1.0 INTRODUCTION

1.1 BACKGROUND

The World Health Organization (WHO) has given insight to the world that every pregnant woman and newborn should receive quality care throughout the pregnancy, childbirth and the postnatal period. Within the continuum of reproductive health care, antenatal care (ANC) provides a platform for important health-care functions, including health promotion, screening and diagnosis, and disease prevention. It has been established that by implementing timely and appropriate evidence-based practices, ANC can save lives. Crucially, ANC also provides the opportunity to communicate with and support women, families and communities at a critical time in the course of a woman’s life(1).

In Tanzania maternal and neonatal mortality remain high despite improvements in recent years. But it seem that maternal mortality has declined from 610 deaths per 100,000 live births in 2006 to 460 in 2010(2). Yet the lifetime risk of maternal death remains 1 in 23. Over the same period, neonatal mortality has fallen slightly from 30 deaths per 1,000 live births to 26, this show the importance of antenatal care during pregnancy (2).

ANC is generally provided by nurses and midwives (80%), with the rest receiving care from doctors, clinical officers, or maternal-child health aides. According to data from the recent national Demographic and Health Surveys (DHS), almost no women received ANC from a traditional birth attendant (TBA).3 In 2002, Tanzania’s Ministry of Health and Social Welfare implemented an ANC program adapted from the World Health Organization’s focused antenatal care (FANC) model. FANC focuses on quality rather than quantity of visits and recommends four visits throughout pregnancy(2). However, in Tanzania, less than half of women receive the recommended minimum number of visits. Furthermore , only 15.1% of women attend their first antenatal visit before the fourth month of pregnancy(2). Most women receive blood pressure measurement, blood tests, and antimalarial treatment during ANC. About half took iron supplements, had their urine tested, and were informed of the signs of pregnancy complications (2).

The FANC model suggests that visits should take place before 12 weeks, at 26 weeks, at 32 weeks, and between 36-38 weeks, although many countries have slightly changed the recommended timing of the visits in their own guidelines to better match their population’s needs(2).
During pregnancy the classic interventions has to be performed to prevent the transmission of HIV from the mother to the fetus. These interventions done at ANC clinic which comprise three visits while the frequency of visits may increase as needed(2). During ANC mother’s HIV, syphilis and other sexual transmitted diseases serological status is tested and recorded in RCH card, for those who discovered to be infected receive treatment to prevent the transmission to fetus and improve fetal and maternal outcomes(3).
As this study seeks to determine the booking time, HIV testing rate and barriers and ART uptake during ANC clinic, because it is the major determinant of risk of transmission of the HIV from mother to the fetus. Whereas the Tanzania government has ensured the effective use of ART during pregnancy by providing free ART and other treatment to the pregnant women, the adherence still not 100% although not poor as those observed in sef-funded treatment(4).  
Thus the ANC setting is the good setting for this study based on avoidance of testing to those who already tested and bias based on the centre for specific services to mothers tested positive.

1.2 PROBLEM STATEMENT

There is still a high burden of mother to child transmission of 18% in Tanzania. This is due to late ANC booking, low uptake of HIV testing and ART. This study will be able to determine these Parameters among pregnant women in Mwanza.

In Tanzania the late ANC attendance appears to be prevalent among all pregnant women as revealed from the demographic data in 2016. The observed timely attendance was only 24% that attended before their fourth month of pregnancy, while only 14% of pregnant women booked within three months of pregnancy. The late booking is a main barrier to PMTCT achievement, since the early detection of HIV and treatment makes the transmission of HIV less likely(5). Since all pregnant women have to be given the voluntary counseling and been tested for HIV during their first ANC visit. Although the acceptability seemed to lag behind expectation in 2004, the willingness among mothers to undertake HIV testing in northern Tanzania was observed to be only 41.7 % (6), while in Dar es Salaam it was around76%- 77.2%(7, 8). From the study done in Moshi Tanzania in 2006, revealed that fear to get back results after VCT as 7% of tested clients did not turn back to collect their results after being tested (9).The major barriers toward HIV testing were related to high likelihood to be HIV positive, partner involvement, lack of confidentiality and negative religious beliefs about HIV positive individuals(6).A study done in misungwi revealed a low intake of HIV services among at a rate of 24%, of note, among those had an HIV test, only 12% took ART (10). Despite the rapid expansion of antiretroviral therapy (ART) programs, uptake of ART in pregnancy remains suboptimal (11). Key challenges to early ART initiation included late first presentation, denial of an HIV diagnosis, fear of disclosure, and treatment side-effects (11). Women expressed difficulties in accepting a lifelong commitment to treatment for maternal health benefit. Pregnant women who require ART face a triple burden of transitioning into pregnancy, accepting the HIV diagnosis, and recognizing the urgent requirement to start lifelong ART before delivery. Focused interventions are required to address the psychosocial barrier to ART uptake and the linkages to care for pregnant HIV-positive women (11).

1.3 RATIONALE OF STUDY

The study will fill the knowledge gap on booking time, HIV testing rate and barriers and uptake of ART, and inform on the need to develop targeted interventions to promote early ANC booking, early HIV testing, uptake of ART and linkage to care.

1.4 RESEARCH QUESTIONS

What are booking times, uptake rate of HIV testing and ART. And what are barriers to access these services?
 
1.5 OBJECTIVES

1.5.1 Broad Objective

To determine the booking time, HIV testing and barriers and ART uptake among pregnant women attending ANC clinics at Makongoro health centre.

1.5.2 Specific Objectives

1. To determine the booking time at ANC visit.
2. To determine HIV testing uptake rate among pregnant women attending ANC at Makongoro health centre.
3. To determine ART uptake rate among pregnant woment attending ANC at Makongoro health centre.
4. To determine barriers for HIV testing among pregnant women attending ANC at Makongoro health centre.