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Home delivery has been associated with mother-to-child transmission of HIV and remains high among HIV-infected women. Predictors for home delivery in the context of HIV have not been fully studied and understood in Northern Uganda. We therefore aimed to find out the incidence and risk factors for home delivery among women living with HIV in Lira, Northern Uganda.
This prospective cohort study was conducted between August 2018 and January 2020 in Lira district, Northern Uganda. A total of 505 HIV infected women receiving antenatal care at Lira regional referral hospital were enrolled consecutively and followed up at delivery. We used a structured questionnaire to obtain data on exposures which included: socio-demographic, reproductive-related and HIV-related characteristics. Data was analysed using Stata version 14.0 (StataCorp, College Station, Texas, U.S.A.). We estimated adjusted risk ratios using Poisson regression models to ascertain risk factors for the outcome of interest which was home delivery (which is delivering an infant outside a health facility setting under the supervision of a non-health worker).
Facility delivery is recommended in the context of HIV to reduce on the risk of mother to child transmission of HIV (MTCT) [1, 2]. Home delivery has been associated with MTCT of HIV [3, 4] because the risk of transmission is reduced when the deliveries are attended to by skilled birth attendants in health institutions. Furthermore, delivering from home deprives an HIV infected woman of prevention of mother-to-child transmission of HIV (PMTCT) interventions during and immediately after labour and delivery which include: receiving ARV prophylaxis for the baby, emergency caesarean section when required, safe delivery practices and use of standard infection prevention practices. HIV infected women who deliver outside a hospital setting are therefore likely to suffer complications resulting into vertical HIV transmission, maternal and (or) infant death . Facility delivery is therefore essential for HIV-infected women and healthcare workers must accentuate its importance during antenatal care.
In addition, home delivery has been found to rank highly among predictors of maternal and neonatal mortality [4,5,6]. Skilled care, attendance in a hospital during the antenatal period and child birth are key in facilitating appropriate referral in case of obstetric complications that can potentially lead to maternal or neonatal mortality. The maternal mortality rate in Uganda is 345 per 100,000 live births . In 2017 alone 6000 maternal deaths occurred in Uganda and of these, 110 were HIV-related. The neonatal mortality rate in Uganda is also high at 19 deaths per 1000 live births [7, 8].
Other risk factors that have been associated with home delivery among HIV infected women include non-attendance of antenatal care, cost of delivery, low perceived quality of care, fear of discrimination during facility-based delivery, poor adherence to ART, lack of maternal education and history of previous home delivery [9,10,11,12,13,14,15,16,17]. Male involvement in maternal and child health care for HIV infected women has been shown to improve utilisation of maternity services like facility-based delivery .
Predictors for home delivery among HIV infected and HIV uninfected women may be comparable , however some factors are unique to HIV infected women like poor maternal ART adherence [14, 15]. These predictors, especially for women living with HIV, have not been fully studied and understood in Northern Uganda. Furthermore, predictors for home delivery vary across different study contexts. We therefore aimed to find out the incidence and risk factors for home delivery among women living with HIV in Lira, Northern Uganda. These findings helped in the identifying of groups of HIV infected women that are most at risk for home delivery. These groups of women can act as a target group for PMTCT interventions to counteract home delivery.
We collected data using pretested structured questionnaires. Data was entered into Epi data (www.epidata.dk, version 220.127.116.11) and then exported to Stata version 14.0 (StataCorp, College Station, Texas, U.S.A.) for analysis. Continuous data that was normally distributed was summarised into means and corresponding standard deviations. Frequencies and proportions we calculated for categorical variables. The incidence of home delivery was estimated by dividing the number of women that delivered at home divided by all those who were assessed women, expressed as a percentage and its confidence limits calculated using the exact method. Poisson regression analysis was used for bivariate and multivariate analyses . All variables that had a p value
We found a high incidence of home delivery in our study. One study  done in Northern Uganda, a context similar to that in our study found that rates of home delivery in the community or general population were higher than that found in our study among HIV infected women. HIV infected women interface with the health care system much more often than their HIV negative counterparts and therefore understand the benefits of health facility delivery especially for the HIV-free survival of their baby hence are most likely to deliver in the hospital that HIV negative women. Various studies have found slightly higher rates of home delivery among HIV infected women. Studies done in Kenya , Zimbabwe , Malawi , South Africa  and Nigeria  all report higher rates of home delivery among HIV infected women than that in our study. All these studies were conducted in different settings like the community  and different types of health facilities like religious based hospitals  or public health facilities . The diversity in the settings and study designs employed within the various studies could explain the difference in the rates of home delivery. Furthermore, LRRH and all other Ugandan public health facilities offer free maternity care and delivery services and this could explain the low rates of home delivery among HIV infected women in our study setting.