Preventing Health Disparities during COVID through Perinatal Home Screening as Black Authoritative Knowledge.

During COVID-19 epidemic, health protocols limited face-to-face perinatal visits and increased reliance on telehealth. To prevent increased health disparities among BIPOC pregnant patients in health-underserved areas, we used a pre-post survey design to pilot a study assessing (1) feasibility of transferring technology including a blood pressure (BP) cuff (BPC) and a home screening tool, (2) providers' and patients' acceptance and use of technology, and (3) benefits and challenges of using the technology. Specific objectives included (1) increasing contact points between patients and perinatal providers; (2) decreasing barriers to reporting and treating maternal hypertension, stress/depression, and intimate partner violence (IPV)/domestic violence (DV); and (3) bundling to normalize and facilitate mental, emotional, and social health monitoring alongside BP screening. Findings confirm this model is feasible. Patients and providers used this bundling model to improve antenatal screening under COVID quarantine restrictions. More broadly, home-monitoring improved antenatal telehealth communication, provider diagnostics, referral and treatment, and bolstered patient autonomy through authoritative knowledge. Implementation challenges included provider resistance, disagreement with lower than ACOG BP values to initiate clinical contact and fear of service over-utilization, and patient and provider confusion about tool symbols due to limited training. We hypothesize that routinized pathologization and projection of crisis onto BIPOC people, bodies, and communities, especially around reproduction and continuity, may contribute to persistent racial/ethnic health disparities. Further research is needed to examine whether authoritative knowledge increases use of critical and timely perinatal services by strengthening embodied knowledge of marginalized patients and, thus, their autonomy and self-efficacy to enact self-care and self-advocacy.

Decolonising the global to local movement: Time for a new paradigm.

Mama Amaan Project (MAP) delivered perinatal education and doula services to underserved refugee and immigrant communities in Seattle, Washington. MAP presented at a 'global to local (glocal)' workshop for US-based global health agencies redirecting their experience and resources to address domestic health crises. Glocal models reference Global South anti-colonial social transformations through Primary Health Care (PHC) - 'health for all as a right' and investment in strong public sectors. As Black women working in our communities, we resisted labelling MAP glocal. Western donors and NGOs appropriate PHC's community participation narratives, meanwhile implementing World Bank/IMF economic structural adjustment health system cuts - thereby shifting austerity-related resource shortfalls to communities. In US contexts of neoliberal shrinking social safety nets and workers' rights, similar strategies to address austerity-related health disparities are promoted as 'global to local'. Projects like MAP cannot substitute quality public services. They expose gaps and build community empowerment to demand quality healthcare. Drawing on MAP and 'global health' experience in Mozambique, we call for re-embracing PHC's activist values - agitating for health as a universal human right for all, rather than putting the burden and blame on underserved communities. We propose decolonising the 'glocal' paradigm by embracing 'transnationality', 'relationality' and 'mutuality'.

Therapeutic Borderlands: Austerity, Maternal HIV Treatment, and the Elusive End of AIDS in Mozambique.

"End of AIDS" requires ambitious testing, treatment, and adherence benchmarks, like UNAIDS' "90-90-90 by 2020." Mozambique's efforts to improve essential maternal/infant antiretroviral treatment (ART) exposes how austerity-related health system short-falls impede public HIV/AIDS service-delivery and hinder effective maternal ART and adherence. In therapeutic borderlands-where household impoverishment intersects with health-system impoverishment-HIV+ women and over-worked care-providers circumnavigate scarcity and stigma. Worrisome patterns of precarious use emerge-perinatal ART under-utilization, delayed initiation, intermittent adherence, and low retention. Ending HIV/AIDS requires ending austerity and reinvesting in a public sector health workforce to ensure universal health coverage as household and community safety nets.

HIV-exposed infant follow-up in Mozambique: formative research findings for the design of a cluster randomized controlled trial to improve testing and ART initiation.

