Barriers and Solutions Pertaining to Pradhan Mantri Matru Vandana Yojana (PMMVY) Implementation in a Block of West Bengal: A Mixed-Methods Approach

Introduction: Improvement of maternal health care services will not only put a positive impact on maternal health, but also on the health of the new born. Objectives: This study was conducted to estimate the proportion of eligible beneficiaries who received the benefits provided by the scheme, to identify the barriers faced by the beneficiaries and health providers related to the scheme and to find possible solutions to overcome the barriers found as suggested by them in a block of West Bengal. Method: A cross-sectional study with sequential explanatory mixed-method approach was conducted in a block of West Bengal from January-December 2021. Quantitative data was collected from the digital portal of PMMVY. All beneficiaries who had their Last Menstrual Period (LMP) on and after 1st March 2020 up to 31st December 2020 were included. To identify the barriers faced and suggest possible solutions, Focused Group Discussions (FGDs) were held with the beneficiaries, ANMs and ASHAs and Key-Informant Interviews (KIIs) with the Block Medical Officer and Data Entry Operator. Data were analyzed using SPSS version 25.0. Descriptive statistics were used to summarize quantitative data while qualitative data were analyzed in the form of themes, codes and verbatim. Results: Total eligible beneficiaries for the three installments were 1066, 917 and 708 respectively. About 95.5% beneficiaries received the first installment, 93.0% received the second and 98.3% had received the third installment. The broad themes [codes] generated from the FGDs were challenges during antenatal care [ANC refused, home visit preferred, home ANC difficult, lockdown], challenges related to the PMMVY scheme [documents unavailable, incomplete forms, payment issues], possible solutions [prepare pre-requisites beforehand, provide cash]. Widely two main themes emerged from the KIIs: Form related issues and Payment issues. Conclusion: Coverage of PMMVY scheme in the block was satisfactory. However, speeding the payment process and stricter monitoring of the scheme is required

Clinico-epidemiological profile of women with high-risk pregnancy utilizing antenatal services in a rural primary health center in India / Journal of Rural Medicine

Objective: Early detection and effective management of high-risk pregnancies can substantially contribute to the reduction of adverse maternal and fetal outcomes. This study aimed to determine the prevalence and clinical profile of women with high-risk pregnancies in rural areas who utilize antenatal services in a primary health center (PHC).Materials and Methods: A retrospective analysis was carried out over a six-month period by reviewing the mother and child protection cards maintained at the PHC’s Maternal and Child Health Center. During the study period, 950 pregnant women were registered, of whom 793 were included in the study based on the completeness of the records. Data analysis was performed using the licensed Statistical Package for the Social Sciences (SPSS) software version 21.0.Results: The prevalence of high-risk pregnancy among the antenatal women was 272 (34.3%) with 95% CI [31.1–37.7]. Of the 272 women, 240 (88.2%) had a single high-risk factor, while 32 (11.8%) had more than one high-risk factor. The major factor contributing to high-risk pregnancy was hypothyroidism (43.7% with 95% CI [37.9–49.6]), followed by a previous lower segment Caesarean section (LSCS) (19.1%).Conclusion: The study found that the prevalence of high-risk pregnancies was 34.3% in this rural setting. The majority of high-risk pregnancies were due to hypothyroidism, followed by more than one previous LSCS or abortion. Further research is required to track high-risk pregnancy outcomes and investigate the newborn thyroid profile of women with hypothyroidism.

Antenatal women's childbearing practices at the Niger Delta university teaching hospital, Okolobiri Nigeria

Background: Overpopulation in a community or a country reflects high fertility desires of its citizens. A country can only progress meaningfully if its resources and amenities can provide for all its citizens. Objectives: To examine the childbearing practices of antenatal attendees at the Niger Delta University Teaching Hospital, Okolobiri, Nigeria and whether there is any suggestion of fertility decline or transition. Materials and Methods: A cross-sectional study of two hundred and fifty-two women who had antenatal care in the hospital during the study period. Data was collected using a structured self-administered questionnaire with a reliability coefficient of 0.85. Data collected were analysed using IBM SPSS Statistics version 25. Statistical significance was a p-value <0.05. Results: The mean age of the respondents was 30.5 ± 5.9 years. More than half (53.6%) had tertiary education and 39.3% had secondary education. Only 29.4% were housewives/unemployed. The median parity was 2 and 229 women accounted for previous deliveries of 596 babies. The median desired total number of children was 4 (range 1 to 8). More than half (56.3%) did not believe in spacing after the first child. Seventy-six (30.2%) had no knowledge of modern contraceptives. There was a significant relationship (p - 0.018) between child sex preference and number of births. Conclusion: With a current median parity of two children/woman and desired total number of children of a median of four children/woman, the childbearing practices of the population studied may not result in a fertility rate far below the Nigeria national average of 5.3 children per woman. Nevertheless, a study to derive the total fertility rate in the study population is necessary to determine whether or not there is ongoing fertility transition.

