Perceptions of Antenatal Attendees on Prevention of Mother-to-Child Transmission of Human Immunodeficiency Virus (HIV) Services in the Central Region of Ghana.

doi:10.21203/rs.3.rs-3991581/v1

Background: Prevention of Mother-to-Child Transmission (PMTCT) of Human Immunodeficiency Virus (HIV) involves a range of interventions that can be implemented during pregnancy, delivery, and breastfeeding to reduce the risk of HIV transmission from mother to the child. However, the success of PMTCT programs largely depends on the uptake of services and the perceptions of the target population.

Aim:This study therefore aims to explore the perceptions of antenatal attendees on PMTCT services in the district hospitals in the central region of Ghana.

Methods: A descriptive cross-sectional study with a quantitative approach was conducted using antenatal attendees between the ages of 15 to 49 in the 11 district hospitals in the central region of Ghana. The convenient sampling procedure was used to sample 448 antenatal attendees from the district hospitals. Data were collected using a structured questionnaire. Statistical Package for Social Sciences (SPSS) version 25 was used to proceed the data.Descriptive and inferential statistics were used to analyzed the data. ANOVA was used to assess the statistical significance of difference between perceptions, beliefs and views among antenatal attendees across the three gestational ages.

Results: A total of 448 antenatal attendees were included in the study. Two hundred and nineteen (48.9%) perceived receiving poor care from midwives when tested positive, 318 (71%) admitted that they fear stigmatization associated with PMTCT of HIV services, 224 (50%) of them admitted that distance to the ANCs was a bother to them and 258 (57.6%) were uncomfortable to use condom for HIV prevention. Anova test reported statistically as perception [F (degree of freedom of the groups) = F-statistic 8.957; p-value = 0.001: p<0.05) beliefs, [F (degree of freedom of the groups) = F-statistic 3.138; p-value = 0.025: p<0.05) and views, [F (degree of freedom of the groups) = F-statistic 3.287; p-value = 0.021: p<0.05).

Conclusion: The antenatal attendees generally had poor perceptions towards the services, hence, affecting their participation in the services available. Thus, they had the perceptions of receiving poor care from ANC midwives, feared experiencing stigma when tested positive, hospitals located far from their homes and discomfort with the use of condoms to prevent further transmissions and complications. Also, the advancement in gestational age improves the antenatal attendees’ perception on PMTCT of HIV services.

Antenatal attendees

Human immunodeficiency virus

Perceptions and Prevention of mother-to-child transmission.

The PMTCT of HIV services aim to prevent the transmission of HIV from HIV-positive mothers to their unborn children during pregnancy, delivery, or breastfeeding [1]. Globally, the HIV pandemics increases, with an estimated five million people infected each year [2]. For decades, the pandemic that was dominated by infected men has become more feminine, with a higher proportion of adult women living with HIV [3]. In sub-Saharan Africa, where about two-thirds of the global disease burden is located, 55% of adults living with HIV are women [4]. As the number of women infected with the virus increases, the number of children infected by their mothers also increases.

In Ghana, the estimated HIV prevalence is 1.7% with 334,713 people living with HIV/AIDS (PLWHA) [5]. Of these, 142,634 were women, mostly of childbearing age. In the same year, the average HIV prevalence among women attending antenatal clinics was 1.9% [4]. Additionally, Ghana had an HIV prevalence of 2.4% among antenatal participants in 2017, with a total of 293,804 people living with the virus. Of these, 178,560 were women aged 15 or older and 32,034 were children under 15. In that same year, HIV prevalence in the central region was 1.8% [6]. Although prevalence in Africa is very low, it is relatively high compared to 2.1 million globally between 2001 and 2015 [7].

According to the [5], there were 27% of untested ANC attendees in the central region in 2016, which was higher than in previous years. In 2014, the region had the lowest percentage of untested ANC attendees (8%), a difference of 86% between 2015 and 2016. A report by the Ghana Health Authority showed that 97 people died of AIDS in the region in 2017, including six children under the age of 15. In the same region, five pregnant teenage girls were infected with HIV and were closely monitored to protect their children from the infection [5]. Without treatment, about 15–30% of babies born to HIV-positive mothers will become infected with HIV during pregnancy and childbirth, and 5–15% will become infected through breastfeeding [8].

To reduce this burden, PMTCT of HIV service has been designed to generally encompass a variety of interventions, including HIV testing and counseling, administering antiretroviral treatment, and offering support for safe infant feeding practices and antenatal care clinic is specifically designed to deliver these interventions to pregnant women, ensuring the monitoring of both their own health and that of their unborn child [9].

Despite the presence of PMTCT of HIV services in Ghana, the prevalence of Mother-To-Child Transmission (MTCT) of HIV persists at an unjustifiably elevated level, resulting in the unfortunate death of children due to HIV/AIDS, a tragedy that could have been avoided [10].

According to [11], the increase in MTCT of HIV has been a major concern in the country, particularly the health sector. This has also led to an increase in HIV infections in the Central Region and suggests that pregnant women attending ANCs are not adequately involved in PMTCT for HIV services. In addition, many women drop out of PMTCT programs and give birth to HIV-positive children for fear of discrimination and exclusion from their male partners and family members [12].

Therefore, the perceptions of antenatal attendees are essential in ensuring that PMTCT of HIV services are effective in preventing MTCT of HIV. It is crucial to understand these opinions of pregnant women towards these services, as this can impact their utilization of the services. Since the program was introduced in the region, limited researches have been conducted to assess how women in Ghana adopt the intervention program. Hence, this study aims to explore the perceptions of antenatal attendees on PMTCT services in the district hospitals in the central region of Ghana.

Theoretical framework

The theoretical framework used in this study was adapted from two theories namely, Pender's Health Promotion Model (HPM) and Theory of Planned Behavior (TPB). These two theories were chosen because they are a perfect pair. That is, they have similar concepts related to each other. Moreover, most of the concepts of the theory of planned behavior were embedded in the construct of the Pender’s Health Promotion model. Furthermore, the concepts of both theories are essential for health promotion and disease prevention, which is consistent with the purpose of this study.

Both theories are used to plan behavior modification interventions to help correct and prevent unhealthy behaviors, thus helping to achieve optimal health promotion for patients and the community. This is related to the aim of this study which is to explore antenatal attendees’ perceptions of PMTCT of HIV services. Exploring the antenatal attendees’ perceptions might increase their awareness and participation in the PMTCT of HIV services and further reduce or prevent the transmission of HIV. Both theories explore the concept that antenatal attendees have their own experiences, which in turn help shape their behavior. Both theories involve the personal factors and perceived behavioral control which have direct impact on the individual motivation for change [13]. That is antenatal attendees’ perceptions of PMTCT of HIV services been negative or positive, might influence their awareness and participation as well as perceptions of significant others. Both the Pender’s health promotion and the theory of planned behavior ends with behavioral outcomes that lead individuals to commit to taking the necessary steps to make changes [13]. Thus, the antenatal attendees’ participating in the PMTCT of HIV services might promote their awareness and prevent MTCT HIV. Because there are many concepts in Pender's health promotion model and the theory of planned behavior, the researchers chose those that best fit the aim of the study.

Figure 1: Conceptual Framework Adapted from Pender’s Health Promotion Model (2011) and The Theory of Planned Behavior (Bosnjak, Ajzen & Schmidt 2020).

Study design and respondents

This study used a descriptive cross-sectional design with a quantitative approach. The study was conducted in the Central Region, which is one of 16 regions in Ghana. The region has 20 administrative districts and the city of Cape Coast as its capital. Out of the 20 districts, 11 have district hospitals serving the region and these 11 district hospitals were the focus of the study.

The population of the antenatal attendees was 90905 and the age range was between 15 and 49, that is women of childbearing age. Pregnant women between 15 to 49 years, who were not involved during pre-testing of data collection instrument and agreed to respond and signed the consent form were included in the study. Those below 15 years and above 49 years and those who were ill during the data collection period were not included in the study. The convenience sampling was used to select 384 antenatal attendees. This was achieved by using the table for determining the sample size for a given population provided by [14].