BACKGROUND: Early infant diagnosis (EID) of HIV-exposed and initiation of HIV-positive infants on anti-retroviral therapy (ART) requires a well-coordinated cascade of care. Loss-to-follow-up (LTFU) can occur at multiple steps and effective EID is impeded by human resource constraints, difficulty with patient tracking, and long waiting periods. The objective of this research was to conduct formative research to guide the development of an intervention to improve the pediatric HIV care cascade in central Mozambique. The study was conducted in Manica and Sofala Provinces where the adult HIV burden is higher than the national average. The research focused on 3 large clinics in each province, along the highly populated Beira corridor. METHODS: The research was conducted in 2014 over 3 months at six facilities and consisted of 1) patient flow mapping and collection of health systems data from postpartum, child-at-risk, and ART service registries, 2) measurement of clinic waiting times, and 3) patient and health worker focus groups. RESULTS: HIV testing and ART initiation coverage for mothers tends to be high, but EID and pediatric ART initiation are hampered by lack of patient tracking, long waiting times, and inadequate counseling to navigate the care cascade. About 76% of HIV-positive infants were LTFU and did not initiate ART. CONCLUSIONS: Effective interventions to reduce LTFU in EID and improve pediatric ART initiation should focus on patient tracking, active follow-up of defaulting patients, reduction in EID turn-around times for PCR results, and initiation of ART by nurses in child-at-risk services. TRIAL REGISTRATION: Retrospectively registered, ISRCTN67747315, July 24, 2019.

HIV-exposed infant follow-up in Mozambique: formative research findings for the design of a cluster randomized controlled trial to improve testing and ART initiation

Background: Early infant diagnosis (EID) of HIV-exposed and initiation of HIV-positive infants on anti-retroviral therapy (ART) requires a well-coordinated cascade of care. Loss-to-follow-up (LTFU) can occur at multiple steps and effective EID is impeded by human resource constraints, difficulty with patient tracking, and long waiting periods. The objective of this research was to conduct formative research to guide the development of an intervention to improve the pediatric HIV care cascade in central Mozambique. The study was conducted in Manica and Sofala Provinces where the adult HIV burden is higher than the national average. The research focused on 3 large clinics in each province, along the highly populated Beira corridor. Methods: The research was conducted in 2014 over 3months at six facilities and consisted of 1) patient flow mapping and collection of health systems data from postpartum, child-at-risk, and ART service registries, 2) measurement of clinic waiting times, and 3) patient and health worker focus groups. Results: HIV testing and ART initiation coverage for mothers tends to be high, but EID and pediatric ART initiation are hampered by lack of patient tracking, long waiting times, and inadequate counseling to navigate the care cascade. About 76% of HIV-positive infants were LTFU and did not initiate ART. Conclusions: Effective interventions to reduce LTFU in EID and improve pediatric ART initiation should focus on patient tracking, active follow-up of defaulting patients, reduction in EID turn-around times for PCR results, and initiation of ART by nurses in child-at-risk services. Trial registration: Retrospectively registered, ISRCTN67747315, July 24, 2019.

NGOs, austerity, and universal health coverage in Mozambique.

In many African countries, hundreds of health-related NGOs are fed by a chaotic tangle of donor funding streams. The case of Mozambique illustrates how this NGO model impedes Universal Health Coverage. In the 1990s, NGOs multiplied across post-war Mozambique: the country's structural adjustment program constrained public and foreign aid expenditures on the public health system, while donors favored private contractors and NGOs. In the 2000s, funding for HIV/AIDS and other vertical aid from many donors increased dramatically. In 2004, the United States introduced PEPFAR in Mozambique at nearly 500 million USD per year, roughly equivalent to the entire budget of the Ministry of Health. To be sure, PEPFAR funding has helped thousands access antiretroviral treatment, but over 90% of resources flow "off-budget" to NGO "implementing partners," with little left for the public health system. After a decade of this major donor funding to NGOs, public sector health system coverage had barely changed. In 2014, the workforce/ population ratio was still among the five worst in the world at 71/10000; the health facility/per capita ratio worsened since 2009 to only 1 per 16,795. Achieving UHC will require rejection of austerity constraints on public sector health systems, and rechanneling of aid to public systems building rather than to NGOs.

Stepped-Wedge Cluster Randomized Controlled Trial to Promote Option B+ Retention in Central Mozambique.

