Skip to main content

Proximate Context of HIV-Related Stigma and Women’s Use of Skilled Childbirth Services in Uganda

AIDS and Behavior volume 21, pages 307–316 (2017)Cite this article

Abstract

HIV-related stigma compromises both HIV prevention and treatment and has recently been described as a barrier to utilization of skilled childbirth services in sub-Saharan Africa. This study uses the 2011 Uganda Demographic Health Survey to estimate the associations between HIV-related stigma, measured both at the individual and community level, and use of facility delivery among women. Consistent with theoretical predictions, higher levels of stigma are associated with reduced likelihood of facility delivery. The negative relationship between stigma and facility delivery is especially pronounced when stigma is measured at the community level, highlighting the importance of understanding the proximate context of HIV-related stigma and its potential effects on behavior. Reducing the stigma of HIV will be critical to achieving the twin goals of reducing overall maternal mortality and preventing mother-to-child HIV transmission.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price includes VAT (USA)
Tax calculation will be finalised during checkout.

References

  1. Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384:980–1004.

    PubMed  PubMed Central  Article  Google Scholar 

  2. Nations U. Goal 3 ensure healthy lives and promote well-being for all at all ages. 2015. https://sustainabledevelopment.un.org/sdg3. Accessed 27 Dec 2015.

  3. Requejo J, Bryce J, Victora C. Fulfilling the health agenda for women and children: the 2014 report. Conference draft.

  4. Hill K, Thomas K, AbouZahr C, Walker N, Say L, Inoue M, et al. Estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data. Lancet. 2007;370(9595):1311–9.

    PubMed  Article  Google Scholar 

  5. Mpembeni RN, Killewo JZ, Leshabari MT, Massawe SN, Jahn A, Mushi D, et al. Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: implications for achievement of MDG-5 targets. BMC Pregnancy Childbirth. 2007;7(1):29.

    PubMed  PubMed Central  Article  Google Scholar 

  6. Ronsmans C, Graham WJ, group LMSSs. Maternal mortality: who, when, where, and why. Lancet. 2006;368(9542):1189–200.

    PubMed  Article  Google Scholar 

  7. Kerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong P, Starrs A, Lawn JE. Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet. 2007;370(9595):1358–69.

    PubMed  Article  Google Scholar 

  8. Campbell OM, Graham WJ, group LMSSs. Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006;368(9543):1284–99.

    PubMed  Article  Google Scholar 

  9. Koblinsky MA, Campbell O, Heichelheim J. Organizing delivery care: what works for safe motherhood? Bull World Health Organ. 1999;77(5):399.

    CAS  PubMed  PubMed Central  Google Scholar 

  10. de Bernis L, Sherratt DR, AbouZahr C, Van Lerberghe W. Skilled attendants for pregnancy, childbirth and postnatal care. Br Med Bull. 2003;67(1):39–57.

    PubMed  Article  Google Scholar 

  11. World Health Organization. Global action for skilled attendants for pregnant women: making pregnancy safer. 2002.

  12. WHO, UNICEF, The World Bank. Reduction of maternal mortality: a joint WHO/UNFPA/UNICEF/World Bank statement. Geneva: World Health Organization; 1999. p. 44.

    Google Scholar 

  13. Raghupathy S. Education and the use of maternal health care in Thailand. Soc Sci Med. 1996;43(4):459–71.

    CAS  PubMed  Article  Google Scholar 

  14. Ikeako L, Onah H, Iloabachie G. Influence of formal maternal education on the use of maternityservices in Enugu Nigeria. J Obstet Gynecol. 2006;26(1):30–4.

    CAS  Article  Google Scholar 

  15. Ahmed S, Creanga AA, Gillespie DG, Tsui AO. Economic status, education and empowerment: implications for maternal health service utilization in developing countries. PLoS One. 2010;5(6):e11190.