An experience extended from the pre-test exercise indicated that the researchers were unable to contact some of the antenatal attendees needed for the study, hence leading to a non-response to some of the questionnaires. Assuming a 10% non-response rate of the sample size was:

N = 384 + 10% of 384 =384 + 38 = 422.

This is because, according to [15] up to 50% of the sample size is added to the sample size to compensate for non-response.

This brought the estimated sample size to 422 and was rounded up to a sample size of 450 because, as the sample size increases, the results become more accurate and devoid sample error [15].

This number, 450 antenatal attendees were contacted to enroll in the study. The sample size 450 was further distributed proportionally across the antenatal care clinics using stratified proportional allocation formula stated below:

Where

nh = stratum sample size for a particular health facility

Nh= population size for a particular health facility

N= Total population size

n= total sample size for the study

For example, the stratified sample size for Abura Dunkwa was calculated as:

Table 2 shows the population and distribution of the sample size across the 11 district hospitals based on the proportional allocation.

Table 1: Population and Sample Size across district hospitals in the Central Region

After the actual data collection, the non-response rate was still experienced since 448 questionnaires were received instead of 450. Therefore, these 448 questionnaires were used for the analysis since a non-response rate of 10% has already been catered for.

Data collection instrument

The main data collection tool for this study was a structured questionnaire with mostly close-ended questions extracted from experts’ opinion and research work in related areas. According to [16] close-ended items are very easy to code, thus, making analysis easy. However, they are quite difficult to construct and there is the likelihood that individual respondents may have other responses either than the options provided.

For this study, the aim of the data collection tool was to explore the perceptions of antenatal attendees on PMTCT services in the 11 district hospitals in the central region of Ghana. The structured questionnaire was developed in the English language and consisted of two scales: scale 1 addressed socio-demographic information of the antenatal attendees with 9 items and scale 2 assessed the perceptions of the antenatal attendees towards PMTCT of HIV services.

The questionnaire started with an introductory statement, which specified the purpose of the research and assured the respondents of confidentiality of their responses. The questionnaire was sent to experts for their comments and suggestions after that it was re-designed and the feedback was integrated into the questionnaire. Before validity and reliability tests were carried out, the researchers refined the questionnaire by administering them to a small group of antenatal attendees similar in characteristics to the intended respondents. This was because researchers are professionals whose language and culture can be different from those of the potential respondents in their study which may influence the meaning and the content of the questionnaire [17].

The validity and reliability of the instrument were pre-tested at the University of Cape Coast Hospital and the University of Education Winneba Hospital which were not part of the study centers but helped to evaluate and refine the statements. These hospitals were chosen for the pre-testing because they were the two main university hospitals in the region with the same category of nurses and perform the same activities at the antenatal care clinic as well as provide PMTCT of HIV services. Also, they were of the same level as the selected district hospitals for this study in terms of their facility and staff strength. This enabled the researchers to clarify all ambiguous questions, identify possible challenges likely to be encountered in the actual exercise and how to address them. The administered questionnaires were carefully checked by a statistician who analysed to report the reliability coefficient (Cronbach alpha coefficient reliability) for each of the items of the instrument and gave an overall Cronbach alpha for the antenatal attendees as .718 which indicated that the instrument was reliable for the study. The principal component factor analysis was used to measure content validity and any question which scored 0.3 and below was considered irrelevant and removed. The questionnaire was modified and attuned based on the responses from the pre-testing. Feedback from UNISA Health Studies Research Ethics Committee and Ghana Health Services Ethics Review Committee was used to improve questionnaire reliability. Excel was used to capture the data and Statistical Package for the Social Sciences (SPSS) version 25.0 was used for statistical analysis. Descriptive and inferential statistics were used to analyze the data. Descriptive statistics analysis was used to calculate frequencies, percentages, means, and standard deviations of independent and dependent variables, and inferential statistics analysis was used to explain respondents' perceptions of PMTCT of HIV services.

Data collection method

Data collection started from 1^st April to 3^rd May, 2020 with the use of structured questionnaires. This was done on any other day between Mondays and Fridays during working hours since there was no specific day with massive attendance because of the focus ANC which comprised of segregating antenatal attendees into those eligible to receive routine ANC care and those who needed specialized care for specific health conditions. This has resulted in the antenatal attendees attending the ANC at most four times within the nine months, hence the attendance declining and not the same throughout the week. Five professional nurses who could speak and understand Fante and English languages were recruited as research assistants for the data collection. They were trained on the purpose and objectives of the study and how to explain it well to the respondents so that they could make informed decisions. In addition, the professional nurses were taken through the research instruments by the researchers to ensure uniform understanding of the research items. This was done one week prior to the data collection (26^th March, 2020) and all the research assistants were taken through each item of the instrument and what they should expect from the respondents.

All the COVID-19 protocols such as handwashing, using sanitizers, wearing of face mask and one-meter social distancing were strictly adhered to. The research assistants distributed the questionnaires to respondents after obtaining their consent. The process took place during the ANC sessions after the antenatal attendees have gone through all the various activities. Each day, a meeting was held by the researchers to check data collection procedures, challenges and to give feedback as necessary.

Demographic Characteristics of Antenatal Attendees on PMTCT

Out of the 448 respondents, 60 (13.4%) were minors below 18 years, while 338 (86.6%) were adults aged 18 years and above. The age of the antenatal attendees ranged from 15 to 49 years. The mean age was 28.4 with a standard deviation of 11.9.

One hundred and thirteen (25.2%) of the antenatal attendees were Charismatic Christians, 132 (29.5%) were Orthodox Christians, 121 (27%) were Pentecostals, 67 (15%) were Islamic, 12 (2.7%) were traditional while 3 (0.7%) belonged to other religious affiliations, which showed that the majority (96.6%) of the antenatal attendees were affiliated with the Christian religion.

Two hundred and fifty-seven (57.4%) representing majority of the antenatal attendees were married, 173 (38.6%) were single, 17 (3.8%) were divorced while 1 (0.2%) was co-habited. Also, 214 (47.8%) of the antenatal attendees were self-employed, 44 (9.8%) were students, 93 (20.8%) were unemployed while 97 (21.7%) were civil servants. In addition, 270 (60.3%) representing the majority of the antenatal attendees had self-employed partners, 126 (28.1%) had their partners being civil servants, 13 (2.9%) had their partners been students whereas 39 (8.7%) had their partners been unemployed.

Two hundred and fifteen (48%) of the sampled antenatal attendees had basic education as their highest level of educational attainment, 76 (17.0%) had senior secondary school education, 117 (26.1%) had completed tertiary education while 40 (8.9%) had no formal education. This means that the majority (91.1%) of the antenatal attendees had attained some levels of formal education. With reference to the level of education of the partners of the antenatal attendees,158 (35.3%) had completed tertiary education, 151 (33.7%) had a basic level of education as their highest level of educational attainment, 103 (23.0%) had attained senior secondary school education while 36 (8.0%) had no formal education.

Two hundred and thirty-two (51.8%) which is a little over half of the antenatal attendees were in their third trimester (27 weeks and above), 180 (40.2%) were in their second trimester (13-26 weeks) while 36 (8.0%) were in their first trimester (3-25 weeks). The gestational age ranged from 3 weeks to 41 weeks. This showed that PMTCT of HIV services were provided for antenatal attendees with different gestational ages. The mean gestational age was 17.3 weeks with a standard deviation of 5.8.

Two hundred and twenty-nine (51.1%) of the antenatal attendees had attended ANC between one and four visits, 204 (45.5%) had attended between five and eight times whereas 15 (3.3%) had attended between 9-12 times. The number of ANC visits ranged from one to 12. The mean number of ANC visits was 4.5 with a standard deviation of 2.2.

