“I do all I can but I still fail them”: Health system barriers to providing Option B+ to pregnant and lactating women in Malawi

Abstract

Malawi’s Option B+ program is based on a ‘test and treat’ strategy that places all HIV-positive pregnant and lactating women on lifelong antiretroviral therapy. The steep increase in patient load placed severe pressure on a health system that has struggled for decades with inadequate supply of health care workers (HCWs) and poor infrastructure. We set out to explore health system barriers to Option B+ by asking HCWs in Malawi about their experiences treating pregnant and lactating women. We observed and conducted semi-structured interviews (SSIs) with 34 HCWs including nine expert clients (ECs) at 14 health facilities across Malawi, then coded and analyzed the data. We found that HCWs implementing Option B+ are so overburdened in Malawi that it reduces their ability to provide quality care to patients, who receive less counseling than they should, wait longer than is reasonable, and have very little privacy. Interventions that increase the number of HCWs and upgrade infrastructure to protect the privacy of HIV-infected pregnant and lactating women and their husbands could increase retention, but facilities will need to be improved to support men who accompany their partners on clinic visits.

“Most of what they do, we cannot do!” How lay health workers respond to barriers to uptake and retention in HIV care among pregnant and breastfeeding mothers in Malawi

“…Malawi has long experienced chronic health worker shortages and empirical studies have demonstrated the additional health system pressures that were created by the scale up of Option B+. Phiri et al 47 describe 'severe pressure' on Malawi's health workers due to increased patient loads associated with Option B+ and reduced ability to deliver quality of care. Workload has been directly (although not exclusively) linked to provider disrespect and abuse of clients, with a substantial body of literature documenting the negative impact of disrespect and abuse in health services generally 48 49 and maternal healthcare in particular.…”

Social determinants of male partner involvement in women's Prevention of Mother to Child Transmission care Program in Malawi

“…Thus, some women viewed male accompaniment as a foreign concept, and they did not want men with them [37,38]. An interpretation of the relation between unemployment and male attendance could be that unemployed women reach the healthcare facility alone because man needs to work during the day, whereas woman has more time available to spend to get to the healthcare centre [8]. Infact, married women (72%) are less likely to have been employed in the last 12 months than currently married men (98%) and women are more likely to being paid less for their work compared to men in Malawi, as reported by DHS [39].…”

“…Previous literature shows that in Sub-Saharan Africa (SSA), male partners are scarcely present during PMTCT services [5]. In many low-income countries, the involvement of men in maternal services is increasingly recognised as an important element of women's access to needed care [6][7][8]. Men involvement could be considered also a disadvantageous to their partner in some circumstances, because it may reinforce their role and promote men control over women's decision [9,10].…”

Social determinants of male partner involvement in women's Prevention of Mother to Child Transmission care Program in Malawi

“…An explanation could be that women highly empowered in healthcare and household decision showed less need to invite men. One interpretation of the relation between unemployment and male attendance could be that unemployed women reach the healthcare facility alone because man needs to work during the day, whereas woman has more time available to spend to get to the healthcare centre [8]. In fact, married women (72%) are less likely to have been employed in the last 12 months than currently married men (98%) and women are more likely to being paid less for their work compared to men in Malawi, as reported by DHS [40].…”

“…Read Full License increasingly recognised as an important element of women's access to needed care [6][7][8]. Men involvement could be considered also a disadvantageous to their partner in some circumstances, because it may reinforce their role and promote men control over women's decision [9,10].…”