    PubMed  PubMed Central  Article  Google Scholar 

  16. Anyait A, Mukanga D, Oundo GB, Nuwaha F. Predictors for health facility delivery in Busia district of Uganda: a cross sectional study. BMC Pregnancy Childbirth. 2012;12(1):132.

    PubMed  PubMed Central  Article  Google Scholar 

  17. Mayhew M, Hansen PM, Peters DH, Edward A, Singh LP, Dwivedi V, et al. Determinants of skilled birth attendant utilization in Afghanistan: a cross-sectional study. Am J Public Health. 2008;98(10):1849.

    PubMed  PubMed Central  Article  Google Scholar 

  18. Say L, Raine R. A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context. Bull World Health Organ. 2007;85(10):812–9.

    PubMed  PubMed Central  Article  Google Scholar 

  19. Gabrysch S, Cousens S, Cox J, Campbell OM. The influence of distance and level of care on delivery place in rural Zambia: a study of linked national data in a geographic information system. PLoS Med. 2011;8(1):150.

    Article  Google Scholar 

  20. Lohela TJ, Campbell OM, Gabrysch S. Distance to care, facility delivery and early neonatal mortality in Malawi and Zambia. PLoS One. 2012;7(12):e52110.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  21. Kruk ME, Mbaruku G, Rockers PC, Galea S. User fee exemptions are not enough: out-of-pocket payments for ‘free’delivery services in rural Tanzania. Trop Med Int Health. 2008;13(12):1442–51.

    PubMed  Article  Google Scholar 

  22. Smith KV, Sulzbach S. Community-based health insurance and access to maternal health services: evidence from three West African countries. Soc Sci Med. 2008;66(12):2460–73.

    PubMed  Article  Google Scholar 

  23. Adjiwanou V, LeGrand T. Gender inequality and the use of maternal healthcare services in rural sub-Saharan Africa. Health Place. 2014;29:67–78.

    PubMed  Article  Google Scholar 

  24. Mrisho M, Schellenberg JA, Mushi AK, Obrist B, Mshinda H, Tanner M, et al. Factors affecting home delivery in rural Tanzania. Tropical Med Int Health. 2007;12(7):862–72.

    Article  Google Scholar 

  25. Amooti-Kaguna B, Nuwaha F. Factors influencing choice of delivery sites in Rakai district of Uganda. Soc Sci Med. 2000;50(2):203–13.

    CAS  PubMed  Article  Google Scholar 

  26. Kyomuhendo GB. Low use of rural maternity services in Uganda: impact of women’s status, traditional beliefs and limited resources. Reprod Health Matters. 2003;11(21):16–26.

    PubMed  Article  Google Scholar 

  27. Griffiths P, Stephenson R. Understanding users’ perspectives of barriers to maternal health care use in Maharashtra India. J Biosoc Sci. 2001;33(03):339–59.

    CAS  PubMed  Article  Google Scholar 

  28. Gabrysch S, Campbell OM. Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth. 2009;9(1):34.

    PubMed  PubMed Central  Article  Google Scholar 

  29. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994;38(8):1091–110.

    CAS  PubMed  Article  Google Scholar 

  30. Turan JM, Hatcher AH, Medema-Wijnveen J, Onono M, Miller S, Bukusi EA, et al. The role of HIV-related stigma in utilization of skilled childbirth services in rural Kenya: a prospective mixed-methods study. PLoS Med. 2012;9(8):e1001295.

    PubMed  PubMed Central  Article  Google Scholar 

  31. MedemaWijnveen JS, Onono M, Bukusi EA, Miller S, Cohen CR, Turan JM. How perceptions of HIV-related stigma affect decision-making regarding childbirth in rural Kenya. PLoS One. 2012;7(12):e51492.

    CAS  Article  Google Scholar 

  32. Turan JM, Nyblade L. HIV-related stigma as a barrier to achievement of global PMTCT and maternal health goals: a review of the evidence. AIDS Behav. 2013;17(7):2528–39.