Two hundred and thirty-one (51.6%) of the antenatal attendees reported taking medication, while 217 (48.4%) denied taking any medication.

Perceptions of antenatal attendees on PMTCT of HIV services

This section describes the perceptions of the antenatal attendees on the PMTCT of HIV services which refers to or has a similar meaning as the perception, beliefs and views towards PMTCT of HIV services. As described by [18], people's acceptance and behavior towards mother-to-child HIV prevention services are largely influenced by their perceptions. As a result, [19], suggested the need to occasionally explore the perceptions of beneficiaries on PMTCT of HIV services to ascertain their underlying views that influence their commitment to participate in the services. Table 2 presents results on the perceptions of antenatal attendees on PMTCT of HIV services.

Table 2: Perceptions of antenatal attendees on PMTCT of HIV services

Fear of stigma associated with receiving PMTCT of HIV services

The result shows that, 201(44.9%) of the antenatal attendees strongly agreed and 117 (26.1%) agreed that they feared stigmatisation associated with receiving PMTCT of HIV services. Eighty-six (19.2%) strongly disagreed and 30 (6.7%) disagreed to that opinion. Fourteen (3.1%) neither agreed nor disagreed to that opinion. Which implied that the majority (71%) of the antenatal attendees were afraid of stigmatization as they participate in PMTCT of HIV services.

Poor care from ANC nurses when tested positive

Further, 113 (25.2%) of the antenatal attendees strongly agreed and 106 (23.7%) agreed that they will receive poor care from ANC midwives when tested positive. On the other hand, 132 (29.5%) of the antenatal attendees strongly disagreed and 80 (17.9%) of them disagreed with these perceptions. Meanwhile 17 (3.8%) neither agreed nor disagreed to this perception. The result showed that a little below half (48.9%) of the antenatal attendees perceived they would be treated poorly by the midwives when tested positive. Which implies that slightly less than half (47.4%) of the antenatal attendees were against this perception.

My partner does not believe in hospital

From the study, 176 (39.3%) of the antenatal attendees strongly disagreed and 122 (27.2%) disagreed to the perception that, their partners do not believe in hospital. On the other hand, 71(15%) of the antenatal attendees strongly agreed and 71 (15%) agreed to that view. Eight (1.8%) did not indicate their opinion to that statement. The result showed that the majority (66.5%) of the antenatal attendees were not in support of that view.

The clinic is situated far away from home

From the study, 107 (23.9%) of the antenatal attendees strongly agreed and 117 (26.1%) agreed that the clinic is situated far away from home. Also,119 (26.6%) of the antenatal attendees strongly disagreed and 99 (22.1%) disagreed that the clinic is situated far away from home. Meanwhile 6 (1.3%) did not indicate their agreement to that perception. Thus, half (50%) of them accepted that distance to the ANCs was a bother to them.

I do not feel comfortable when using a condom

Out of the 448 respondents, 155 (34.6%) strongly agreed and 103 (23.0%) agreed they did not feel comfortable when using condoms. On the other hand, 97 (21.7%) of the respondents strongly disagreed and 61 (13.6%) of them also disagreed to that perception. Thirty-two (7.1%) did not indicate the level of agreement to this perception. This means that the majority (57.6%) of the antenatal attendees admitted that condom use was uncomfortable.

My partner does not like a condom

The result shows that, 183 (40.8%) of the respondents strongly agreed and 98 (21.9%) agreed that their partners do not like condom. Meanwhile, 83 (18.5%) strongly disagreed and 55 (12.3%) disagreed to that perception. Twenty-nine (6.5%) did not indicate their stand to this statement. This mean that majority of the antenatal attendees agreed that their partners did not like condoms during sexual intercourse.

Spent too much time at the ANC

Results from Table 2 further showed that 118 (26.3%) of the antenatal attendees strongly agreed and 127 (28.3%) agreed that they spent too much at the ANC. Ninety-two (20.5%) of the antenatal attendees strongly disagreed and 104 (23.2%) of them disagreed to this perception. Meanwhile 7 (1.6%) did not indicate their stand in this regard. Which showed that the majority (64.6%) of the antenatal attendees were not comfortable with the number of hours they spent at the ANC.

Table 3: Views of antenatal attendees on PMTCT of HIV services

Pregnant women should be screened for HIV

Results from Table 3 showed that, 320 (71.4%) strongly agreed and 103 (23.0%) of the antenatal attendees agreed that pregnant women should be screened for HIV. Eighteen (4.0%) disagreed and 6 (1.3%) strongly disagreed to this view. One respondent (0.2%) did not indicate her level of agreement to this view. This shows that majority (94.4%) of the antenatal attendees had developed positive attitudes towards the testing for HIV during pregnancy.

It is stressful referring HIV mothers to other services

Out of the 448 respondents, 114 (25.4%) strongly agreed and 141 (31.5%) agreed that it is stressful referring HIV mothers to other services. Also, 89 (19.9%) of them strongly disagreed and 78 (17.4%) disagreed to that perception. Twenty-six (5.8%) did not indicate their level of agreement in this regard. On the whole, the majority (56.9%) of the antenatal attendees were of the view that it is indeed stressful referring HIV mothers to other services.

HIV infected pregnant women must be delivered by skilled personnel

The results showed that 170 (37.9%) of the antenatal attendees strongly agreed and 146 (32.6%) agreed that HIV infected pregnant women must be delivered by skilled personnel. Sixty-five (14.5%) and 46 (10.3%) of the respondents disagreed and strongly disagreed to that view while 21 (4.7%) of them did not indicated their level of agreement to that view. On a whole, majority (70.5%) of the antenatal attendees had that opinion.

HIV infected women should not breastfeed their children if there is a risk of infection

Table 3 further showed that 159 (35.5%) and 133 (29.7%) of the respondents strongly agreed and agreed that HIV infected women should not breastfeed their children if there is a risk of infection. Forty-eight (10.7%) and 87 (19.4%) of them disagreed and strongly disagreed to that view while 21 (4.7%) responded don’t know to this statement.

Pregnancy should be terminated if mother is HIV infected

Out of the 488 respondents, 73 (16.3%) and 55 (12.3%) strongly agreed and agreed that pregnancy should be terminated if the mother tested positive for HIV. Forty-five (10.0%) and 236 (52.7%) disagreed and strongly disagreed to that view. Thirty-nine (8.7%) of them responded don’t know.

Table 4: Beliefs of antenatal attendees on HIV

HIV is an infection that results from a supernatural means

Out of the 488 respondents, 74 (16.5%) and 62 (13.8%) strongly agreed and agreed that HIV is an infection that results from supernatural means. Seventy-three (16.3%) and 199 (44.4%) disagreed and strongly disagreed to that cause while 40 (8.9%) responded don’t know.

HIV can be transmitted through breast milk

The results showed that 180 (40.2%) and 128 (28.6%) of the respondents strongly agreed and agreed that HIV can be transmitted through breast milk. Forty-eight (10.7%) and 49 (10.9%) of them disagreed and strongly disagreed while 43 (9.6%) responded don’t know.

HIV can be prevented by washing the vagina after sex

From table 4, 94 (21.0%) and 55 (12.3%) of the respondents strongly agreed and agreed that HIV can be prevented by washing the vagina after sex. Fifty-seven (12.7%) and 200 (44.6%) disagreed and strongly disagreed to that belief. Forty-two (9.4%) of them responded don’t know.

HIV can be prevented by the use of a condom

Out of the 488 respondents, 273 (40.9%) and 99 (22.1%) strongly agreed and agreed that HIV can be prevented by the use of a condom. Thirty-six (8.0%) and 28 (6.3%) of the respondents disagreed and strongly disagreed to that belief while 12 (92.7%) responded don’t know.

HIV can be prevented when one remains faithful to the partner

The results showed that, 252 (56.3%) and 112 (25.0%) of the respondents strongly agreed and agreed that HIV can be prevented when one remains faithful to the partner. Thirty-four (7.6%) and 40 (8.9%) of the respondents disagreed and strongly disagreed to that belief while 10 (2.2%) of them responded don’t know.

