Characteristics of the ANCs and Study Participants.
Table 3 summarises the characteristics of the 12 ANCs. The clinics were owned by private entities (n = 5) or the government (n=7). Privately owned clinics were more likely to be in semi-urban areas. Eight clinics, distributed equally among private and government hospitals, served 1000 to 2000 pregnant women annually. A privately owned clinic in a semi-urban setting served less than 1,000 pregnant women in a year. Public hospitals recorded a higher workload per week per clinical staff than their counterparts in private facilities (61 clients per provider in the public clinic versus 33 clients per provider in private facilities). Both public and private clinics universally provide focused ANC and group health talks, with private clinics leading in additional lab services (60%). Government clinics average more clinicians (mean: 3) and perform more HIV tests per staff (mean: 60.7) compared to private clinics (mean: 2 and 33, respectively).
Table 3 Profile of clinics included in this study.
Clinic variable
|
Government (n=7)
|
Private (n=5)
|
Location
|
|
|
|
Urban
|
5(71.4)
|
3(60)
|
|
Semi-urban
|
2(28.6)
|
2(40)
|
Estimated clinic attendance
|
|
|
|
>2000/month
|
3(42.9)
|
0(0.0)
|
|
1000-2000/month
|
4(57.1)
|
4(80)
|
|
<1000/month
|
0 (0.0)
|
1(20)
|
ANC -related services
|
|
|
|
Focused ANC, n (%)
|
7(100)
|
4(80)
|
|
A group health talk, n (%)
|
7(100)
|
5(100)
|
|
History taking & physical examination, n (%)
|
7(100)
|
5(100)
|
|
Lab services (e.g. syphilis, malaria, G6PD), n (%)
|
3(42.9)
|
3(60)
|
|
Time spent in delivering health talk, mean (SD)
|
19(3.7)
|
18(2.8)
|
|
Size of a group for a health talk, mean (SD)
|
41(18)
|
61(11)
|
HIV-related services
|
|
|
|
The opt-out offer of HIV test, n (%)
|
7(100)
|
5(100)
|
|
HIV service available 5 days/week, n (%)
|
6(85.7)
|
2(40)
|
|
Rapid HIV testing, n (%)
|
7(100)
|
5(100)
|
|
Information about HIV testing giving during health talk (Yes), n (%)
|
7(100)
|
5(100)
|
|
Positive test results confirmed at ANC, n (%)
|
4(57.1)
|
1(20)
|
|
Initiation of ART for pregnant women testing positive for HIV (Yes), n (%)
|
4(57.1)
|
1(20)
|
|
HIV testing performed by ANC staff, n (%)
|
6(85.7)
|
1(20)
|
|
HIV testing performed by dedicated staff outside the ANC, n (%)
|
2(28.6)
|
3(60)
|
Human resource capacity
|
|
|
|
No clinicians (mean, range)
|
3(0-18)
|
2(0-4)
|
|
No of nurses (mean, range)
|
10 (3-30)
|
9(3-20)
|
|
No of HIV testing pregnant women/week (range)
|
426.3(260-1153)
|
392.3(175-459.3)
|
|
No of weekly HIV testing clients/staff (range)
|
60.7 (32.8-103.3)
|
33(27-41)
|
ANC=ANC; HIV=Human Immunodeficiency virus Source: ANC register/field notes
Table 4: Qualitative Findings Summary: ANC Context, Complexity, Facilitation, and Responsiveness.
