title: Integration of HIV care into maternal health services: a crucial change required in improving quality of obstetric care in countries with high HIV prevalence.
abstract: BACKGROUND
  The failure to reduce preventable maternal deaths represents a violation of women's right to life, health, non-discrimination and equality. Maternal deaths result from weaknesses in health systems: inadequate financing of services, poor information systems, inefficient logistics management and most important, the lack of investment in the most valuable resource, the human resource of health workers. Inadequate senior leadership, poor communication and low staff morale are cited repeatedly in explaining low quality of healthcare. Vertical programmes undermine other service areas by creating competition for scarce skilled staff, separate reporting systems and duplication of training and tasks.
  
  
  CONCLUSIONS
  Confidential enquiries and other quality-improvement activities have identified underlying causes of maternal deaths, but depend on the health system to respond with remedies. Instead of separate vertical programmes for management of HIV, tuberculosis, and reproductive health, integration of care and joint management of pregnancy and HIV would be more effective. Addressing health system failures that lead to each woman's death would have a wider impact on improving the quality of care provided in the health service as a whole. More could be achieved if existing resources were used more effectively. The challenge for African countries is how to get into practice interventions known from research to be effective in improving quality of care. Advocacy and commitment to saving women's lives are crucial elements for campaigns to influence governments and policy -makers to act on the findings of these enquiries. Health professional training curricula should be updated to include perspectives on patients' rights, communication skills, and integrated approaches, while using adult learning methods and problem-solving techniques.
  
  
  CONCLUSIONS
  In countries with high rates of Human Immunodeficiency Virus (HIV), indirect causes of maternal deaths from HIV-associated infections now exceed direct causes of hemorrhage, hypertension and sepsis. Advocacy for all pregnant HIV-positive women to be on anti-retroviral therapy must extend to improvements in the quality of service offered, better organised obstetric services and integration of clinical HIV care into maternity services. Improved communication and specialist support to peripheral facilities can be facilitated through advances in technology such as mobile phones.
authors.affiliation: Department of Anaesthesia, University of Botswana School of Medicine, Gaborone, Botswana. faraitose@hotmail.com
authors.forename: Farai D
authors.initials: FD
authors.lastname: Madzimbamuto
authors.forename: Sunanda
authors.initials: S
authors.lastname: Ray
authors.forename: Keitshokile D
authors.initials: KD
authors.lastname: Mogobe
mesh_terms: D000328:Adult; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D003710:Demography; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D008427:Maternal Health Services / Q000458:organization & administration* / Q000592:standards*; D008428:Maternal Mortality; D011247:Pregnancy; D011295:Prenatal Care / Q000458:organization & administration / Q000592:standards; D011787:Quality of Health Care / Q000592:standards; D013019:South Africa
keywords: Maternal mortality, HIV, Health systems, Quality of obstetric care, Southern Africa, Integrated HIV and maternity services