ANOVA on perceptions on PMTCT services and gestation age of antenatal attendees

The study also performed a test of difference between perceptions, beliefs and views of the antenatal attendees on PMTCT of HIV services across the gestation period. This was essential because the more one advances on the gestation stages, the more the person is taken through the PMTCT of HIV services to influence her perceptions, beliefs and views on HIV. Composite variables were created for perceptions, beliefs and views of the antenatal attendees on PMTCT of HIV services. ANOVA was used to assess the statistical significance of difference between perceptions, beliefs and views of antenatal attendees on PMTCT of HIV services across the three gestation ages (first, second and third trimesters). Prior to the performance of the ANOVA test, the study explored the skewness of the three composite distributions to establish their normality to merit parametric test. From the normality test, the skewness values for perceptions, beliefs and views of the antenatal attendees on PMTCT of HIV services were 0.59, 0.48 and 0.55, respectively. Table 5 presents results on the tests of differences.

Table 5: ANOVA on perceptions on PMTCT services and gestation age of antenatal attendees

Table 5 shows that there was a statistically significant difference in perceptions, beliefs and views among antenatal attendees across the three gestation ages (first, second and third trimesters). This is reported statistically as [F (degree of freedom of the groups) = F-statistic 8.957; p-value = 0.001: p<0.05) beliefs, [F (degree of freedom of the groups) = F-statistic 3.138; p-value = 0.025: p<0.05) and views, [F (degree of freedom of the groups) = F-statistic 3.287; p-value = 0.021: p<0.05). This was because the p-values were all within the acceptable margin of error of 0.05. The differences could be attributed to the fact that the more one advances through the gestation period, the more she undergoes the PMTCT of HIV services to improve their understanding and issues about HIV among pregnant women. Thus, lessons through the PMTCT of HIV services help to improve the perceptions, beliefs and views of antenatal attendees [20].

The main result of our study is the poor perception of antenatal attendees towards PMTCT of HIV services. Stigmatization was a key issue as they participate in PMTCT of HIV services which could sometimes discourage antenatal attendees from enrolling on PMTCT of HIV services. As suggested by [21] that stigmatization against persons living with HIV compels them to stay away from designated care and treatment centers. The results from the study indicated that majority (71%) of the antenatal attendees were afraid of stigmatization as they participate in PMTCT of HIV services. This is similar to a study by [22] who opine that fear of stigma prevent PMTCT of HIV participation hence affecting MTCT elimination. [23] were with the assertion that, HIV related stigma needs to be redressed to prevent depression among women and encourage participation in the PMTCT services.

As a result, [21] suggested the need to incorporate PMTCT of HIV services into the normal health care activities and treatment system as well as educating families and communities to avoid suspicions and stigma on patients. This suggests the need for the Ghana Health Service to build the capacity (in terms of technical and resources) of sub-district health facilities to provide PMTCT of HIV services to eliminate possible suspicions and stigmas HIV-positive pregnant mothers encounter in undergoing PMTCT services in district hospitals, while other antenatal attendees have all their issues addressed at the community-based health facilities.

Further, a slightly equal number of the antenatal attendees were of a different perception towards the care they will receive from ANC nurses when tested positive. Some were of the perception that they will be treated poorly by midwives when tested positive for HIV while the others were against that perception. These negative perceptions could discourage some of the antenatal attendees from seeking regular care and support through the PMTCT of HIV services. The result concurs with the assertion by [24], that poor handling of HIV-positive mothers at the health facilities sometimes compels them to seek alternative health care from herbal and traditional healers as well as religious institutions. In other words, poor perceptions about ANC midwives could discourage HIV-positive pregnant mothers from seeking PMTCT of HIV services, which could have serious negative implications on the government’s efforts in controlling the transmission of the infection. On the other hand, the number of antenatal attendees that had positive perceptions was also significant in the sense that, slightly less than half of the antenatal attendees disagreed with these perceptions. This implies that some of the midwives render good care and services to the antenatal attendees which could encourage HIV-positive pregnant mothers to seek PMTCT of HIV services. This is supported by the prior related behaviour of Pender’s Health Promotion Model which states that past experiences been positive or negative could affect the decision of women towards PMTCT of HIV services [25].

Partners’ support for seeking care and treatment from the hospital was very important as issues on seeking care and treatment support for HIV are sometimes planned and decided among couples [26]. This suggests that the partners of the antenatal attendees supported the care and treatment provided through the PMTCT of HIV services of the hospitals. This is likely to encourage the antenatal attendees to be regular in their attendance to PMTCT of HIV services. The implication is that the views of partners of HIV-positive pregnant mothers are very important in their decisions to access PMTCT services from health facilities. This concurs with the assertion by [27] that positive feedback from male sexual partner leads to male support, which is an important component in the uptake of PMTCT services. In contrast [28] were with the assertion that male partners views and involvement were very low hence affecting the pregnant women participation in PMTCT services. Therefore, the existing strategies to improve male involvement should be strengthened.

Another important result was that, distance to the ANCs was a bother to them. This is likely to discourage some of the antenatal attendees from being regular at the PMTCT of HIV services. This support the study by [29] that high stress associated with accessing antenatal and PMTCT of HIV services compel HIV-positive mothers to sometimes skip some of their attendance. This was very critical because pregnancy has its stress-related issues on women and as such, any additional stress caused by difficulties in accessing antenatal services sometimes becomes highly unbearable for women. The situation might even be worse among HIV-positive pregnant women who may also be undergoing psychological stress with their HIV status and societal stigma. Efforts to provide PMTCT of HIV services at the community level could therefore help to relieve HIV-positive mothers from any other psychological and physical stress they may be going through to encourage them to be more regular at PMTCT of HIV sessions.

The use of condoms helps to reduce the level of exposure of HIV-positive women and their partners to the risk of transmission and the development of further health complications in the process of treating the infection [30]. However, the antenatal attendees admitted that condom use was not comfortable and that their partners also did not like condoms. This is in consonance with the assertion by [31, 32] that condom use among people of their reproductive age is on the lower side since partners dislike it. According to them, condom use is most dependent on the male partners and most women are unable to negotiate consistent use of a condom with their partners. It is also in agreement with the assertion by [33] that majority of women avoid the use of a condom with the fear of being labelled as sex workers. This could discourage antenatal attendees from using condoms in their conjugal activities, which could also expose them and their partners to possible transmissions and complications in the treatment of the infection. The result is in variance with the assertion by [34, 33] that antenatal women always use condoms with their spouse to prevent HIV infection and that most women feel comfortable negotiating with their partners on condom use which makes them have control over the sexual encounter. According to [35], unprotected sex among persons living with HIV contributes to the high rate of transmission as well as the development of health complications associated with the treatment of the disease. [35] therefore recommended the need for continuous counselling and education among persons living with HIV to accept the use of condoms during sexual intercourse to reduce the risk of exposure to themselves and their sexual partners to prevent further complications from the infection.

The number of hours spent at the ANC was a bother to the antenatal attendees. [36] posited that waiting time for pregnnat women receiving MTCT and PMTCT care was significantly higher than the average time expected. This could add to the stress the antenatal attendees already experienced with the long-distance and difficulties in getting transportation to the hospitals for PMTCT services, which could compel them to skip some of the ANC’s schedules. This is supported by the prior related behaviour of the conceptual framework of the study which argues that waiting time at the ANCs could influence the decision of the women towards their participation in the PMTCT of HIV services [25].

The antenatal attendees had developed positive attitudes towards the testing for HIV during pregnancy. This suggests a growing acceptance and normalization of HIV testing during pregnancy which is crucial in the context of reducing stigma associated with HIV, making testing a routine part of antenatal care, and encouraging pregnant women to willingly undergo screening. This concurs with the assertion by [37, 20] that antenatal attendees had good attitude towards HIV testing. In contrast, [38, 39] were of the assertion that, pregnant women had negative attitudes towards HIV screening which may be linked to persistent stigma and discrimination associated with HIV.