Main category
|
Sub-themes
|
Example quotes
|
Context
|
Structural organisation of ANC
|
"The room is too small, and the patients are many. How do we follow the many things contained in the guidelines?" (Focus group participant 5; Public hospital)
|
ANC communication strategies
|
"We do not provide much detail" (Nurse # 10; Public hospital)
|
Dominant ‘sake of the child’ narrative
|
"Once I mention the unborn child, they agree to test. No woman will allow her child to be infected with the deadly virus" (Midwife #6; Private hospital)
|
Institutional coercion and fear of consequences
|
"The midwife said the test is a government's initiative, so every pregnant woman must be tested, maybe that is why she did not ask whether I will do it or not. She must do it to not get into trouble" (Pregnant woman #6; Public hospital)
|
Complexity
|
Opt-out intervention poorly understood
|
"I know testing is routine, which means we should test all women coming to the clinic. For the opt-out, I have not heard about that" (Midwife #2 public)
|
Facilitation
|
Guideline availability and utilization
|
"There is nothing to guide what exactly to tell the women...we communicate different things to them" (FGD participant #1, Public hospital)
|
Training and skill development challenges
|
"The training was many years ago when they showed us the new ways of testing women. Since then, I have not had the opportunity to receive further training" (Midwife #5, Public Hospital)
|
Supervision and feedback deficiencies
|
"They usually check to see whether we are doing the entries well or not. They collect our register and check entries to see if they match what they came with from the region. They never enter the testing room to see what is going on there" (HCP # 6; Private hospital)
|
Logistical challenges
|
"the OraQuick is scarce in this hospital, so the ART coordinator usually gives us about 10, which last for about a month depending on the number of positive results we get" (Nurse manager #3; private hospital)
|
Responsiveness
|
Stakeholder views on intervention
|
"GAC officials considered themselves adopters of the policy and therefore emphasised strict adherence. Officers of NACP, responsible for translating the policy into practice, advocated flexibility in implementing the policy" (Text summary)
|
Providers' perception of the intervention
|
"Most of my students are incredibly good at pricking and applying the buffer. Rapid testing does not need any technical expertise. They will let me know if they have problems. If a woman tested positive, they know what to do. They will usually discard that test kit and then refer the woman to me. I will do the test again and then disclose it. Disclosing test results is beyond them" (Midwife #6, Private hospital)
|
Context of the ANC
Structural Organisation of the ANC as a Moderator of Adherence
Some clinics fully or partially integrated HIV testing, while others had standalone or makeshift testing spaces. In clinics with fully integrated testing, the test is often in the same room where standard ANC services occur. Most of the consulting rooms were often small, overcrowded, and poorly ventilated, which compromised auditory and visual privacy: The room was too small, and the patients were many. How do we follow the many things contained in the guidelines? (Focus group participant 5; Public hospital). It was a common practice for two midwives to see two women simultaneously in the same consulting room. A midwife explained: Because of inadequate space and many patients, one midwife is doing palpation while the other will be consulting with a second patient (Nurse #2, Public Hospital). Ensuring that the process was confidential had not been possible in these spaces. One midwife revealed that many women testing positive for HIV cry inconsolably, and this draws attention to the positive test result. The midwife would have to come up with a strategy to create private space:
When the test is positive, we ask the other woman to go out so that we talk to the client alone. Sending them out does not even help the situation, as most of them have been in this room and have received their negative test results in front of other women, so why is she sending us out now? They then wait outside for the woman to come out (Focus Group participant #4; Public Hospital).
Two hospitals had makeshift spaces designed at the back of the ANC where testing occurred. Such a setup made it problematic for the midwife when a woman tests positive for HIV: Some may cry, but we make sure they don’t get out of the consulting room; otherwise, others would know that something has gone wrong. We usually keep talking to them until they are relaxed before going out (Nurse-Midwife #1; Public hospital). Some women expressed a desire to have their HIV testing separated from the regular services: If I had gone specifically for the HIV test, then I would expect it to be confidential. The midwife would not have allowed another woman to be in the same consulting room (Pregnant woman #20; Public hospital).
Delivering and receiving the required pre-test information was hampered by the large group size: we used to discuss the test when the groups were small. Today, the group you saw, do you think we can discuss HIV testing there? (Focus group participant #7; Public hospital). In two ANCs, HCPs dealt with the large client numbers by practising what they referred to as rapid group testing. With this approach, HCPs called all the women queuing for an HIV test into the counselling room at one time. They then pricked each, put the sample on the test kit, and labelled them. The health professional then called the women one after the other and delivered the results to them. The practice appears time-saving but could lead to incorrect results: We once had three women with the same surname. One was positive. When we called the first name, we later realised that the positive individual was still sitting there (Focus group participant #6; Private hospital).