    PubMed  Article  Google Scholar 

  33. Amnesty International. Struggle for maternal health: barriers to antenatal care in South Africa. Report. London: Amnesty International. 2014.

    Google Scholar 

  34. Turan JM, Miller S, Bukusi E, Sande J, Cohen C. HIV/AIDS and maternity care in Kenya: how fears of stigma and discrimination affect uptake and provision of labor and delivery services. AIDS Care. 2008;20(8):938–45.

    CAS  PubMed  Article  Google Scholar 

  35. Suthar AB, Hoos D, Beqiri A, Lorenz-Dehne K, McClure C, Duncombe C. Integrating antiretroviral therapy into antenatal care and maternal and child health settings: a systematic review and meta-analysis. Bull World Health Organ. 2013;91(1):46–56.

    PubMed  Article  Google Scholar 

  36. Both J, Van Roosmalen J. The impact of Prevention of Mother to Child Transmission (PMTCT) programmes on maternal health care in resource-poor settings: looking beyond the PMTCT programme—a systematic review. BJOG. 2010;117(12):1444–50.

    CAS  PubMed  Article  Google Scholar 

  37. Thorsen VC, Sundby J, Martinson F. Potential initiators of HIV-related stigmatization: ethical and programmatic challenges for PMTCT programs. Dev World Bioeth. 2008;8(1):43–50.

    PubMed  Article  Google Scholar 

  38. Cuca YP, Onono M, Bukusi E, Turan JM. Factors associated with pregnant women’s anticipations and experiences of HIV-related stigma in rural Kenya. AIDS Care. 2012;24(9):1173–80.

    PubMed  PubMed Central  Article  Google Scholar 

  39. Spangler SA, Onono M, Bukusi EA, Cohen CR, Turan JM. HIV-positive status disclosure and use of essential PMTCT and maternal health services in rural Kenya. J Acquir Immune Defic Syndr. 2014;67(Suppl 4):235.

    Article  Google Scholar 

  40. Tsai AC, Subramanian S. Proximate context of gender-unequal norms and women’s HIV risk in sub-Saharan Africa. AIDS. 2012;26(3):381–6.

    PubMed  PubMed Central  Article  Google Scholar 

  41. Hung KJ, Scott J, Ricciotti HA, Johnson TR, Tsai AC. Community-level and individual-level influences of intimate partner violence on birth spacing in sub-Saharan Africa. Obstet Gynecol. 2012;119(5):975–82.

    PubMed  Article  Google Scholar 

  42. Kelly JD, Weiser SD, Tsai AC. Proximate context of HIV stigma and its association with HIV testing in Sierra Leone: a population-based study. AIDS Behav. 2015;20:1–6.

    Google Scholar 

  43. Uganda AIS. Demographic and Health Surveys. Fairfax: ICF International; 2012.

    Google Scholar 

  44. Bannink-Mbazzi F, Lowicki-Zucca M, Ojom L, Kabasomi SV, Esiru G, Homsy J. High PMTCT program uptake and coverage of mothers, their partners, and babies in northern Uganda: achievements and lessons learned over 10 years of implementation (2002–2011). JAIDS J Acquir Immune Defic Syndr. 2013;62(5):e138–45.

    PubMed  Article  Google Scholar 

  45. Chan BT, Weiser SD, Boum Y, Siedner MJ, Mocello AR, Haberer JE, et al. Persistent HIV-related stigma in rural Uganda during a period of increasing HIV incidence despite treatment expansion. AIDS. 2015;29(1):83–90.

    PubMed  PubMed Central  Article  Google Scholar 

  46. Tsai AC, Venkataramani AS. The causal effect of education on HIV stigma in Uganda: evidence from a natural experiment. Soc Sci Med. 2015;142:37–46.

    PubMed  PubMed Central  Article  Google Scholar 

  47. HIV and AIDS Prevention and Control Act. (2014).

  48. Uganda: Deeply Flawed HIV bill approved. Human Rights Watch. 2014. https://www.hrw.org/news/2014/05/13/uganda-deeply-flawed-hiv-bill-approved. Accessed 17 July 2015.