According to the antenatal attendees, it was indeed stressful referring HIV mothers to other services. This stress could emanate from the fact that PMTCT of HIV services is provided at the district hospitals and as such most of the antenatal attendees had to travel from their communities to the district capitals where the district hospitals are situated to access such services. In some cases, the cost of transportation and difficulties in getting transportation also create additional psychological and physical stress for the antenatal attendees in attending PMTCT of HIV services at the district level. Such jurisdictional demarcation in accessing antenatal services sometimes creates unnecessary rumours and stigma for HIV-positive pregnant mothers as other community members begin to suspect them about their HIV status. It will therefore be very critical for the Ghana Health Service to further decentralise the provision of PMTCT of HIV services to sub-district and community health facilities to reduce the stress, suspicions and stigma that HIV-positive pregnant mothers had to go through in accessing PMTCT of HIV services. This agrees with the assertion of [40] that easy access to PMTCT of HIV services helps to encourage participation among HIV-positive pregnant mothers. [40] also indicated that the incorporation of PMTCT of HIV services into the usual antenatal services helps to reduce suspicions and stigma mostly experienced by HIV-positive pregnant women.

The antenatal attendees were also of the opinion that HIV infected pregnant women must be delivered by skilled personnel. This agrees with a study by [20, 41, 42] that it is necessary for HIV-infected pregnant women to be delivered by skilled personnel. This indicate a heightened awareness of the potential risks associated with HIV transmission during childbirth and implies that antenatal attendees within the region are informed about the benefits of professional care in reducing the risk of mother-to-child transmission. The positive opinion likely reflects trust in the expertise of skilled healthcare professionals which is crucial for ensuring that pregnant women with HIV receive the necessary medical attention, adherence to protocols, and interventions to minimize the risk of transmission and optimize both maternal and neonatal outcomes.

The study also found that, if there is the risk of infection, then breastfeeding should not be encouraged. This concurs with a study by [20] that HIV infected women should not breastfeed their children if there is a risk of infection. This implies that antenatal attendees were advocating for the avoidance of breastfeeding to minimize the risk of MTCT. Hence, formula feeding might be considered a safer alternative to breastfeeding to prevent HIV transmission. However, other studies found that HIV-positive lactating mothers were aware of the risk of HIV transmission through breastfeeding but still chose to breastfeed their infants due to the significant health advantages of breastfeeding [43].

The result from the study suggested that individuals attending antenatal clinics are generally not supportive of the idea of terminating a pregnancy solely on the grounds of the mother being HIV-infected. This is supported by the assertion by [44] that HIV positive pregnant women did not consider terminating their pregnancies. In contrast [20] were of the view that some women consider termination due to fear of transmission. This implies that there may be a prevailing sentiment among antenatal attendees that factors other than HIV status should be considered when making decisions about pregnancy termination.

The result of this study disabuses the belief that HIV is caused by supernatural means. [45] also rejected the notion that HIV is caused by supernatural factors, hence dispelling such beliefs. According to [46], the antenatal attendees possessed a strong understanding of MTCT of HIV, comprehending that a mother infected with HIV can transmit the virus to her child. [20] also argued that pregnant women were conscious of the fact that MTCT can take place during breastfeeding, pregnancy, and labor hence demonstrated a substantial understanding of HIV and its transmission routes, which suggest that they had undergone counseling and educational sessions on the topic [42].

The study found that HIV can be transmitted through breast milk. This concurs with a study by [20] who opine that antenatal attendees’ belief that HIV can be transmitted through breastfeeding. However, another study by [43] also found that HIV positive women were aware that HIV can be transmitted to their children which might influence the woman's decision to breastfeed or formula-feed. However, a significant proportion of the antenatal attendees had a different belief which reveal gaps in knowledge or misunderstandings about HIV transmission routes. Hence, educational and awareness programs should be organized during antenatal care to dispel myths and provide accurate information.

The respondents disabused with the view that HIV can be prevented by washing the vagina after sex. This is similar to a study by [47, 20] that there is no evidence that washing the vagina after sex can prevent HIV transmission. The result indicates a positive change in knowledge, as antenatal attendees seem to be corrected of the mistaken belief. This could be attributed to successful health education campaigns, interventions, or improved dissemination of accurate information among the antenatal attendees. However, [47, 20] argued that vaginal washing is a practice among pregnant women.

The respondents were of the view that, HIV can be prevented by the use of a condom which suggests that there is a positive awareness among antenatal attendees about the importance of safe sexual practices in preventing HIV transmission. This is consistent with a study by [48] that condom use is relatively high among college students and has been a key intervention in addressing the HIV pandemic which has averted millions of HIV infections. This implies that condom use is widely recognized as an effective barrier method to reduce the risk of sexually transmitted infections, including HIV. In contrast, [49] uncovered that condom use has been stigmatized as indicators of unfaithfulness. Additionally, the study conducted by [50] indicated that healthcare workers believed the absence of female condoms played a role in insufficient utilization. In summary, although certain studies demonstrated favorable views on condom use for HIV prevention, others underscored obstacles and adverse perceptions linked to condom use.

Promoting faithfulness is a primary strategy for HIV prevention [51]. This study reports that HIV can be prevented when one remains faithful to the partner. This implies that there is an open communication and trust within the antenatal attendees’ relationship which creates an environment conducive to faithfulness and contribute to HIV prevention. The result is similar to the assertion by [52] that PMTCT programs emphasize the significance of marital faithfulness as a key theme, leading to a reduction in the risk of HIV infection when spouses remain faithful.

Limitation of the study

Engaging the antenatal attendees at the health facilities right after ANC services was not appropriate, since one is more likely to be influenced by her experience for the day, which might not be a true reflection of the entire PMTCT of HIV services. The cross-sectional nature of the study which takes a snapshot of data for action without engaging the respondents to track changes in the assessment of a phenomenon was also another limitation [53].

The respondents were engaged at a single point in time in their assessment of the PMTCT of HIV services in the Central Region of Ghana. However, using cross-sectional design in the assessment of such programs could not guarantee fairness as respondents are more likely to be influenced by their recent interactions with the program. The COVID-19 pandemic which came into Ghana at the time of data collection caused a delay in the data collection process since most of the district hospitals were not allowing entry into their facilities. It also affected the time spent with each respondent since the more time spent with someone or outside the home increases the risk of getting infected. As a result, in-depth communication with the respondents was affected but the researcher managed to adhere to the COVID-19 protocols and put on the required personal protective equipment to go through the data collection process successfully. Generalization of the results to the whole of the Ghanaian population is not possible since only one region out of the 16 regions in Ghana was used for the study.

The above results indicated that the antenatal attendees had poor perception of PMTCT of HIV services. Thus, they had the perceptions of receiving poor care from ANC midwives, feared been stigmatized when tested positive, hospitals located far from their homes, not comfortable with the use of condoms to prevent further spread and complications, spending too much time during ANC sessions and stressful referring HIV mothers to other services. The poor perceptions about the PMTCT of HIV services generally emanated from the recommended changes in their lifestyles to effectively accommodate their situation to uphold the tenets of PMTCT, while others emanated from discomfort in accessing PMTCT of HIV services. Therefore, in order to encourage HIV-positive mothers to attend such meetings, health professionals should be more tolerant and welcoming during PMTCT of HIV services. This is important because some of the women might be facing stigma in their families and communities and may seek consolation from health care professionals to lead responsible lives that will help to prevent further spread of the infection.

ANC: antenatal care; AIDS: Acquired Immunodeficiency Syndrome; ANOVA: Analysis of Variance; HIV: Human Immunodeficiency Virus; HPM: Health Promotion Model; MTCT: Mother-to-Child-Transmission; PLWHA: People Living with HIV/AIDS; PMTCT: Prevention of Mother-to-Child-Transmission; TPB: Theory of Planned Behavior.