ANC Communication Strategies and Power Imbalances
Limited Autonomy in Decision-Making: Our interviews and clinic observation revealed that HCPs relied on an unbalanced power relationship to control the amount of HIV-related information delivered: I am careful not to give the women a lot of information or even ask them whether they have questions, especially the educated ones. We must not act weak; otherwise, they will have the opportunity to say 'no’ (Focus group participant #3; Private hospital). HCPs offer highly scripted, procedural, and often closed-ended information: Mostly, we tell them what we do here and ask them whether they want to test. We do not provide much detail (Nurse # 10; Public hospital). A pregnant woman testing considered the HCP's approach to the test offer rather directive: 'She (the midwife) told me to sit down. She said, ‘Can you give me your hand’? I need some blood to do something' (Pregnant woman #3; Public hospital). Some of the women expected more information about the gravity of an HIV-positive diagnosis than they received. Some women complained about being tested without prior knowledge. A woman from a public hospital expressed frustration, stating, I expected the midwife to at least tell me she was about to test me for HIV and apologise for the needle prick being a bit painful. The midwives and nurses treat us like we know everything (Pregnant woman #10; Public hospital). Despite this expectation for additional information, none of the women interviewed explicitly requested it. Some women mentioned that undergoing HIV testing without prior notice was the rule in the clinic (Pregnant women #16; Public hospital). For some, asking questions felt like disobeying provider instructions: What the midwives say is what holds. They (HCPs) would not be happy if one kept asking them what they were doing (Pregnant woman #2; Private hospital).
Dominant ‘sake of the child’ narrative: Interviews with HCPs and women revealed a reliance on the sake of the child message when presenting HIV tests. Midwives appear to exploit the value Ghanaian women place on delivering a healthy baby to influence their decision to test: Once I mention the unborn child, they agree to test. No woman will allow her child to be infected with the deadly virus (Midwife #6; Private hospital). This approach is reflected in women's narratives about the test's benefits, where most could only mention how it may protect the unborn child. A woman at an ANC in a private facility shared her experience: The midwife explained that she was doing the test because it would help the child in my womb. She said even if I have the virus, they have medicine to prevent the child from getting the disease (Pregnant woman #1; Private hospital). For many of the women interviewed, protecting the unborn child became the main reason for testing. Many believed that being pregnant meant losing control over one's body: 'When you become pregnant, you do not have your will, all the labs become compulsory for you (Pregnant woman #17; Public hospital). Considering their bodies are reservoirs for HIV, these women considered it their responsibility to get tested: I know the blood in me is what the child uses, so if I’m positive and do not get the treatment the innocent child would suffer (Pregnant woman #19; public hospital). Protecting the unborn child became the professional responsibility of the midwife: Most of these women had the disease through having multiple sexual partners. As a midwife, I could not look on while the poor child became infected (Midwife # 9; Public Hospital).
Institutional coercion and fear of consequences: HCPs often framed the HIV test as unavoidable, citing it as an order from the doctor or a government policy. This strategy, mentioned by a participant in a focus group (Focus group participant #7), emphasises the compulsory nature of the test in ANCs. A pregnant woman wanting further services may feel compelled to comply, as one expressed, The midwife said the test is a government initiative, so every pregnant woman must be tested, maybe that is why she did not ask whether I would do it or not. She must do it to not get into trouble (Pregnant woman #6; Public hospital). Considering the HIV test as a government policy essential for subsequent care, some women feared lacking proper treatment guidance without it: The midwife and doctor base their decision on the test results to treat us. If I refuse to test, they may prescribe the wrong medication for me (Pregnant woman #5; Public hospital). Refusing the test might impact relationships with providers and service quality, influencing women to test against their preferences: I think the midwife can decide not to care for me because I refused an important test. I even heard they look at the test results before admitting you into the delivery room (Pregnant woman #8; Public hospital). To enforce testing, a clinic stamped the folders of women who tested, restricting progress in antenatal care. This practice was known to women: The midwives will write in our ANC book that we refused the test. This will cause them to deny us care during delivery (Pregnant woman #9; Public hospital). A nurse described it as a policy to reduce test refusals: Putting a stamp at the back of the folder is our policy. If a woman’s folder is not stamped, those in the doctor's consulting room will send them back. If we do not do that, most of them will not do the test, and you know they must do it (Nurse #4; Public Hospital). Similarly, in a private hospital, women refusing the test were referred to the doctor, leveraging the doctor's authority: We do not force women who refuse to test. We refer them to the doctor. They usually will agree to test once they hear the doctor's name (Nurse #9; Private hospital).
