Safe Motherhood and Prevention of Vertical Transmission

What Works

Preventing Unintended Pregnancies
Antenatal Care - Testing and Counseling
Antenatal Care - Treatment

Three vital components of AIDS programming for women living with HIV are ensuring safe motherhood through access to health care before, during and after pregnancy and childbirth; ensuring access to treatment; and ensuring access to services to prevent vertical HIV transmission. While much progress has been made in reducing vertical transmission, more could be done. A recent demographic model showed that if the 25 countries with the largest numbers of HIV-positive pregnant women implement the new WHO Prevention of mother-to-child transmission (PMTCT) recommendations between 2010 and 2015 and provide more effective ARV prophylaxis or treatment (for those eligible) with 90% coverage, one million new child infections could be averted by 2015 (Mahy et al., 2010a). Further, reducing new HIV infections in women of reproductive age, eliminating the unmet need for contraception among women living with HIV, and limiting breastfeeding to 12 months (with ARV prophylaxis) by women living with HIV could avert an additional 264,000 infections.

HIV Contributes to Maternal Mortality

PMTCT is too much about the baby and not enough about the mother." —Woman in a PMTCT program, Malawi (Bwirire et al., 2008: 1997Estimates of maternal mortality for 181 countries from 1980 to 2008 found that of the 342,900 estimated maternal deaths worldwide in 2008, 61,400 were attributed to HIV (Hogan et al., 2010). In 2008, HIV accounted for 11% of maternal deaths, with an estimated 42,000 to 60,000 pregnant women who died because of HIV (UNAIDS, 2011a; UNAIDS, 2011c) and there is increasing evidence that HIV is becoming a major cause of maternal mortality in resource-constrained settings, particularly in sub-Saharan Africa (Moodley et al., 2011). In 2008, an estimated 1.4 million pregnant women living with HIV in low- and middle-income countries gave birth. Sub-Saharan Africa accounted for 91% of all pregnant women living with HIV (UNAIDS, 2009d). Due to scale up of antiretroviral drugs, the estimated number of maternal deaths due to HIV has declined to 56,100 for 2011 (Lozano et al., 2011).  

Prevention of Vertical Transmission Hinges on Access to Antenatal and Perinatal Care

Access to perinatal care is vital. In 1990, the percent of women in developing countries delivering with skilled attendants was 54%; by 2008, 63% (UNICEF, 2010a). About 40% of women in developing countries give birth without a skilled attendant; fewer than 40% have a postnatal visit by a skilled health worker; and only about 50% of women in low-income countries complete the recommended series of four antenatal visits with a doctor or nurse (Altman, 2011), all of which impact whether a woman has access to services for safe motherhood and prevention of vertical transmission. Conservative estimates are that there will be between 130 million to 180 million births without skilled birth attendants between 2011 and 2015 in South Asia and sub-Saharan Africa, mostly in rural areas (Crowe et al., 2012). For example, less than 70% of women in the Middle East and North Africa region have at least one antenatal checkup, hindering PMTCT efforts (Remien et al., 2009). In Cambodia, 78% of births occur at home or outside medical facilities in which PMTCT services are available (ITPC, 2009).

Poor women are less likely to access care. The poorest women are least likely to deliver with skilled attendants: in developing countries, only 28% of the poorest 20% delivered with skilled attendants, whereas among the richest 20%, 84% delivered with skilled attendants (UNICEF, 2010a). Once a woman does access a health facility for birth, quality care is critical (Barker et al., 2011; HRW, 2011b; Hulton et al., 2002 cited in Gay et al., 2003).

A recent study in Ethiopia found that women who delivered at home were less likely to have used antiretroviral therapy (ART) to prevent vertical transmission (Mirkuzie et al., 2010). However, a study of 257 health facilities supported by PEPFAR from eight sub-Saharan African countries found that an increase in the number of pregnant ART patients was associated with an increase in facility deliveries by both HIV-positive and HIV-negative pregnant women (Kruk et al., 2012). “... Significant increases in PMTCT coverage among those at risk can only be achieved by substantially increasing uptake of general ANC and delivery services... PMTCT programmes need to be strengthened by investing more generally in maternal health services...” (Kasenga et al., 2009: 1). Some PMTCT projects in Rwanda have, through outreach, community education and some incentives, increased the percent of women delivering in participating health center from 56% in 2007 to 72% in 2008, while the 2008 Rwandan national average was only 45% (Lim et al., 2010).