None.

Acknowledgements

The authors would like to thank the Central Regional Health Directorate of Ghana, the selected district hospitals in the Central Region of Ghana and all the individuals who supported the project, as well as the respondents who provided valuable information and other health care professionals who assisted in the data collection processes.

Author contributions

ROD contributed to the conception of the study, the analysis and interpretation of data and the drafting of the manuscript. DSK was the study supervisor and contributed to the drafting of the manuscript as well as provided critical revision of the manuscript.

Ethical considerations

Respondents were fully informed about the purpose of the study, the potential risks and benefits of participating, and their right to withdraw from the study at any time. Informed consent was obtained in writing and verbally, depending on the local regulations and the respondent's preferences. Confidentiality was protected at all times and steps were taking to ensure that respondents' data were kept confidential and that they were not identified in any publications or presentations resulting from the study. The researchers took steps to minimize any potential risks and ensured that respondents have access to appropriate support and counseling if needed. Researchers ensured that respondents had the opportunity to ask questions, and that their concerns were addressed in a timely and respectful manner. Although the data collection process could be time-consuming, respondents were informed that the information collected would help prevent innocent children from becoming infected with HIV. In addition, the data collected would be used only for the purposes for which it was collected and confidentiality would be maintained. Respondents under the age of 18 were considered minors and parental consent were sought on their behalf. Ethical approval was obtained from the Health Studies Research Ethics Committee (HSREC) of the Department of Health Studies, University of South Africa. Institutional consent was also obtained from the Ghana Health Services Ethics Review Committee after the researchers had applied. On the other hand, permission was obtained from the Regional Health Directorate in the Central Region of Ghana, the district hospitals in the region as well as the respondents of the antennal care clinics. The institutions were assured of obtaining the respondents consent before providing them with the questionnaires. All sources of information were cited according to the university standards and style and data fabrication was avoided.

Consent for publication

This is not available.

Data availability

The data that support the results of this study are available from the corresponding author upon reasonable request.

Finding

None.

