Perceptions and understandings of pregnancy, antenatal care and postpartum care among rural Lao women and their families.

BACKGROUND: Lao People's Democratic Republic (Lao PDR) has the highest maternal mortality rate (MMR) and infant mortality rate (IMR) due to traditional practice and beliefs on pregnancy, delivery and postpartum. The objective of this study was to get a better understanding of cultural beliefs and practices surrounding pregnancy, ANC and postpartum care among rural women in Lao PDR. METHODS: Eight focus group discussions and 52 interviews were carried out with delivered women, husbands, mothers, traditional birth attendants, head villagers, Lao Women's Union members and healthcare workers, in Khammouane and Champasack provinces in Lao PDR. In order to accurately grasp participants' perceptions and understandings, content analysis was used to analyze the transcripts. RESULTS: Most women in the study claimed to have attended ANC, but participants also explained that it was unnecessary to attend ANC and give birth at a clinic if the woman felt healthy. Factors that discouraged ANC attendance and giving birth at clinics included: time and money constraints; the perceived necessity of giving birth on a "hot bed"; the need for "mother-roasting" after giving birth; the belief that preparing for a birth was a bad omen for the birth; the belief that colostrum is unhealthy for the newborn child; and the preference for cutting the umbilical cord with a piece of sharpened bamboo. CONCLUSIONS: Harmful cultural practices such as discarding colostrum should be discouraged; beneficial practices such as family involvement in birthing and keeping a mother warm after birth could be integrated into biomedical practice. Given the prevalence and importance of the cultural understandings we have described in this study, it is clear that proposed changes in cultural practices need to be addressed with sensitivity and that community stakeholders and trusted leaders will need to be involved.

Sexual relationships among men who have sex with men in Hanoi, Vietnam: a qualitative interview study.

BACKGROUND: The prevalence of HIV among men who have sex with men (MSM) in Vietnam's two largest cities, Hanoi and Ho Chi Minh City, may be above 10%. The aim of this study was to explore sexual relationship patterns and experiences among MSM in Hanoi, to inform HIV preventive efforts. Using purposive sampling we recruited 17 MSM in Hanoi, Vietnam, for in-depth interviews. Participants were aged between 19 and 48 years and came from diverse socio-economic backgrounds. Interviews were tape-recorded, transcribed verbatim, and translated into English. Content analysis was used. RESULTS: Almost all men in the study saw their same-sex attraction as part of their "nature". Many informants had secret but rich social lives within the MSM social circles in Hanoi. However, poor men had difficulties connecting to these networks. Lifetime sexual partner numbers ranged from one to 200. Seven participants had at some point in their lives been in relationships lasting from one to four years. For several men, relationships were not primarily centered on romantic feelings but instead intimately connected to economic and practical dependence. Sexual relationships varied greatly in terms of emotional attachment, commitment, trust, relationship ideals, sexual satisfaction and exchange of money or gifts. Faithfulness was highly valued but largely seen as unobtainable. Several informants felt strong family pressure to marry a woman and have children. CONCLUSIONS: This study contextualizes sexual relationships among MSM in Hanoi and highlights the extent to which HIV prevention activities need to not only consider HIV prevention in the context of casual sexual encounters but also how to adequately target preventive efforts that can reach MSM in relationships.

Reasons for poor adherence to antiretroviral therapy postnatally in HIV-1 infected women treated for their own health: experiences from the Mitra Plus study in Tanzania.

BACKGROUND: In a study of prevention of mother-to-child transmission of HIV (PMTCT) by triple antiretroviral therapy (ART) in Dar es Salaam, Tanzania (the Mitra Plus study), retrospective viral load testing revealed a high and increasing frequency of detectable viral load during follow-up for two years postnatally in women given continuous ART for their own health suggesting poor adherence. This study explored women's own perceived barriers to adherence to ART post-delivery so as to identify ways to facilitate better drug adherence among women in need of ART for their own health. METHODS: Semi-structured interviews were conducted with 23 of the 48 women who had detectable viral load at 24 months postnatally. Content analysis was used to analyze the data. RESULTS: Most women in the study did not acknowledge poor adherence until confronted with the viral load figures. Then, however, they revealed multiple reasons for failing to adhere. They said that their motivation to take ART decreased once they had protected their children from becoming infected and successfully weaned them. Feeling well for some, and a feeling of hopelessness for others, also decreased motivation to continue ART. The overwhelming demands of everyday life, poverty and lack of empowerment also posed significant barriers to long-term adherence. The need to keep their HIV status a secret and not let anyone see them taking the drugs was another steep barrier. CONCLUSION: Reasons for postnatal failure to adhere by mothers put on ART for life during pregnancy included lack of motivation to continue ART after weaning the child, poverty and stigma. Projects that simultaneously address stigma, poverty and women's lack of empowerment may be necessary for PMTCT and ART to reach their full potential. Our results indicate that the new WHO proposal to start all HIV-infected pregnant women on lifelong ART regardless of CD4 cell count needs to address the challenging realities of women in resource-poor contexts if it is to be successful.