Prevention of Vertical Transmission Must Focus on Both Mother and Child

Programs to prevent vertical transmission – often referred to as prevention of mother-to-child transmission (PMTCT) programs – have historically focused on infant outcomes, rather than both the mother and infant. In fact, PMTCT, itself, is “a name that implies that mothers are the source of the virus, rather than the latest in a long chain of transmission” (Lewis and Donovan, 2009: iv). (This resource primarily uses the term vertical transmission). However, recently there has been a shift to recognize the importance of pregnant women for their own health (Mbori-Ngacha, 2012). “The crucial link between maternal health and infant survival is now broadly recognized and keeping mothers alive and healthy is now an explicit goal of global programming to address vertical transmission” (ITPC, 2011: 5).

A 2008 review on child survival and PMTCT reported that child survival depends largely upon the mother’s health and survival. Having a deceased mother has been shown to be a significant risk factor for infant mortality (Kurewa et al., 2010; Sartorius et al., 2010) and the survival of young children (Mepham et al., 2011). Caregiver death from HIV is associated with a three- to four-fold increase in mortality for HIV-negative children (Mermin et al., 2008 cited in Leeper and Reddi, 2010). UNICEF now promotes a change of PMTCT programs on “coverage of ARV prophylaxis to the health of mothers and HIV-free survival of children” (UNICEF et al., 2010: 28), of which antiretroviral treatment is a critical component. In the United States, triple combination therapy has resulted in vertical transmission rates of less than 2% (Dorenbaum et al., 2002 cited in USHHS, 2011). Success has been achieved in some resource-limited settings as well, such as in South Africa: of 2,888 HIV infants exposed, the rate of vertical transmission at 8 weeks postpartum was 4% (Goga et al., 2011). In the absence of HAART, women living with HIV suffer from very high rates of morbidity and mortality up to two years postpartum and beyond (Coutsoudis et al., 2010). As of 2011, UNAIDS has the goal of providing 90% of pregnant women in need of antiretroviral therapy for their own health with life-long antiretroviral therapy (UNAIDS, 2011c).

Vertical Transmission Can Occur At Multiple Points

Vertical HIV transmission can occur in utero, during delivery and during breastfeeding (Buchanan and Cunningham, 2009). These are all points for reducing the probability of transmission while also serving as critical points for addressing women’s health needs. While it is impossible for an HIV-negative woman to give birth to an HIV-positive infant, it is possible for a woman to seroconvert during her pregnancy; starting her pregnancy as HIV-negative and becoming HIV-positive through sexual transmission from a sexual partner, unscreened blood transfusions, injecting drug use or rape during the course of pregnancy. In some societies, men are encouraged to have multiple partners while their wife/partner is pregnant or breastfeeding which can lead to a woman seroconverting during pregnancy (Ghanotakis, 2010). Studies also show that significant proportions of women who are pregnant suffer from violence (Dunkle et al., 2004; Guo et al., 2004 cited in Tang et al., 2008; Cripe et al., 2008; Ellsberg, 2006), which can be correlated with acquiring HIV.  [See also Addressing Violence Against Women] If a woman is recently (acutely) infected, the likelihood of vertical transmission is increased. [See Antenatal Care - Treatment]

Transmission can occur during pregnancy, labor and delivery and during the postpartum period, through breastfeeding for two or three years following birth. A woman can acquire HIV before or after the birth of her child and vertical transmission of HIV is still possible as long as breastfeeding continues. If a woman is HIV-positive and breastfeeds, because safe drinking water and replacement feeding are not available to her, or to avoid HIV stigma, her infant born HIV-negative can become HIV-positive. However the transmission can be reduced by ART treatment during the breastfeeding period.

The Four Components of Safe Motherhood and Prevention of Vertical Transmission

Prevention of vertical transmission has been categorized into four components, each of which contributes to preventing HIV acquisition and transmission (UNAIDS, 2011c; WHO, 2010k).

Component 1: Preventing Primary HIV Infection in Women

Primary prevention of HIV among women of reproductive age remains critical to any efforts to reduce vertical transmission. Women who remain HIV-negative cannot transmit HIV to their infants. Further, “children whose mothers have died, regardless of the mother’s HIV status, are less likely to survive to their fifth birthday than are children of HIV-infected women who are still alive” (Zaba et al., 2005 cited in Heymann et al., 2007a). The programming in Prevention for Women, Prevention for Key Affected Populations, Prevention and Services for Adolescents and Young People, and Strengthening the Enabling Environment addresses this first component of preventing primary HIV infection in women.