  49. Medley A, Garcia-Moreno C, McGill S, Maman S. Rates, barriers and outcomes of HIV serostatus disclosure among women in developing countries: implications for prevention of mother-to-child transmission programmes. Bull World Health Organ. 2004;82:299–307.

    PubMed  PubMed Central  Google Scholar 

  50. Uganda Bureau of Statistics II. Uganda Demographic and Health Survey; The DHS Program. (2011) August 2012. Report No.

  51. Montagu D, Yamey G, Visconti A, Harding A, Yoong J. Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data. PLoS One. 2011;6(2):e17155.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  52. Joharifard S, Rulisa S, Niyonkuru F, Weinhold A, Sayinzoga F, Wilkinson J, et al. Prevalence and predictors of giving birth in health facilities in Bugesera District, Rwanda. BMC Public Health. 2012;12(1):1049.

    PubMed  PubMed Central  Article  Google Scholar 

  53. Kitui J, Lewis S, Davey G. Factors influencing place of delivery for women in Kenya: an analysis of the Kenya demographic and health survey, 2008/2009. BMC Pregnancy Childbirth. 2013;13(1):40.

    PubMed  PubMed Central  Article  Google Scholar 

  54. Wang W, Alva S, Wang S, Fort A. Levels and trends in the use of maternal health services in developing countries. DHS Comparative Reports 26. 2011.

  55. Link BG, Cullen FT, Frank J, Wozniak JF. The social rejection of former mental patients: Understanding why labels matter. Am J Sociol. 1987;1461–500.

  56. Bogardus ES. Measuring social distance. J Appl Sociol. 1925;9(2):299–308.

    Google Scholar 

  57. Pryor JB, Reeder GD, Vinacco R, Kott TL. The instrumental and symbolic functions of attitudes toward persons with AIDS1. J Appl Soc Psychol. 1989;19(5):377–404.

    Article  Google Scholar 

  58. Scambler G, Hopkins A. Being epileptic: coming to terms with stigma. Sociol Health Illn. 1986;8(1):26–43.

    Article  Google Scholar 

  59. Nyblade L, MacQuarrie K, Phillip F, Kwesigabo G, Mwambo J, Ndega J, et al. Measuring HIV stigma: results of a field-test in Tanzania. Washington, DC: Social & Scientific Systems, Inc.; 2005.

    Google Scholar 

  60. Yoder PS, Nyblade L. Comprehension of questions in the Tanzania AIDS Indicator Survey. Calverton, MD: ORC Macro; 2004.

    Google Scholar 

  61. Adjiwanou V, LeGrand T. Does antenatal care matter in the use of skilled birth attendance in rural Africa: a multi-country analysis. Soc Sci Med. 2013;86:26–34.

    PubMed  Article  Google Scholar 

  62. Ackerson LK, Kawachi I, Barbeau EM, Subramanian S. Effects of individual and proximate educational context on intimate partner violence: a population-based study of women in India. Am J Public Health. 2008;98(3):507.

    PubMed  PubMed Central  Article  Google Scholar 

  63. Filmer D, Pritchett LH. Estimating wealth effects without expenditure Data—Or tears: an application to educational enrollments in states of india. Demography. 2001;38(1):115–32.

    CAS  PubMed  Google Scholar 

  64. Ensor T, Cooper S. Overcoming barriers to health service access: influencing the demand side. Health Policy Plan. 2004;19(2):69–79.

    PubMed  Article  Google Scholar 

  65. Mishra V, Retherford RD. The effect of antenatal care on professional assistance at delivery in rural India. Popul Res Policy Rev. 2008;27(3):307–20.

    Article  Google Scholar 

  66. Bloom SS, Lippeveld T, Wypij D. Does antenatal care make a difference to safe delivery? A study in urban Uttar Pradesh India. Health Policy Plan. 1999;14(1):38–48.