Reasons rural Laotians choose home deliveries over delivery at health facilities: a qualitative study.

BACKGROUND: Maternal mortality among poor rural women in the Lao People's Democratic Republic (Lao PDR) is among the highest in Southeast Asia, in part because only 15% give birth at health facilities. This study explored why women and their families prefer home deliveries to deliveries at health facilities. METHODS: A qualitative study was conducted from December 2008 to February 2009 in two provinces of Lao PDR. Data was collected through eight focus group discussions (FGD) as well as through in-depth interviews with 12 mothers who delivered at home during the last year, eight husbands and eight grandmothers, involving a total of 71 respondents. Content analysis was used to analyze the FGD and interview transcripts. RESULTS: Obstacles to giving birth at health facilities included: (1) Distance to the health facilities and difficulties and costs of getting there; (2) Attitudes, quality of care, and care practices at the health facilities, including a horizontal birth position, episiotomies, lack of privacy, and the presence of male staff; (3) The wish to have family members nearby and the need for women to be close to their other children and the housework; and (4) The wish to follow traditional birth practices such as giving birth in a squatting position and lying on a "hot bed" after delivery. The decision about where to give birth was commonly made by the woman's husband, mother, mother-in-law or other relatives in consultation with the woman herself. CONCLUSION: This study suggests that the preference in rural Laos for giving birth at home is due to convenience, cost, comfort and tradition. In order to assure safer births and reduce rural Lao PDR's high maternal mortality rate, health centers could consider accommodating the wishes and traditional practices of many rural Laotians: allowing family in the birthing rooms; allowing traditional practices; and improving attitudes among staff. Traditional birth attendants, women, and their families could be taught and encouraged to recognize the signs of at-risk pregnancies so as to be able to reach health facilities on time.

Customary adolescent sexual practices among the Akha of northern Lao PDR: considerations for public health.

Based on interviews and focus group discussions conducted in northern Laos, this study explores Akha understandings of customary first pre-pubertal sex acts, a thonh thong ('break through vagina' [BV]) for girls and yaha heu ('open foreskin' [OF]) for boys, which are thought to enable the maturing of bodies into adulthood. The study also examines the practice of a thor ta yang ('Welcome Guest') in which sexually initiated girls have sex with male visitors to Akha villages. The study found that many young women experience BV as painful and traumatic. However, since all Akha in the study 'knew' that young bodies will not mature into attractive, healthy adults if they do not perform BV and OF, attitudes were largely positive. Both men and women are at increasing risk of STIs, including HIV, since resettlement and an influx of non-Akha into the area. We conclude that Akha villagers should be included in the planning of future public health strategies that do not violate their cultural commitments and dignity but that help them resist potential exploitation and threats to their health. Such strategies might include sexual education programs and encouraging the delay of BV and OF.

Mistrust in marriage--reasons why men do not accept couple HIV testing during antenatal care- a qualitative study in eastern Uganda.

BACKGROUND: A policy for couple HIV counseling and testing was introduced in 2006 in Uganda, urging pregnant women and their spouses to be HIV tested together during antenatal care (ANC). The policy aims to identify HIV-infected pregnant women to prevent mother-to-child transmission of HIV through prophylactic antiretroviral treatment, to provide counseling, and to link HIV-infected persons to care. However, the uptake of couple testing remains low. This study explores men's views on, and experiences of couple HIV testing during ANC. METHODS: The study was conducted at two time points, in 2008 and 2009, in the rural Iganga and Mayuge districts of eastern Uganda. We carried out nine focus group discussions, about 10 participants in each, and in-depth interviews with 13 men, all of whom were fathers. Data were collected in the local language, Lusoga, audio-recorded and thereafter translated and transcribed into English and analyzed using content analysis. RESULTS: Men were fully aware of the availability of couple HIV testing, but cited several barriers to their use of these services. The men perceived their marriages as unstable and distrustful, making the idea of couple testing unappealing because of the conflicts it could give rise to. Further, they did not understand why they should be tested if they did not have symptoms. Finally, the perceived stigmatizing nature of HIV care and rude attitudes among health workers at the health facilities led them to view the health facilities providing ANC as unwelcoming. The men in our study had several suggestions for how to improve the current policy: peer sensitization of men, make health facilities less stigmatizing and more male-friendly, train health workers to meet men's needs, and hold discussions between health workers and community members. CONCLUSIONS: In summary, pursuing couple HIV testing as a main avenue for making men more willing to test and support PMTCT for their wives, does not seem to work in its current form in this region. HIV services must be better adapted to local gender systems taking into account that incentives, health-seeking behavior and health system barriers differ between men and women.