Component 2: Preventing Unintended Pregnancy Among Women Living with HIV

Preventing unintended pregnancies is a fundamental right for women and can have a significant impact on reducing perinatal transmission of HIV. Once fully informed of her options, a woman can decide about her reproductive choices and make an informed decision about her fertility. The benefits of family planning include preventing unintended pregnancies; reducing maternal and infant deaths; and greater educational and economic opportunities for women (Halperin et al., 2009a). A 2006 modeling study found that for the same cost as treatment with antiretroviral drugs to prevent perinatal transmission, contraceptive use can avert nearly 30 percent more unintended HIV-positive births (Reynolds et al., 2006a). It is estimated that 22 percent of unintended HIV-positive births are already being prevented through current levels of contraceptive use in sub-Saharan Africa (Reynolds et al., 2006a). Women living with HIV often face stigma and discrimination when planning a pregnancy. “One of the neglected areas in PMTCT globally has been the issue of fertility desires and fertility planning for HIV-positive women and their partners” (McIntyre and Lallemant, 2008b: 137).  Interventions related to this component are included in this section as well as in Meeting the Sexual and Reproductive Health Needs of Women Living With HIV.

Component 3: Preventing Vertical Transmission of HIV During Pregnancy, Delivery and Postpartum

Well-functioning maternal health programs are essential for all women, but particularly for pregnant women living with HIV. Access to preconception care, HIV testing and counseling that guarantees confidentiality, HIV treatment options, and evidence-based options in delivery and for postpartum care are critical to meeting the needs of women living with HIV and preventing perinatal transmission. Interventions related to this component are included in this section.

Component 4: Family Treatment – Providing Care, Treatment and Support to HIV-Positive Women, Their Children and Families

Family treatment (also referred to as PMTCT-Plus) refers to programming that aims to reduce vertical transmission as well as to provide ART services before, during and after pregnancy for women living with HIV and to other family or household members. Globally, maternal-child health facilities have traditionally excluded men even though fatherhood is important in almost all societies and women often want the support of their male partners during pregnancy, labor, delivery and the postpartum period. Good maternal health can also be highly dependent on access to HIV prevention, treatment and care for men, as focusing on men in addition to women protects the health of women and, by extension, their children. Interventions related to this component are included in Treatment, Preventing, Detecting and Treating Critical Co-Infections, and Care and Support.

Most PMTCT Programs Focus On Component 3

Recent modeling from data in 25 highly affected countries indicates that to eliminate new child infections by 2015, major progress is needed in all four components (UNAIDS, 2011a). Despite the importance of components one and two in preventing vertical transmission, “for most programs in the field, PMTCT is in fact focused on the program’s third and fourth components” (Msellati, 2009: 808), with most emphasis, to date, on component three (Padian et al., 2011b: 272). While this section touches on component two, additional information on preventing unintended pregnancies is in Meeting the Sexual and Reproductive Health Needs of Women Living With HIV. The majority of this section focuses on component three – safe motherhood and prevention of vertical transmission. The other components are covered, however, in additional sections as noted above.

Men Play An Important Role in Prevention of Vertical Transmission

In addition, another component is needed. Women are at exceptionally high risk of acquiring HIV while they are pregnant and during the postpartum period (Lockman et al., 2011 cited in WHO et al., 2011b), making efforts to keep women HIV-negative during pregnancy and postpartum imperative. Involving men in PMTCT programs—with the permission of women—can be an important way to increase women’s uptake of HIV testing, prevention, treatment and care (Ghanotakis, 2010). Traditionally, PMTCT programs have focused on pregnant women and the role of men has been ignored (Mohlala et al., 2011). Research on male support in the context of PMTCT has usually narrowly focused on male attendance at MCH clinics and male uptake of HIV testing (Maman et al., 2011). One study found that men in South Africa support their partners in numerous ways – facilitating access to the MCH clinic, with money, food, reminders to go to the clinic, emotional support, childcare, discussions on infant feeding, and infant testing (Maman et al., 2011). But MCH clinics often preclude men attending, either because the hours conflict with work or because of lack of space for men (Maman et al., 2011). Male views on safe motherhood and vertical transmission are lacking (Auvinen et al., 2010). Involving men in PMTCT programs may also help address some of the gender issues that impact women’s acquisition of HIV, as well as in accessing to prevention, testing, treatment and care. [See also Strengthening the Enabling Environment]

Yet “we need to acknowledge that male involvement may not always be in the best interests of women” (Maman et al., 2011: 330). Some pregnant women in the study in South Africa had valid reasons for not involving men, such as one HIV-positive woman who was quoted: “My baby’s father says if he gets HIV, I would be the one to blame... He says he would kill me” (Maman et al., 2011: 329).

Recent work has focused on men and fatherhood (Barker et al., 2010a). A number of programs, such as EngenderHealth’s Men as Partners or Catholic Medical Mission Board’s Men Taking Action in Zambia are working to increase the positive involvement of men in maternal health care in general, but few evaluated studies were found for PMTCT programs. PMTCT programs may learn from involving men in other reproductive health programming.

