title: How perceptions of HIV-related stigma affect decision-making regarding childbirth in rural Kenya.
abstract: BACKGROUND
  HIV prevalence among pregnant women in Kenya is high. Furthermore, there is a high risk of maternal mortality, as many women do not give birth with a skilled healthcare provider. Previous research suggests that fears of HIV testing and unwanted disclosure of HIV status may be important barriers to utilizing maternity services. We explored relationships between women's perceptions of HIV-related stigma and their attitudes and intentions regarding facility-based childbirth.
  
  
  METHODS
  1,777 pregnant women were interviewed at their first antenatal care visit. We included socio-demographic characteristics, stigma scales, HIV knowledge measures, and an 11-item scale measuring health facility birth attitudes (HFBA). HFBA includes items on cost, transport, comfort, interpersonal relations, and services during delivery at a health facility versus at home. A higher mean HFBA score indicates a more positive attitude towards facility-based childbirth. The mean HFBA score was dichotomized at the median and analyses were conducted with this dichotomized HFBA score using mixed effects logit models.
  
  
  RESULTS
  Women who anticipated HIV-related stigma from their male partner had lower adjusted odds of having positive attitudes about giving birth at the health facility (adjusted OR = .63, 95% CI 0.50-0.78) and less positive attitudes about health facility birth were strongly related to women's intention to give birth outside a health facility (adjusted OR = 5.56, 95% CI 2.69-11.51).
  
  
  CONCLUSIONS
  In this sample of pregnant women in rural Kenya, those who anticipated HIV-related stigma were less likely to have positive attitudes towards facility-based childbirth. Furthermore, negative attitudes about facility-based childbirth were associated with the intention to deliver outside a health facility. Thus, HIV-related stigma reduction efforts might result in more positive attitudes towards facility-based childbirth, and thereby lead to an increased level of skilled birth attendance, and reductions in maternal and infant mortality.
authors.affiliation: University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands. j.s.wijnveen@umcg.nl
authors.forename: José S
authors.initials: JS
authors.lastname: Medema-Wijnveen
authors.forename: Maricianah
authors.initials: M
authors.lastname: Onono
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Bukusi
authors.forename: Suellen
authors.initials: S
authors.lastname: Miller
authors.forename: Craig R
authors.initials: CR
authors.lastname: Cohen
authors.forename: Janet M
authors.initials: JM
authors.lastname: Turan
mesh_terms: D000293:Adolescent; D000328:Adult; D001294:Attitude to Health; D016000:Cluster Analysis; D003657:Decision Making; D036861:Delivery, Obstetric; D003710:Demography; D005260:Female; D015658:HIV Infections / Q000523:psychology*; D006268:Health Facilities; D006801:Humans; D007630:Kenya; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008880:Midwifery; D015999:Multivariate Analysis; D036801:Parturition / Q000523:psychology*; D011247:Pregnancy; D012424:Rural Population; D057545:Social Stigma; D055815:Young Adult