BACKGROUND: This randomized trial studied performance of Option B+ in Mozambique and evaluated an enhanced retention package in public clinics. SETTING: The study was conducted at 6 clinics in Manica and Sofala Provinces in central Mozambique. METHODS: Seven hundred sixty-one pregnant women tested HIV+, immediately initiated antiretroviral (ARV) therapy, and were followed to track retention at 6 clinics from May 2014 to May 2015. Clinics were randomly allocated within a stepped-wedge fashion to intervention and control periods. The intervention included (1) workflow modifications and (2) active patient tracking. Retention was defined as percentage of patients returning for 30-, 60-, and 90-day medication refills within 25-35 days of previous refills. RESULTS: During control periods, 52.3% of women returned for 30-day refills vs. 70.8% in intervention periods [odds ratio (OR): 1.80; 95% confidence interval (CI): 1.05 to 3.08]. At 60 days, 46.1% control vs. 57.9% intervention were retained (OR: 1.82; CI: 1.06 to 3.11), and at 90 days, 38.3% control vs. 41.0% intervention (OR: 1.04; CI: 0.60 to 1.82). In prespecified subanalyses, birth before pickups was strongly associated with failure-women giving birth before ARV pickup were 33.3 times (CI: 4.4 to 250.3), 7.5 times (CI: 3.6 to 15.9), and 3.7 times (CI: 2.2 to 6.0) as likely to not return for ARV pickups at 30, 60, and 90 days, respectively. CONCLUSIONS: The intervention was effective at 30 and 60 days, but not at 90 days. Combined 90-day retention (40%) and adherence (22.5%) were low. Efforts to improve retention are particularly important for women giving birth before ARV refills.

Option B+ in Mozambique: Formative Research Findings for the Design of a Facility-Level Clustered Randomized Controlled Trial to Improve ART Retention in Antenatal Care.

INTRODUCTION: With the rollout of "Option B+" in Mozambique in 2013, initial data indicated major challenges to early retention in antiretroviral therapy (ART) among HIV-positive pregnant women. We sought to develop and test a pilot intervention in 6 large public clinics in central Mozambique to improve retention of mothers starting ART in antenatal care. The results from the formative research from this study described here were used to design the intervention. METHODS: The research was initiated in early 2013 and completed in early 2014 in each of the 6 study clinics and consisted of (1) patient flow mapping and measurement of retention through collection of health systems data from antenatal care registries, pharmacy registries, ART clinic databases, (2) workforce assessment and measurement of patient waiting times, and (3) patient and worker individual interviews and focus groups. RESULTS: Coverage of HIV testing and ART initiation were over 90% at all sites, but retention at 30-, 60-, and 90-day pharmacy refill visits was very low ranging from only 5% at 1 site to 30% returning at 90 days. These data revealed major systemic bottlenecks that contributed to poor adherence and retention in the first month after ART initiation. Long wait times, short consultations, and poor counseling were identified as barriers. CONCLUSIONS: Based on these findings, we designed an intervention with these components: (1) workflow modification to redefine nurse tasks, shift tasks to community health workers, and enhance patient tracking and (2) an adherence and retention package to systematize active patient follow-up, ensure home visits by community health workers, use text messaging, and intensify counseling by health staff. This intervention is currently under evaluation using a stepped wedge design.

Early ART initiation among HIV-positive pregnant women in central Mozambique: a stepped wedge randomized controlled trial of an optimized Option B+ approach.

BACKGROUND: Despite effective prevention strategies and increasing investments in global health, maternal to child transmission (MTCT) of HIV remains a significant problem globally, especially in sub-Saharan Africa. In 2012, there were 94,000 HIV-positive pregnant women in Mozambique. Approximately 15% of these women transmitted HIV to their newborn infants, resulting in nearly 14,000 new pediatric HIV infections that year. To address this issue, in 2013, the Mozambican Ministry of Health implemented the World Health Organization-recommended "Option B+" strategy in which all newly diagnosed HIV-positive pregnant women are counseled to initiate combination anti-retroviral therapy (ART) immediately upon diagnosis regardless of CD4 count and to continue treatment for life. Given the limited experience with Option B+ in sub-Saharan Africa, few rigorous pragmatic trials have studied this new treatment strategy. METHODS: This study utilizes an initial formative research process involving patient and health care provider interviews and focus groups, workforce assessments, value stream mapping, and commodity utilization assessments to understand the strengths and weaknesses in the current Option B+ care cascade. The formative research is intended to guide identification and prioritization of key workflow modifications and the development of an enhanced adherence and retention package. These two components are bundled into a defined intervention implemented and evaluated across six health facilities utilizing a stepped wedge randomized controlled trial study design. The overall objective of this trial is to develop and test a pilot intervention in central Mozambique to implement the new Option B+ guidelines with high fidelity and increase the proportion of HIV-positive pregnant women in target antenatal clinics (ANC) who start ART prior to delivery and are retained in care. DISCUSSION: This pragmatic study utilizes research strategies that have the potential to meaningfully improve the Option B+ care cascade in central Mozambique and to decrease the MTCT of HIV. This trial is designed to identify critical low-cost improvement strategies that can be bundled into a defined intervention. If this intervention has a measurable impact, it can be rapidly scaled up to other ANC in Mozambique and sub-Saharan Africa. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02371265.