    CAS  PubMed  Article  Google Scholar 

  67. Bartus T. Estimation of marginal effects using margeff. Stata J. 2005;5(3):309–29.

    Google Scholar 

  68. Froot KA. Consistent covariance matrix estimation with cross-sectional dependence and heteroskedasticity in financial data. J Financ Quant Anal. 1989;24(03):333–55.

    Article  Google Scholar 

  69. Rogers W. Regression standard errors in clustered samples. Stata Techn Bull. 1993;13:19–23.

    Google Scholar 

  70. Williams RL. A note on robust variance estimation for cluster-correlated data. Biometrics. 2000;56(2):645–6.

    CAS  PubMed  Article  Google Scholar 

  71. Turan JM, Bukusi EA, Onono M, Holzemer WL, Miller S, Cohen CR. HIV/AIDS stigma and refusal of HIV testing among pregnant women in rural Kenya: results from the MAMAS Study. AIDS Behav. 2011;15(6):1111–20.

    PubMed  Article  Google Scholar 

  72. Iroezi ND, Mindy D, Kawale P, Chikowi G, Jansen PA, Hoffman RM. A qualitative analysis of the barriers and facilitators to receiving care in a prevention of mother-to-child program in Nkoma, Malawi. Afr J Reprod Health. 2013;17(4):11.

    Google Scholar 

  73. Parkhurst JO, Rahman SA, Ssengooba F. Overcoming access barriers for facility-based delivery in low-income settings: insights from Bangladesh and Uganda. J Health Popul Nutr. 2006;24(4):438.

    PubMed  PubMed Central  Google Scholar 

  74. Tsai AC. Socioeconomic gradients in internalized stigma among 4,314 Persons with HIV in Sub-Saharan Africa. AIDS Behav. 2015;19(2):270–82.

    PubMed  PubMed Central  Article  Google Scholar 

  75. Tsai AC. A typology of structural approaches to HIV prevention: a commentary on Roberts and Matthews. Soc Sci Med. 2012;75(9):1562–7.

    PubMed  PubMed Central  Article  Google Scholar 

  76. Nayar US, Stangl AL, De Zalduondo B, Brady LM. Reducing stigma and discrimination to improve child health and survival in low-and middle-income countries: promising approaches and implications for future research. J Health Commun. 2014;19(sup1):142–63.

    PubMed  PubMed Central  Article  Google Scholar 

  77. Gorman SE. A new approach to maternal mortality: the role of HIV in pregnancy. Int J Women’s Health. 2013;5:271.

    Article  Google Scholar 

  78. Turan JM, Nyblade L. Global maternal and child health goals will not be achieved without addressing HIV-related stigma. J Acquir Immune Defic Syndr. 2013;64(1):e9–10.

    PubMed  Article  Google Scholar 

Download references

Acknowledgments

We would like to thank Measure DHS for access and authorization to the 2011 Uganda Demographic Health Survey data files for research purposes. The authors received no specific funding for this study and acknowledge salary support from U.S. National Institutes of Health K23MH096620. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Author information

Authors and Affiliations

  1. Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Ave, 11th Floor, Boston, MA, 02115, USA

    Courtney K. Ng

  2. MGH Global Health, Massachusetts General Hospital, Boston, MA, USA

    Alexander C. Tsai

  3. Harvard Center for Population and Development Studies, Cambridge, MA, USA

    Alexander C. Tsai

Authors
  1. Courtney K. Ng
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alexander C. Tsai
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Courtney K. Ng.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (PDF 249 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ng, C.K., Tsai, A.C. Proximate Context of HIV-Related Stigma and Women’s Use of Skilled Childbirth Services in Uganda. AIDS Behav 21, 307–316 (2017). https://doi.org/10.1007/s10461-016-1401-2

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10461-016-1401-2

Keywords

  • HIV stigma
  • Skilled childbirth services
  • Maternal health
  • PMTCT