Complexity of the Intervention
Many HCPs were either not aware of the opt-out intervention's expectations or had never heard about the word opt-out HIV testing; 'I know testing is routine, which means we should test all women coming to the clinic. For the opt-out, I have not heard about that.' (Midwife #2 public). The few providers who reported being aware of the opt-out approach found the difference between eliciting consent by opt-out and opt-in difficult. Data from fieldnotes revealed that many providers asked women: Do you agree for me to test you for HIV? (i.e. opt-in approach)' instead of informing the clients that they will be tested for HIV as part of your blood work, however, you have the option to decline if you do not want to (opt-out approach). Such misinterpretation of the policy was apparent in the narratives of many providers, who repeatedly mentioned that they were supposed to 'initiate' testing without necessarily obtaining informed consent. Observation of testing activities revealed that many HCPs found the act of pricking a woman and applying the right amount of buffer solution difficult: 'Even how to prick the woman was difficult. Sometimes, out of fear, I pricked lightly, and no blood would come, and even how to draw the blood and put it on the test strip, most of us do not know how to do it (Community Health Nurse #1, Private). Even more challenging is when the woman tests positive. Without accurate test information offered to the woman, a midwife with little experience with HIV testing found it challenging to disclose a positive test result or offer post-test counselling: if a woman tested positive, it became problematic. How do I look at a healthy-looking professional and tell her that she is positive for HIV? (Midwife #10, public).
Facilitation Strategies
Guideline Availability and Utilisation
At the national level, Ghana has established HIV policy documents, including 'handbooks or manuals,' policy documents, and strategic frameworks, designed to guide the delivery of HIV testing services. However, none of these guidelines were present at the facility level. ANC managers explained how the approach of guideline distribution led to non-availability at the clinics: Workshop organisers give the guidelines to workshop attendees. These staff assumed ownership of the guidelines and took them home instead of presenting them to the clinic for us all to use (ANC manager #4, private hospital). The consequence of this practice is a lack of reference materials for providers during activities such as delivering pre-test information: There is nothing to guide what exactly to tell the women...we communicate different things to them (FGD participant #1, Public hospital).
Training and Skill Development Challenges
National-level interviews revealed that training HCPs on the opt-out intervention occurred in 2008 when the policy was first introduced. The training focused on equipping selected midwives with the skills to handle difficult counselling situations. However, follow-up training had been infrequent; The training was many years ago when they showed us the new ways of testing women. Since then, I have not had the opportunity to receive further training. I am not sure if our new midwives get trained at all (Midwife #5, Public Hospital). Midwives with less than five years' experience learned how to test and counsel by observing what their senior colleagues did: I have been testing for some time after watching a colleague, but I never knew that sometimes when the drop of buffer solution is thick, just a drop or two is enough. I recall squeezing all the drops on the test kit. I still think about the result I gave that woman (focus group participant #3, private hospital). While many HCPs expressed the desire to test women, most felt inadequately prepared to undertake the intervention's technical aspect.