Chikotsa--secrets, silence, and hiding: social risk and reproductive vulnerability in central Mozambique.

In this article, I examine pregnancy narratives and patterns of reproductive health seeking among women of fertile age in central Mozambique. I map the interplay between gendered economic marginalization, maternal risk perceptions, and pregnancy management strategies. By interpreting my data in light of Shona illness theories, I illuminate the ways that embodied experiences of reproductive vulnerability, risk perceptions, and social inequalities are linked: women attribute the most serious maternal complications to human- or spirit-induced reproductive threats of witchcraft and sorcery. This construction of reproductive vulnerability as social threats related to material and social competition significantly influences prenatal health seeking. Data reveal the structural and cognitive gap between biomedical constructions of risk and lay social threat perceptions. Plural health care systems are strategically utilized by women seeking to minimize both social and biological harm. On-the-ground ethnography shows that maternal health initiatives must take this plurality into full and accommodative account to achieve viable improvements in reproductive care and outcomes.

Radical contextualization: contributions to an anthropology of racial/ethnic health disparities.

There is indisputable evidence of deep and persistent racial/ethnic inequalities in health status and health care in the USA. Growing awareness of these disparities has fueled a cross-disciplinary debate about appropriate approaches to racial/ethnic disparities in public health research and policy discourse, yet anthropologists have been marginalized in this discourse. What does the current work of anthropologists have to offer that is most useful in the crucial work of understanding and eliminating health disparities? We examine anthropological research and practice that constitute core contributions to an anthropology of racial/ethnic health disparities. We identify the following themes: (1) using ethnography as a tool for new inequality knowledge; (2) studying up; and (3) formulating alternative models of biosocial pathogenesis. These elements of anthropological methods, theory and practice can contribute to a better understanding of the social processes that underpin racial/ethnic health disparities and help identify opportunities for interrupting them.

A nova vida: the commoditization of reproduction in Central Mozambique.

In Central Mozambique economic austerity and shifts in domestic organization have transformed kinship and gender relations in ways that reinforce reproductive demands on women. Against this backdrop of economic and social restructuring, commodification of long-standing reproductive practices has intensified. This paper examines the influence of commodification and female economic marginalization on virginity reviews, seduction fees, bride wealth payments, and childbirth assistance. Constructions of reproductive risk as human or spirit-induced threats of witchcraft, sorcery, or spirit possession resonate in this atmosphere of competition and instability. Rather than disappearing, occult practices may be increasing in response to the new inequalities associated with "modernity." This pressure contributes to women's reproductive vulnerability and informs new strategies to manage risk during pregnancy. Life history and pregnancy case study data reveal how women facing growing inequality and increasing danger to reproductive health mobilize cultural resources in ways that, paradoxically, both reinforce and contest dominant relations of reproduction.

Endangering safe motherhood in Mozambique: prenatal care as pregnancy risk.

Despite high infant and maternal mortality rates, many Mozambican women with access to prenatal services delay prenatal clinic consultations, limiting opportunity for prevention and treatment of preventable pregnancy complications. Ethnographic research, interviews with health providers and longitudinal pregnancy case studies with 83 women were conducted in Central Mozambique to examine pregnant women's underutilization of clinic-based prenatal services. The study found that pregnancy beliefs and prenatal practices reflect women's attempts to influence reproduction under conditions of vulnerability at multiple levels. Women reported high maternal reproductive morbidity, frequent pregnancy wastage, and immense pressure to bear children throughout their reproductive years. Reproductive vulnerability is intensified by poverty and an intense burden placed on poor, peri-urban women farmers for family subsistence and continuous fertility in a period of economic austerity, land shortages, and increasing social conflict and inequality. In this environment of economic insecurity exacerbated by congested living conditions, women report competing for scarce resources, including male support and income. This vulnerability heightens women's perceptions that they and their unborn infants will be targets of witchcraft or sorcery by jealous neighbors and kin. They respond by hiding pregnancy and delaying prenatal care. Within the context of women's perceived reproductive risks, delayed prenatal care can be seen as a strategy to protect pregnancy from purposeful human and spirit harm. Women mobilized limited resources to acquire prenatal care outside the formal clinic setting. It is concluded that provision of clinical prenatal services is insufficient to reduce reproductive risks for the most socially and economically marginal since it is their vulnerability that prevents women from using available services. Confidential maternity services and social safety nets for greater economic security are recommended.