Investigation into the reasons for maternal default from HIV care postpartum: a 3-year retrospective review.

Over 100 HIV-positive women currently deliver annually in Ireland. Many attend a dedicated antenatal clinic at the Rotunda Hospital in Dublin, and are referred for follow-up at the Mater Hospital in Dublin, for their own care postpartum. In Ireland, special provision is made for the protection of the right to life of the unborn (Charter of Fundamental Rights and Articles 40-44 of Bunreacht na hÉireann: the Irish Constitution). Arising from this, both mother and State owe a duty of care to the unborn child and therefore care in pregnancy is promoted. However, many mothers will not follow up for their own postpartum care. This study investigated the proportion of HIV-positive women who default from their own postpartum care at the Mater Hospital and explored reasons for and impact of default. Medical records of all HIV-positive women delivering over a 3-year period (2007 to 2009) were reviewed to ascertain how many defaulted from their own care postpartum. Defaulting was defined as not attending appointments straight after delivery or during the next 6 months for a period of at least 6 months. This cut-off value has been widely used in other studies to evaluate retention in HIV treatment. Reasons for defaulting from care were noted. Women who attended were compared to women who defaulted to identify contributing factors to maternal default. Medical outcomes for these two groups were assessed. Data collected included age, HIV viral load, CD4 cell count, dates of connection to care, Emergency Department attendance, socioeconomic level, reasons for default, reasons for reattendance, and child’s HIV status. Normally distributed data were analyzed using t-test or ANOVA; non-normally distributed data were analyzed using the appropriate nonparametric equivalent (Mann-Whitney U or Kruskal-Wallis) tests. Univariate associations between categorical variables were explored using the v or Fisher’s exact test for variables. Multivariate analysis was performed using logistic regression. Tests were two-tailed and p < 0.05 was considered significant. Statistical analyses were performed using SPSS version 18. Between January 1, 2007 and December 31, 2009, 71 HIVpositive women delivered at the Rotunda Hospital and were referred to the Mater ID clinic postnatally. Of these, 27 (38%) did not follow up postpartum and 16 (59% of defaulters) started defaulting straight after delivery. Reported reasons for defaulting are listed ( b T1 Table 1). In 11 cases (40% of defaulters), reasons were not recorded as all attempts to contact the woman had been unsuccessful. Avoidance was recorded when patients were happy to present in other hospital departments but not in the Infectious Diseases clinic or when they actively mentioned a reluctance to come in or issues with secrecy, fear of recognition, or stigma before defaulting. Univariate analysis of patient characteristics ( b T2 Table 2) showed higher default rates when: