International Journal of Drug Policy 15 (2004) 207–210
Short report
The extent of use of maternity and child health services by pregnant women injecting illicit drugs Lev Khodakevich a,∗ , Lidia Andrushchak b , Roman Gailevich c , Rudick Adamian d , Stela Bivol e a
Marshal Novikov Street 12, Block 2, Apartment 23, 123098 Moscow, Russia b Kiev, Ukraine c UNAIDS, Minsk, Belarus d UNAIDS, Almaty, Kazakhstan e c/o Gabriela Ionaschu, Moldavia
Received 21 October 2002; received in revised form 14 August 2003; accepted 28 August 2003
Abstract Following explosive HIV epidemics in Eastern Europe in the mid-1990s, the number of children born to HIV infected women has been increasing since 1999. A significant proportion of these women were using injectable drugs. This raises the issue about the extent of their contact with Maternity and Child Health (MCH) services for ante and post-natal care. A rapid assessment was therefore undertaken to determine the use of MCH services among IDU pregnant women. All female IDUs attending selected outreach units in 13 cities and towns were interviewed over one to two weeks in December 2000 in Ukraine and Belarus and in January 2001 in Kazakhstan and Moldova. The study revealed that 60–96% of women were registered at MCH services at various periods of pregnancy in Ukraine, Belarus and Moldova. In Temirtau city in Kazakhstan the coverage was poor. Most of the women were registered before the last trimester of their pregnancy which offers sufficient time for them to undergo HIV testing and receive counselling and short courses of anti-retroviral therapy before delivery. © 2003 Published by Elsevier B.V. Keywords: IDUs; Pregnant women; MCH services
Introduction From 1995 HIV started spreading among injecting drug users (IDUs) in Ukraine, Belarus, Moldova, Kazakhstan and Russia (Dehne & Kobyshcha, 2000). By the end of 2000 the cumulative number of reported cases in Russia exceeded 80,000, in Ukraine about 35,000 and in Belarus more than 3000. From 65 to 90% of all cases had been registered among IDUs, predominantly men. At the same time, an average of between 25 and 35% (range 10–80%) of all sex workers injected drugs (Baggaley, 2000). The proportion of cases reported in IDUs is decreasing while the proportion of cases reported in persons infected ∗
Corresponding author. Tel.: +7095-105-3835. E-mail addresses:
[email protected] (L. Khodakevich),
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[email protected] (S. Bivol). 0955-3959/$ – see front matter © 2003 Published by Elsevier B.V. doi:10.1016/j.drugpo.2003.08.003
heterosexually is on the increase. In 1999, in Ukraine and Belarus in particular, the proportion of persons infected heterosexually increased to 23 and 30% of HIV cases, respectively, from 13 and 7% in 1996 (De Vincenzi & Malyavin, 1999). The number of children born to HIV-infected mothers is still small, but their numbers are rapidly increasing. By the end of 1999 about 1300 infants were born to HIV infected mothers in Ukraine, with almost half of them born during that year. In Russia the number of mother to child transmission (MTCT) cases increased exponentially, from 20 cases during the period of 1987–1996 to 203 cases by the end of October 1999 (Baggaley, 2000). Currently ante-natal delivery and post-natal care are accessible to most women and the services are of a high quality (Baggaley, 2000). However there is concern that the MCH services are not available to several groups of women with a high risk of HIV infection, such as drug users, sex workers and illegal migrants (Baggaley, 2000; De Vincenzi &
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Malyavin, 1999; Murzi, 1999). A low attendance may pose particular challenges for interventions aimed at prevention of MTCT. Sero-positive pregnant women are referred to an AIDS centre (Dehne, Grund, Khodakevich, & Kobyshcha, 1999) however, these centres have a poor reputation among women who can disappear from the care system and then present in labour at the maternity units. It was therefore, important to identify which services were most accessible to IDU pregnant women for prevention of MTCT. In order to understand the potential role of the MCH services for this task a study was organised in four countries in November 2000–January 2001.
Study Objectives The study aimed to determine how many women IDUs were attending MCH services, the duration of their service use prior to childbirth, and the location of delivery.
Methods Interviews were conducted with women attending needle exchange and harm reduction outreach units. The questionnaire collected information on the number of women with children, the number of pregnancies after commencement of injecting drug use, the period of registration at a MCH clinic and the location of their delivery. The questionnaires were administered by staff at outreach units in 13 cities in four countries. In Ukraine, the cities of Nikolaev, Donetsk and Odessa were chosen to participate in the study as they had the longest-running services for IDUs, this was also the case for Temirtau in Kazakhstan.
In Belarus all six cities with outreach harm reduction activities (Vitebsk, Mogilyov, Pinsk, Soligorsk, Svetlogorsk and Minsk) and in Moldova, Chisinau, Balti, Faleshty and Orhei were included in the study. All female IDUs attending selected outreach units over a period of one to two weeks in December 2000 (Ukraine and Belarus), and in January 2001 (Kazakhstan and Moldova) were interviewed.
Results A summary of the interviews is presented in Tables 1–3. The sample comprised of nearly 1300 persons, of whom 399 (30.8%) had children. A total of 440 deliveries occurred after commencement of injecting drug use. The large majority of pregnant IDUs had been registered at their local MCH clinic during pregnancy. This was highest in Moldova followed by Belarus and Ukraine. Poorer coverage (56.4%) was reported in Nikolaev of Ukraine, where MCH clients required passports for registration or payment for blood prior to the delivery, requirements that some women were unable to fulfil. The poorest coverage was in Temirtau. In Ukraine, the time of registration at MCH was evenly distributed across the three trimesters of pregnancy. In Belarus about half of all women registered between four and six months before delivery and the rest were evenly distributed between the first and last trimesters. In Temirtau all four women registered late. In Moldova two-thirds of the registered women applied to MCH services within the second trimester. In Kazakhstan and Moldova all women gave birth at clinics in their hometowns. In Belarus, the figure was—59 out of 60, and in Ukraine about 90%.
Table 1 Use of MCH services by the pregnant women injecting drugs (ID): women questioned, had children and deliveries Country
Number of women questioned
Ukraine Belarus Kazakhstan Moldova
549 272 178 295
All countries
(42.4%) (21.0%) (13.8%) (22.8%)
1294 (100.0%)
Number of women with children
Number of deliveries after starting ID
236 63 13 87
266 63 13 98
399
440
Table 2 Use of MCH services by the pregnant women injecting drugs (ID): registration at MCH services prior to deliveries City
Pregnant not registered at an MCH clinic
Registered at an MCH clinic
Ukraine Belarus Kazakhstan Moldova
52 6 9 4
68 (25.6%) 14 (23.3%) 0 4 (4.1%)
All countries
71 (16.2)
(19.5%) (10.0%) (69.2%) (4.1%)
7–9 months before delivery
86 (19.7)
4–6 months before delivery 71 (26.7%) 28 (46.7%) 0 75 (76.5%) 174 (39.8)
1–3 months before delivery 75 12 4 15
(28.2%) (20.0%) (30.8%) (15.3%)
106 (24.3)
L. Khodakevich et al. / International Journal of Drug Policy 15 (2004) 207–210 Table 3 Use of MCH services by the pregnant women injecting drugs (ID): location of delivery City
Delivered At a clinic
At home
In the same city
In another city
Ukraine Belarus Kazakhstan Moldova
239 59 13 98
24 (9.0%) 1 (1.6%) 0 0
3 (1.1%) 1 (1.6%) 0 0
All countries
409 (93.4)
25 (5.7)
4 (0.9)
(89.9%) (96.7%) (100.0%) (100.0%)
Discussion The number of women interviewed in each country varied. The major reasons for this were the size of the cities/towns and the extent of local drug use, the number of outreach units involved in the study and the number of drug users attending each unit. In Donetsk 1.5% of the city population use drugs, in Odessa—3% and in Nikolaev—4% (Semikop, 2001), while in Svetlogorsk the number of IDUs has been estimated at nearly 7% of the population (Pavskii, 1997). Given these caveats the sample cannot be considered to be representative of IDUs in these cities. It is estimated that women represent between 10 and 20% of attendees of HIV prevention outreach units, and although a small proportion of the female population (see above), they may play an important role in prevention of MTCT. Observations from Poland indicated that women IDUs represented over 90% of all registered HIV positive pregnant women (Niemiec, 2003). Their early registration and anti-retroviral therapy can significantly reduce the rates of vertical transmission of HIV. Most of the women were registered before the last trimester of their pregnancy and that could offer sufficient time for them to undergo HIV testing, receive counselling and short courses of anti-retroviral therapy before delivery. This however should not prevent care providers from contacting IDU pregnant women through the harm reduction and needle exchange services. The estimates, from the cities in the study, suggest that between 10 and 40% of IDUs attended harm reduction services. However, the European Regional Strategy (UNAIDS, 1999) expects expansion of services to reach 60% of IDUs. This would allow the harm reduction programmes to play a more significant role in prevention of MTCT. In any case pregnant IDUs would benefit significantly from the establishment of a referral system between the harm reduction programmes and MCH services. This should include the geographic linkage of outreach units with respective MCH clinics and two-way communication between these services. Most of the women delivered in their city of residence, with the exception of Donetsk where 17.5% of all the
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women interviewed delivered in a settlement outside their city. The study has shown a high attendance at maternity units for child-birth and this would allow the application of MTCT preventive strategies for pregnant women during delivery and for both mother and child in the first week of the post-natal period. Public health services in the countries of the former Soviet Union have deteriorated in recent years (AMS, RF, 2000; UN RC, Ukraine, 2000; UNDP, 1999). MCH services had represented a kind of a continuum of care for pregnant women, who were registered at the first signs of pregnancy, followed up through periodic physical and laboratory tests, referred to delivery clinics and had their health (mother and baby) monitored after discharge. A pregnancy or delivery without registration at a clinic of the MCH services was exceptionally rare. In the newly independent states the lack of government budget, qualified staff and a “commercialised” re-orientation of medical services in the absence of well-developed health insurance systems have reduced the quality of, and access to, health services. This study was the first to assess IDU pregnant women’s access to MCH services using interviews at the population level rather than analysis of official statistics. This approach may provide a better insight into the efficiency of the services at contacting various sections of the population. Though such an approach is important it should be supplemented by interviews with MCH personnel to provide a more comprehensive picture of service provision in the various cities. The study had certain limitations. It was conducted only in thirteen cities and towns of four countries therefore, the results should be considered as indicative rather than conclusive. Secondly, out of several groups of women mentioned in the ‘Introduction’, the study covered only women injecting illicit drugs. Additional studies are needed to determine health-seeking behaviour of female sex workers, and migrant women.
Acknowledgements The authors would like to express their high appreciation to the contributors who arranged for and carried out the interviews at the outreach units. We would also like to thank Yuri Kobyshcha and Veena Lakhumalani, who reviewed the paper and provided very valuable comments.
References Academy of Medical Sciences (AMS) of RF. (2000). The State Report on the Population Health in the Russian Federation in 1999 (p. 103). Ministry of Health of RF, Moscow GEOTAD-MED. Baggaley, R. (2000, November). Discussion paper on models for VCT for MTCT interventions in Eastern Europe. UNAIDS.
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