What Works in Safe Motherhood and Preventing Vertical Transmission

A number of proven strategies reduce the risk of HIV transmission from mother to child, as well as reduce primary infection in women, and progress has been achieved: the number of children newly infected with HIV in 2009 (370,000) was 26% lower than in 2001 (UNAIDS, 2011a). Provision of contraception to women who wish to avoid pregnancy is a critical step in preventing vertical transmission. Creating preconception care could improve maternal health, family health and reduce vertical transmission. In order to best advise a woman living with HIV about her options for safe motherhood and prevention of HIV transmission to her future child, it is optimal to reach her prior to pregnancy. However, most women become aware of their positive serostatus once they are pregnant, via HIV testing during antenatal care. Confidential HIV testing with counseling during antenatal care that includes women, and with their permission, their partners, is a critical foundation for reducing vertical transmission of HIV. It allows women to know their serostatus, protect their own health and make appropriate decisions to prevent vertical transmission. During antenatal care, HIV testing, treatment options, syphilis screening, malaria prophylaxis and other essential antenatal care must be fundamental services for pregnant women living with HIV. [See Preventing, Detecting and Treating Critical Co-Infections] Access to emergency obstetric care is also essential for pregnant women living with HIV. Maternal use of ARV therapy for her own health saves the lives of both mother and child and reduces orphan deaths in the long term. [See Treatment and Antenatal Care - Treatment] HAART for pregnant women dramatically reduces perinatal transmission; reduces the risk of resistance to antiretroviral drugs related to monotherapy or duo therapy; and the risk of virological failure of HAART for HIV-positive children (Russo et al., 2009). In 2010, WHO released new rapid advice recommending ARV use for treatment or prophylaxis for pregnant women:

“Prevention of MTCT [mother-to-child-transmission] of HIV infection cannot be viewed in isolation from optimization of maternal health and survival” (Mofenson, 2010b: S131). Improvement of maternal health services globally will be necessary to reach all women and infants who need services, ensuring safe motherhood and prevention of vertical transmission. “The complex and interrelated challenges of MCH against the devastating global backdrop of HIV require comprehensive models of care that combine HIV/AIDS and MCH initiatives” (Leeper and Reddi, 2010: 2148). “A strong commitment toward both coverage and quality of services is required to serve the many women and infants in need” (Baek and Rutenberg, 2010: 303). “...Practitioners on the ground increasingly recognize that quality HIV care cannot be provided without improvements in TB, antenatal, malaria, outpatient and inpatient care services, and basic administrative systems” (Pfeiffer et al., 2010: 3). PMTCT programs “require attention to strengthening maternal and child services as a whole, synergizing with efforts to avert maternal and neonatal mortality” (De Cock et al., 2011). All the interventions noted in “What Works, Safe Motherhood” (Gay et al., 2003) take on additional importance for HIV-positive women []. For recent evidence and information on maternal health, see also WHO documents (WHO et al., 2011c; WHO, 2010a; WHO, 2009g; WHO, 2006c) and the website of the Maternal Health Taskforce:

Not All Of The Science Related to PMTCT Is Resolved

In many respects, programming for PMTCT is quite advanced and yet for some aspects of PMTCT, current research provides incomplete and complex guidance, adding to the ongoing challenge of programming to meet the needs of women and to reduce vertical transmission. Many unknowns remain about HIV in pregnancy and how best to provide appropriate and good care to women and their infants. Topics such as perinatal ARV therapy and breastfeeding continue to raise questions. Some of the scientific evidence points to contradictory conclusions. “...After more than two decades of intensive research into HIV, the precise mechanism or even route of the vertical transmission of the virus remains unknown” (de Vries and Peek, 2008: 679). But pregnancy is a time where many women have multiple contacts with health providers, “creating an opportunity to assess and address women’s sexual risk and HIV and STI status” (Kershaw et al., 2006: 310). However, one fact remains clear: it is vital that HIV-positive women are given counseling and support with the most accurate and comprehensive information available to date so that they can make informed decisions about their health and the health of their children and that access to ARV should be available for protecting both babies and mothers.

This Section is Organized According to How Women Access Services

The evidence for what works in safe motherhood and preventing vertical transmission is organized according to the way women access health services, particularly maternal health services: prevention of unintended pregnancies, preconception planning; antenatal care (testing and counseling, treatment); delivery; and postpartum. As noted above, other components such as preventing primary HIV infection in women are addressed in the sections. The topic of pediatric HIV treatment is not covered in this website. Improving health systems and providing evidence-based interventions to ensure safe motherhood and prevention of vertical transmission is critical for all women, and especially so for women living with HIV.