Conflicts of Interest

None

Bhatta M, Dutta N, Nandi S, Dutta S, Saha MK. Mother-to-child HIV transmission and its correlates in India: Systematic review and meta-analysis. BMC Pregnancy and Childbirth. 2020;20(1), 1–15. https://doi.org/10.1186/s12884-020-03193-3.
Gona PN, Gona CM, Ballout S, Rao SR, Kimokoti R, Mapoma CC, Mokdad AH. Burden and changes in HIV/AIDS morbidity and mortality in Southern Africa Development Community Countries, 1990-2017. BMC Public Health. 2020;20(1), 1–14. https://doi.org/10.1186/s12889-020-08988-9.
Owusu AY. A gendered analysis of living with HIV/AIDS in the Eastern Region of Ghana. BMC Public Health. 2020; 20(1), 1–15. https://doi.org/10.1186/s12889020-08702-9.
UNAIDS. FACT SHEET 2021 Global Hiv Statistics. Ending the AIDS Epidemic, June, 1–3. 2021.
Ghana AIDS Commission. National Prevalence of HIV and AIDS. 1–15. http://www.ghanaids.gov.gh/gac1/pubs/EXPRESSION OF INTEREST SUB PROJECT.pdf. 2019.
Ghana AIDS Commission. National HIV and AIDS Strategic Plan. 1–8. http://www.ghanaids.gov.gh/gac1/pubs/EXPRESSION OF INTEREST SUB PROJECT.pdf. 2018.
O’Sullivan OP, Chang NH, Njovana D, Baker P, Shah A. Quality improvement in forensic mental health: the East London forensic violence reduction collaborative. BMJ Open Quality. 2020;9(3), 1–7. https://doi.org/10.1136/bmjoq-2019-000803.
Bansaccal N, Van der Linden D, Marot JC, Belkhir L. HIV-Infected Mothers Who Decide to Breastfeed Their Infants Under Close Supervision in Belgium: About Two Cases. Frontiers in Pediatrics. 2020;8(May),1–5. https://doi.org/10.3389/fped.2020.00248.
Mutabazi JC, Gray C, Muhwava L, Trottier H, Ware LJ, Norris S, Murphy K, Levitt N, Zarowsky C. Integrating the prevention of mother-to-child transmission of HIV into primary healthcare services after AIDS denialism in South Africa: perspectives of experts and health care workers - a qualitative study. BMC Health Services Research. 2020;20(1), 582. https://doi.org/10.1186/s12913-020-05381-5.
Choi WA, Sakeah E, Oduro AR, Aburiya JBA, Aborigo RA. Compliance to HIV testing and counseling guidelines at antenatal care clinics in the Kassena-Nankana districts of northern Ghana: A qualitative study. PLoS ONE. 2022;17(9 September), 1–19. https://doi.org/10.1371/journal.pone.0274871.
Ali H, Amoyaw F, Baden D, Durand L, Bronson M, Kim A, Grant-greene Y, Imtiaz R, Swaminathan M. Ghana’ s HIV epidemic and PEPFAR’s contribution towards epidemic control. 2019;53(1), 59–62.
Nordberg B, Gabriel EE, Were E, Kaguiri E, Ekström AM, Kågesten A, Rautiainen S. Social concerns related to HIV status disclosure and participation in the prevention of mother-to-child transmission of HIV care among pregnant women in Kenya. BMC Pregnancy and Childbirth. 2020; 20(1), 1–https://doi.org/10.1186/s12884-020-02907-x.
Butts JB, Rich KL. Philosophies and theories for advanced nursing practice (3rd ed.). [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781284143010. 2018.
Bukhari SAR. Sample Size Determination Using Krejcie and Morgan Table. Kenya ProjectsOrganization(KENPRO),February,607–610. https://doi.org/10.13140/RG.2.2.11445.19687. 2021.
Ogundimu EO, Collins GS. A robust imputation method for missing responses and covariates in sample selection models. Statistical Methods in Medical Research. 2019;28(1), 102–116. https://doi.org/10.1177/0962280217715663.
Sun J, Yan L. Using topic modeling to understand comments in student evaluations of teaching. Discover Education. 2023;2(1).https://doi.org/10.1007/s44217-023-00051-0.
Einola K, Alvesson M. Behind the Numbers: Questioning Questionnaires. In Journal of Management Inquiry. 2021;30(1)102–114). https://doi.org/10.1177/1056492620938139.
Opoku-Danso R, Habedi DSK. Midwives’ perceptions of and attitudes towards prevention of mother-to-child-transmission of HIV. Curationis. 2023;46(1),1–11. https://doi.org/10.4102/curationis.v46i1.2353.
Phislemon RN, Mmbaga BT, Bartlett J, Renju J, Mtuy T, Mboya IB, Msuya SE. Do women enrolled in PMTCT understand the recommendations: A case study from Kilimanjaro. Patient Preference and Adherence. 2021;15(April),1301–1309. https://doi.org/10.2147/PPA.S307847.
Yeshaneh A, Abebe H, Tafese FE, Workineh A. Knowledge, attitude, and practice towards prevention of mother-to-child transmission of HIV among antenatal care attendees in Ethiopia, 2020 PLoS ONE. 2023; 18(2 February), 1–15. https://doi.org/10.1371/journal.pone.0277178.
Fauk NK, Hawke K, Mwanri L, Ward PR. Stigma and discrimination towards people living with hiv in the context of families, communities, and healthcare settings:A qualitative study in indonesia. International Journal of Environmental Research and Public Health. 2021;18(10). https://doi.org/10.3390/ijerph18105424.
Breton G, Diallo OH, Cissé M, Diallo OH, Diallo NA, Soumaoro SA, Camara Y, Montoyo A, Rouzioux C, Koita Y, Peytavin G, Tubiana R, Frange P, Basla J, Becquet R, D’Ortenzio E,Tubiana R. HIV stigma limits the effectiveness of PMTCT in Guinea: the ANRS 12344-DIAVINA study. Journal of Antimicrobial Chemotherapy. 2022; 77(11), 3093–3101. https://doi.org/10.1093/jac/dkac287.
Yator O, Mathai M, Albert T, Kumar M. Burden of HIV-Related Stigma and Post-Partum Depression: A Cross-Sectional Study of Patients Attending Prevention of Mother-to-Child Transmission Clinic at Kenyatta National Hospital in Nairobi. Frontiers in Psychiatry. 2021; 11(February), 1–12. https://doi.org/10.3389/fpsyt.2020.532557.
Egbe TO, Nge CA, Ngouekam H. Stigmatization among people living with HIV/AIDS at the Kumba Health District, Cameroon. Journal of the International Association of Providers of AIDS Care (JIAPAC). 2020; https://doi.org/10.1177/2325958219899305.
Travis K. UNM Digital Repository: Application of Pender ’ s Health Promotion Model in Preventing Pediatric Unintentional Injury and Booster Seat Use. 2020.
Sack DE, Seabi TM, Frisby MB, Diemer M.A, Ndlovu GH, Wagner RG, Audet C M. Exploratory validation of relationship functioning and non-pregnant partner behavior scales in pregnant people living with HIV in Mpumalanga Province, South Africa. Global Health Action. 2023; 16(1). https://doi.org/10.1080/16549716.2023.2210882.
Mkandawire AK, Jumbe V, Nyondo-Mipando AL. To disclose or not: experiences of HIV infected pregnant women in disclosing their HIV status to their male sexual partners in Blantyre, Malawi. BMC Public Health. 2022;22(1), 1–14. https://doi.org/10.1186/s12889-022-13974-4.
Melis T, Fikadu Y. Magnitude and determinants of male partner involvement in PMTCT service utilization of pregnant women attending public health facilities of Ethiopia, 2021: a systematic review and meta-analysis. AIDS Research and Therapy. 2022; 19(1), 1–7. https://doi.org/10.1186/s12981-022-00436-5.
Appiah SCY, Kroidl I, Hoelscher M, Ivanova O, Dapaah JM. A phenomenological account of HIV disclosure experiences of children and adolescents from Northern and Southern Ghana. International Journal of Environmental Research and Public Health. 2019;16(4). https://doi.org/10.3390/ijerph16040595.
UNAIDS. Country Progress Report on 90-90-90-Ghana.1–42. https://www.unaids.org/sites/default/files/country/documents/GHA_2019_countryr eport.pdf.
Ajayi AI, Ismail KO, Akpan W. Factors associated with consistent condom use: A cross-sectional survey of two Nigerian universities. BMC Public Health. 2019;19(1), 1–11. https://doi.org/10.1186/s12889-019-7543-1.
Kanda L, Mash R. Reasons for inconsistent condom use by young adults in Mahalapye, Botswana. African Journal of Primary Health Care and Family Medicine. 2018;10(1), 1–7. https://doi.org/10.4102/phcfm.v10i1.1492.
Brody C, Reno R, Chhoun P, Kaplan K, Tuot S, Yi S. Female Entertainment Workers and Condom Use Negotiation in Post-100% Condom Use Era Cambodia. Archives ofSexual Behavior.2020;49(8),3065–3074. https://doi.org/10.1007/s10508-020-01649-3.
Mukhtar M, Quansar R, Bhat SN, Khan, SMS. Knowledge, attitude and practice regarding mother-to-child transmission of HIV, its prevention, and associated factors among antenatal women attending a health care facility in district Srinagar, North India: a cross sectional study. International Journal Of Community Medicine And Public Health. 2020;7(7), 2622.https://doi.org/10.18203/2394- 6040.ijcmph20202987.
Govender K, Masebo WGB, Nyamaruze P, Cowden RG, Schunter BT, Bains A. HIV Prevention in Adolescents and Young People in the Eastern and Southern African Region: A Review of Key Challenges Impeding Actions for an Effective Response.TheOpenAIDSJournal.2018;12(1),53–67. https://doi.org/10.2174/1874613601812010053.
Zegeye B, Lemma G, Balcha A, Taderegew MM. Prevention of Mother-to-Child HIV Transmission Service Utilization among Pregnant Women in Northeast Ethiopia: A Cross-Sectional Survey. Scientifica, 2020. https://doi.org/10.1155/2020/7584975.
Elsiddig Elsheikh I, Crutzen R, Adam I, Ibrahim Abdelraheem S, Van den Borne HW. Determinants of HIV Testing during Pregnancy among Pregnant Sudanese Women: A Cross-Sectional Study. Behav. Sci. 2022, 12, 150. https://doi.org/10.3390/bs12050150.
Irinyenikan TA. Knowledge and practice of HIV testing for PMTCT among antenatal clinic attendees. Trop J Obstet Gynaecol 2019;36:232‑7.
Jahangiry L, Aliyari Z, Ponnet K. A Study on the Knowledge, Attitudes, and Behaviors of Pregnant Women Regarding HIV and Routine Rapid Testing: An Assessment in a High-Risk Marginal Area. Healthcare. 2021;9, 793. https:// doi.org/10.3390/healthcare9070793.
Akal CG, Afework DT. Status of Prevention of Mother-to-Child Transmission (PMTCT) Services Utilization and Factors Affecting PMTCT Service Uptake by Pregnant Women Attending Antenatal Care Clinic in Selected Health Facilities of Afar Regional State, Ethiopia. Journal of Environmental and PublicHealth. 2018; https://doi.org/10.1155/2018/5127090.
Lucas Viana Roly D, Rodrigues da Silva N, Gomes da Silva S, Erson Allyson Gomes Ferreira J, Carolina Salustino dos Santos M, Corrêa Bezerra de Araújo R. (n.d.). O ENFERMEIRO COMO PRINCIPAL ORIENTADOR EM SAÚDE DAS GESTANTES PORTADORAS DO VÍRUS HIV THE NURSE AS MAIN HEALTH ADVISOR OF PREGNANT WOMEN WITH THE HIV VIRUS Nathalia Claudino do Nascimento 6 Pollyana Lima Nogueira 7.
Haruna TS, Assenga E, Shayo J. A qualitative study on the voluntariness of counselling and testing for HIV amongst antenatal clinic attendees: Do women have a choice? BMC Medical Ethics. 2018;19(1), 1–10. https://doi.org/10.1186/s12910-018-0329-7.
Sarah N. Awareness and attitude of HIV-positive lactating mothers towards breast feeding at Kabwohe health center IV, Sheema district. Idosr Journal of Science and Technology. 2023;9(2), 33–51. https://doi.org/10.59298/idosr/jst/03.1.12003.
Maccarthy S, Maccarthy S, Rasanathan J, Crawford-roberts A, Dourado I. (n.d.). University of Southern California Law Contemplating Abortion : HIV-Positive Women ’ s Decision to Terminate Pregnancy Contemplating Abortion : HIV-Positive Women’ s Decision to Terminate Pregnancy.
Workagegn F, Kiros G, Abebe L. Predictors of HIV-test utilization in PMTCT among antenatal care attendees in government health centers: Institution-based cross-sectional study using health belief model in Addis Ababa, Ethiopia, 2013. HIV/AIDS -Research and Palliative Care. 2015; 7, 215–222. https://doi.org/10.2147/HIV.S82000.
Njah J, Chiasson MA, Reidy W. Known HIV status among adolescent women attending antenatal care services in Eswatini, Ethiopia and Mozambique. Reproductive Health. 2021;18(1), 1–8. https://doi.org/10.1186/s12978-021-01090-2.
Nkamedjie Pete PM, Mabvouna Biguioh R, Bita Izacar A. G, Béchir Adogaye S, Ben Nguemo C. Genital hygiene behaviors and practices: A cross-sectional descriptive study among antenatal care attendees. Journal of Public Health in Africa. 2019; 10(1). https://doi.org/10.4081/jphia.2019.746.
Teffo ME, Mokgatle MM. Assessing Condom Use and Views on HIV Counselling and Testing among TVET College Students in Limpopo Province, South Africa. International Journal of Environmental Research and Public Health. 2023;20(11). https://doi.org/10.3390/ijerph20116044.
Broderick K, Aristide C, Bullington BW, Mwanga-Amumpaire J, Downs JA, Sundararajan R. Stigma of infidelity associated with condom use explains low rates of condom uptake: qualitative data from Uganda and Tanzania. Reproductive Health. 2023;20(1), 1–8. https://doi.org/10.1186/s12978-023-01563-6.
Mashanda-Tafaune B, Monareng LV. Perception and attitude of healthcare workers towards the use of a female condom in Gaborone, Botswana. Health SA Gesondheid. 2016;21,162–170. https://doi.org/10.1016/j.hsag.2015.12.002.
Singleton R, Billaud M, McLeod H, Tiendrebeogo G, Dia F, Obong’o C, Nkambule Vilakati S, Mbakwem B, Sabben G, Winskell K. Making sense of fidelity: young Africans’ cross-national and longitudinal representations of fidelity and infidelity in their HIV-related creative narratives, 1997-2014. SAHARA J : Journal of Social Aspects of HIV/AIDS Research Alliance. 2021; 18(1), 86–97. https://doi.org/10.1080/17290376.2021.1950042.
Chibango V. Exploring the meanings of male partner involvement in the prevention of MTCT of HIV in Zimbabwe. HTS Teologiese Studies / Theological Studies. 2020; 76(3), 1–9. https://doi.org/10.4102/hts.v76i3.6023.
Cowell JM. Publishing Cross-Sectional Studies. Journal of School Nursing. 2020; 36(1), 6–7. https://doi.org/10.1177/1059840519896452.

