mothers who were attending PNC clinic will be included.
Exclusion criteria: Severely ill (those who couldnt talk) post natal mothers will be excluded.
Sample size determination and Sampling technique

The sample size will be calculated using single population proportion formula with estimated
proportion of 10% (0.1) vertical transmission (MTCT) of HIV, according to Ethiopian Survey on
post natal mother (SPM) II [14] assuming that marginal error and 5% non-respondent.

Sample size estimation

Sample size was calculated using the following formula
n= Z2P (1-P)
E2
Where;
n= required sample size
Z=reliability coefficient at 95% confidence interval (standard value of 1.96)
P= Proportional of targeted population which have knowledge of PMTCT. This estimated from
previous study done in Black Lion Hospital. The proportion found to be 69%
E= Margin of error at 5% (standard value 0.05)
Therefore from the formula above
N = 1.962 x 69 (100 69)
25
N = 330
The sample size will taken to be 330.

Sampling
Convenient sampling method will be used where all eligible women were asked to participate in
the study.

Research assistants
An experienced nurses and midwife on PMTCT who will be trained for one day
by the principal researcher on the purpose of the study, how to select patients, consent form
administration and questionnaire filling.

Research instruments, measurements and data collection

A pre- visit will be done and the questionnaires will be pre-tested. English questionnaires will be
translated into Amharic and then back into Amharic. Amharic structured questionnaire will be
then fully developed and used for data collection.
The questionnaire will have five parts.
Part one

Included clients socio demographic information for example age, clients marital status, level of
education, occupation and HIV status.
Part two
Gathered information about clients basic HIV/AIDS knowledge. This part included five
questions on modes of transmission, risk factors and preventive measures.
Part three
Contained questions specific to mother to child transmission of HIV and included seven
questions. The questions were used to enquire information on whether pregnant women knew
of the possibility of an infected pregnant woman transmitting the infection to her unborn child,
the timing of transmission, risk factors that increase transmission during pregnancy, labour
and delivery. It also included information on preventive measures and the timing of ARV
prophylaxis.
Part four
Enquired information on infant feeding knowledge for HIV positive mothers, risk factors that
increase mother to child transmission during breastfeeding and it included three questions.
Part five
Assessed attitude towards PMTCT and included 8 questions. These questions assessed
clients feelings on the importance of HIV testing for every pregnant woman, their feelings
about HIV infected women getting pregnant, on the issue of using protective gears (condoms)
during pregnancy and breastfeeding.
Some questions inquired opinions on why some mothers breastfeed beyond six months despite
being HIV infected and for those infected, whether they feel/think their families will support
them on the modes of feeding their babies and if they supported the National strategies for
PMTCT.

Data collection
The principal investigator and research assistants approached individually post natal mothers
attending the clinic to explain the purpose of the study and will ask for consent for them to
participate. Only those who consented will be enrolled in the study. A room will be prepared for
the principal investigator for interview and both the research assistants will have their working
rooms that they used. The interviews will take a maximum of 20min and women will be
interviewed after consultation with the doctor. Before the interviews clients will be requested to
sign a written consent and will given a chance to ask questions after the interviews. Clarifications
will be given to clients who had the poorest knowledge.

Data analysis
Data will be entered into a computer using SPSS statistical software. Analysis including
frequencies, percentages, odds ratios and bivariate analyses will be used for reporting the
findings.

Ethical consideration
The respondents will be explained in detail about the study and they will let to decide on
whether to participate or not and this ensured self-determination and autonomy.

The data obtained will be treated privately with no name tag on it. This study caused no physical
or psychological harm to the patient and they werent exploited in any way. The respondents will
be treated with respects and their rights to privacy and confidentiality will be observed through
anonymity.
After the interview respondents will given a chance to ask questions and those with poor
knowledge were given the necessary knowledge about MTCT and its prevention.

Ethical clearance
The college of health science ethical committee will reviewed the proposal for ethical
consideration and approval to conduct this study will be given. The permission to conduct the
study in Debre Berhan Referal Hospital will be given by the District Medical Officer.