title: The role of HIV-related stigma in utilization of skilled childbirth services in rural Kenya: a prospective mixed-methods study.
abstract: BACKGROUND
  Childbirth with a skilled attendant is crucial for preventing maternal mortality and is an important opportunity for prevention of mother-to-child transmission of HIV. The Maternity in Migori and AIDS Stigma Study (MAMAS Study) is a prospective mixed-methods investigation conducted in a high HIV prevalence area in rural Kenya, in which we examined the role of women's perceptions of HIV-related stigma during pregnancy in their subsequent utilization of maternity services.
  
  
  RESULTS
  From 2007-2009, 1,777 pregnant women with unknown HIV status completed an interviewer-administered questionnaire assessing their perceptions of HIV-related stigma before being offered HIV testing during their first antenatal care visit. After the visit, a sub-sample of women was selected for follow-up (all women who tested HIV-positive or were not tested for HIV, and a random sample of HIV-negative women, n = 598); 411 (69%) were located and completed another questionnaire postpartum. Additional qualitative in-depth interviews with community health workers, childbearing women, and family members (n = 48) aided our interpretation of the quantitative findings and highlighted ways in which HIV-related stigma may influence birth decisions. Qualitative data revealed that health facility birth is commonly viewed as most appropriate for women with pregnancy complications, such as HIV. Thus, women delivering at health facilities face the risk of being labeled as HIV-positive in the community. Our quantitative data revealed that women with higher perceptions of HIV-related stigma (specifically those who held negative attitudes about persons living with HIV) at baseline were subsequently less likely to deliver in a health facility with a skilled attendant, even after adjusting for other known predictors of health facility delivery (adjusted odds ratio = 0.44, 95% CI 0.22-0.88).
  
  
  CONCLUSIONS
  Our findings point to the urgent need for interventions to reduce HIV-related stigma, not only for improving quality of life among persons living with HIV, but also for better health outcomes among all childbearing women and their families.
authors.affiliation: Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA. jmturan@uab.edu
authors.forename: Janet M
authors.initials: JM
authors.lastname: Turan
authors.forename: Abigail H
authors.initials: AH
authors.lastname: Hatcher
authors.forename: José
authors.initials: J
authors.lastname: Medema-Wijnveen
authors.forename: Maricianah
authors.initials: M
authors.lastname: Onono
authors.forename: Suellen
authors.initials: S
authors.lastname: Miller
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Bukusi
authors.forename: Bulent
authors.initials: B
authors.lastname: Turan
authors.forename: Craig R
authors.initials: CR
authors.lastname: Cohen
mesh_terms: D000293:Adolescent; D000328:Adult; D002983:Clinical Competence; D036861:Delivery, Obstetric; D003710:Demography; D005260:Female; D015658:HIV Infections / Q000150:complications*; D006268:Health Facilities / Q000706:statistics & numerical data; D006296:Health Services / Q000706:statistics & numerical data*; D006801:Humans; D007630:Kenya; D016015:Logistic Models; D015999:Multivariate Analysis; D036801:Parturition / Q000502:physiology*; D049590:Postpartum Period; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000821:virology; D011446:Prospective Studies; D012424:Rural Population; D057545:Social Stigma; D011795:Surveys and Questionnaires; D055815:Young Adult