Table 1: Population and Sample Size across district hospitals in the Central Region

District Population of

hospitals pregnant

women

Sample size

Abura Dunkwa Hospital 3696

Ajumako District Hospital 5448

Cape Coast Metropolitan Hospital 6289

Dunkwa Municipal Hospital 10286

St. Francis Xavier 10279

St. Luke Catholic Hospital 4676

Swedru Government Hospital 14093

Praso Government Hospital 10803

Saltpond Hospital 5485

Our Lady of Grace 9388

Winneba Municipal Hospital 10462

18

26

31

51

23

71

54

27

46

52

Total 90905

450

Source: District Health Information Management System (DHIMS), 2018

Table 2: Perceptions of antenatal attendees on PMTCT of HIV services

Perceptions	Responses	Frequency	Percentage
Fear of stigma associated with receiving PMTCT of HIV services	Strongly agree	201	44.9
	Agree	117	26.1
	Disagree	30	6.7
	Strongly disagree	86	19.2
	Don’t know	14	3.1
	Total	448	100.0
Poor care from ANC nurses when tested positive	Strongly agree	113	25.2
	Agree	106	23.7
	Disagree	80	17.9
	Strongly disagree	132	29.5
	Don’t know	17	3.8
	Total	448	100.0
My partner does not believe in hospital	Strongly agree	71	15.8
	Agree	71	15.8
	Disagree	122	27.2
	Strongly disagree	176	39.3
	Don’t know	8	1.8
	Total	448	100.0
The clinic is situated far away from home	Strongly agree	107	23.9
	Agree	117	26.1
	Disagree	99	22.1
	Strongly disagree	119	26.6
	Don’t know	6	1.3
	Total	448	100.0
I do not feel comfortable when using a condom	Strongly agree	155	34.6
	Agree	103	23.0
	Disagree	61	13.6
	Strongly disagree	97	21.7
	Don’t know	32	7.1
	Total	448	100.0
My partner does not like a condom	Strongly agree	183	40.8
	Agree	98	21.9
	Disagree	55	12.3
	Strongly disagree	83	18.5
	Don’t know	29	6.5
	Total	448	100.0
Spent too much time at the ANC	Strongly agree	118	26.3
	Agree	127	28.3
	Disagree	104	23.2
	Strongly disagree	92	20.5
	Don’t know	7	1.6
	Total	448	100.0

Source: Field survey (2020)

Table 3: Views of antenatal attendees on PMTCT of HIV services

Views	Responses	Frequency	Percentage
Pregnant women should be screened for HIV	Strongly agree	320	71.4
	Agree	103	23.0
	Disagree	18	4.0
	Strongly disagree	6	1.3
	Don’t know	1	.2
	Total	448	100.0
It is stressful referring HIV mothers to other services	Strongly agree	114	25.4
	Agree	141	31.5
	Disagree	78	17.4
	Strongly disagree	89	19.9
	Don’t know	26	5.8
	Total	448	100.0
HIV infected pregnant women must be delivered by skilled personnel	Strongly agree	170	37.9
	Agree	146	32.6
	Disagree	65	14.5
	Strongly disagree	46	10.3
	Don’t know	21	4.7
	Total	448	100.0
HIV infected women may not breastfeed their children if there is a risk of infection	Strongly agree	159	35.5
	Agree	133	29.7
	Disagree	48	10.7
	Strongly disagree	87	19.4
	Don’t know	21	4.7
	Total	448	100.0
Pregnancy should be terminated if mother is HIV infected	Strongly agree	73	16.3
	Agree	55	12.3
	Disagree	45	10.0
	Strongly disagree	236	52.7
	Don’t know	39	8.7
	Total	448	100.0

Source: Field survey (2020)

Table 4: Beliefs of antenatal attendees on HIV

Beliefs	Responses	Frequency	Percentage
HIV is an infection that results from a supernatural means	Strongly agree	74	16.5
	Agree	62	13.8
	Disagree	73	16.3
	Strongly disagree	199	44.4
	Don’t know	40	8.9
	Total	448	100.0
HIV can be transmitted through breast milk	Strongly agree	180	40.2
	Agree	128	28.6
	Disagree	48	10.7
	Strongly disagree	49	10.9
	Don’t know	43	9.6
	Total	448	100.0
HIV can be prevented by washing the vagina after sex	Strongly agree	94	21.0
	Agree	55	12.3
	Disagree	57	12.7
	Strongly disagree	200	44.6
	Don’t know	42	9.4
	Total	448	100.0
HIV can be prevented by the use of a condom	Strongly agree	273	60.9
	Agree	99	22.1
	Disagree	36	8.0
	Strongly disagree	28	6.3
	Don’t know	12	2.7
	Total	448	100.0
HIV can be prevented when one remains faithful to the partner	Strongly agree	252	56.3
	Agree	112	25.0
	Disagree	34	7.6
	Strongly disagree	40	8.9
	Don’t know	10	2.2
	Total	448	100.0

Source: Field survey (2020)

Table 5: ANOVA on perceptions on PMTCT services and gestation age of antenatal attendees

Perceptions	Statistics	Sum of squares	Df	Mean square	F	Sig.
Perceptions	Between groups	32.283	2	10.761	8.957	0.001
	Within groups	533.396	445	1.201
	Total	565.679	447
Beliefs	Between groups	3.886	2	1.295	3.138	0.025
	Within groups	183.255	445	0.413
	Total	187.141	447
Views	Between groups	15.119	2	5.040	3.287	0.021
	Within groups	680.825	445	1.533
	Total	695.944	447

Source: Field survey (2020)

No competing interests reported.

Perceptions of Antenatal Attendees on Prevention of Mother-to-Child Transmission of Human Immunodeficiency Virus (HIV) Services in the Central Region of Ghana.

Status:

Version 1

Abstract

Figures

BACKGROUND

METHODS

RESULTS

Perceptions of antenatal attendees on PMTCT of HIV services

DISCUSSION

CONCLUSION

Abbreviations

Declarations

Ethical considerations

References

Tables

Additional Declarations

Status:

Version 1