Supervision and Feedback Deficiencies
Lack of supervision and prompt feedback was another facilitation issue. Even when supervision occurred at the clinic level, managers often focused on routine ANC testing activities without paying any attention to core intervention principles. When regional HIV testing officers visited, they solely focused on the accuracy of HIV-related data entry and not how they went about testing: They usually check to see whether we are doing the entries well or not. They collect our register and check entries to see if they match what they came with from the region. They never enter the testing room to see what is going on there (HCP # 6; Private hospital).
The difficulty in supervising HIV testing activities appears to have been caused by a lack of adequate regional-level supervisors for the increased HIV testing centers. The study revealed that the regional monitoring team could often conduct a twice-yearly targeted external quality assessment (EQA) even within this limited human resource capacity. According to the regional HIV coordinator, part of EQA involved doing proficiency testing for staff engaged in rapid testing: …we issue simulated specimens to clinics, and performance is assessed by comparing reported results with the expected results (regional HIV testing officer- Key informant). The key informant explained that they often compared the results they received from the various clinics with a standardised test result. If the staff of a particular hospital recorded false results, it alerted them that the staff of that hospital required training and target supervision.
Logistical Challenges
Facilitation, in terms of logistics, was not a problem in many of the clinics. HCPs involved in testing reported having enough test kits to screen women (first response). They, however, reported an insufficient supply of test kits needed to confirm a positive test (OraQuick): The OraQuick is scarce in this hospital, so the ART coordinator usually gives us about 10, which last for about a month depending on the number of positive results we get (Nurse manager #3; private hospital).
Participants' Perception of the Intervention: Responsiveness
Responsiveness is the last moderating factor addressed in this study. We were interested in finding out how various stakeholders viewed the intervention. The national level officers in GAC and NACP responsible for policy formulation and implementation, respectively, differed in their views regarding the required level of adherence to the intervention's core components. GAC officials considered themselves adopters of the policy and therefore emphasised strict adherence. Officers of NACP, responsible for translating the policy into practice, advocated flexibility in implementing the policy. The NACP officials noted that the practice environments differ, which meant that careful adaptation and streamlining of the policy would improve fit individual clinic needs.
Frontline staff were optimistic about their role in testing. Some did not view HIV testing as a separate function, but rather, as one of the many activities midwives undertake to ensure a safe pregnancy and birth. These midwives argued that detecting women living with HIV and putting them on medication was an essential professional responsibility for their clients.
'We test the women here for syphilis, and the women are okay with it. HIV is not different from it; it is part of what we went to school to learn. Our employer must add HIV testing to our job description to help in our salary negotiation' (Key informant #2: Regional HIV facilitator).
Many HCPs identified HIV testing as an additional role that added to their workload. They addressed this challenge by assigning the test to the student or newly trained midwife while they concentrated on palpation and other activities considered more technical:
‘Most of my students are incredibly good at pricking and applying the buffer. Rapid testing does not require any technical expertise. They will let me know if they have problems. If a woman test positive, they know what to do. They will usually discard that test kit and then refer the woman to me. I will do the test again and then disclose it. Disclosing test results is beyond them’ (Midwife #6, Private hospital).
Providers who viewed HIV testing as part of their role held the opinion that the 'ritual' of client autonomy and informed consent practices if emphasised, may come in the way of delivering their professional mandate. The provider narrated: 'I know HIV has a stigma to it, but once the woman comes for ANC services, they consent to all procedures in the clinic. Do I have to get permission before undertaking all the activities on them? (Focus group participant #9; public hospital). For a midwife who sees HIV testing as an integral part of her role, the very act of seeking informed consent appeared paradoxical, especially when the test is free. For many of these midwives, coming to the clinic for services means the woman has implicitly consented. For some providers, pregnant women have come to know them, therefore, going back to ask for informed consent may suggest a betrayal of this trust. Other frontline staff viewed testing women for HIV as a way to protect the midwife delivering the woman, and therefore a positive test result should not be kept confidential from their other colleagues who may be caring for the woman later. Clinic observation indeed reveals a pracitce where any staff working in the clinic and other departments became interested in the test results of women.