Birth Preparedness and Complication Readiness Among Pregnant Women Attending an Urban Health Centre in Surat, India

Background: Birth preparedness is an important strategy to reduce MMR. It includes knowledge of key danger signs; identification of: birth place; birth attendant, fund, transport and compatible blood donor for emergency use beforehand. Objective: This study aims to explore birth preparedness in Surat and determine factors associated with it. Methods: Study conducted facility based cross-sectional study among 310 antenatal women at Urban Health Training Centre attached to Government Medical College, Surat, Gujarat. Predesigned, semi- structured, pretested questionnaire was used for data collection after acquiring informed written con-sent. Result: A total of 310 women participated in the study. Mean age of participants was 22.9 + 3.6 years. Almost one-third (30.3%) of participants were illiterate. Almost six-tenth (61.9%) of participants were involved in unskilled or semi-skilled work and two-fifth (38.1%) of participants were homemakers. Ma-jority of participants (96.7%) were registered in first trimester. Most known factor during pregnancy as danger sign was bleeding (81.9%). BPACR index was calculated as ∑Indicator/7 which was observed to be 62.3%. There was statistically significant association between awareness about health problems dur-ing pregnancy and type of family. Conclusion: Raising awareness regarding components of BPACR among antenatal women will help to reduce morbidity and mortality in antenatal women and achieve sustainable development goal

Prevalence and outcome of gestational diabetes mellitus in women from rural population attending antenatal clinic at a teaching hospital, Tamil Nadu, India

Background: Prevalence of gestational diabetes mellitus shows wide variation across our country. From the recent studies, it is observed that incidence of gestational diabetes mellitus in antenatal women is increasing globally and India is not an exception from this. Gestational diabetes mellitus should be considered as a serious risk factor for both mother and baby as it affects two generations by having chance of developing diabetes and its related complications in future.Methods: A total of 585 pregnant women with 24 to 28 weeks of gestational age were recruited for the study. The study population was divided into four groups based on the age range; Group I include antenatal women with age <20 years, Group II includes antenatal women of age range 21-24 years, Group III includes antenatal women of age range 25-29 years, and Group IV includes antenatal women of age range ≥30 years.Results: In the present study GDM was diagnosed in 94 women among 585 antenatal women screened for GDM (16.06%). Majority of the studied population are in the age range of 20-29 years (441/585, 75.38%). The mean age of participants was 27.54±3.58 years (range 18-34 years). The prevalence of GDM was higher in the group of women aged ≥30 years (Group IV) followed by ≤20 years (Group I) (23.21% and 15.62% respectively) compared to the groups II and III (14.78% and 13.74% respectively). This observation was found to be statistically significant (p<0.001). Among 585 patients, delivery outcome was 100% successful, all delivered live babies, among them 64 patients delivered babies with macrosomia (11%).Conclusions: The study showed GDM prevalence of 16.06% from the neighboring rural villages attending our teaching hospital.

A prospective study of demographic profile, risk factors and pregnancy outcome in Hepatitis B and Hepatitis C virus positive pregnant women in a tertiary care centre

Background: Viral hepatitis is the most common liver disease in pregnancy and is also the most common cause of jaundice in pregnancy in tropical countries. Risk factors for transmission are intravenous drug abuse, surgical and dental procedures done without adequate sterilization of instruments, sexual route etc. Early diagnosis and management can prevent maternal and fetal complications. This study was done to evaluate the frequency, risk factors and pregnancy outcome in hepatitis B virus (HBV) and hepatitis C virus (HCV) positive antenatal women.Methods: This case control study was conducted in Teerthankar Mahaveer Medical College and Research Centre, Moradabad, Uttar Pradesh, India from January 2017 to June 2018 on total 2511 pregnant women. The serum samples were checked for presence of hepatitis B surface antigen (HBsAg) and presence of IgG antibodies to HCV. Analysis of sociodemographic profile, risk factors and pregnancy outcome were done in all HBV and HCV positive women.Results: Out of 2511 pregnant women, 292 were tested positive for hepatitis. Maximum number of women were in the age group of 21-30 years. Most of the seropositive women were multipara. Frequency of positivity was maximum for HCV (67.1%). The risk factors for transmission in study population were intravenous drug abuse, blood transfusion, history of surgery and tattooing.Conclusions: Hepatitis infection rate is increasing. Universal screening for HBV and HCV can be recommended in pregnant women in developing countries. Education and awareness of public and health care workers can reduce the risk of transmission.

Neuro-imaging in severe hypertensive disorders of pregnancy: a study from North Indian tertiary health care institution

Background: Hypertensive disorders of pregnancy comprising of pre-eclampsia and eclampsia are a major cause of adverse pregnancy outcomes. Neurological manifestations of pregnancy induced hypertension are the most common cause of maternal and foetal morbidity and mortality. Cranial neuro-imaging reveals focal regions of symmetric hemispheric oedema; with parietal and occipital regions getting most commonly affected.Methods: The study was conducted among 65 antenatal women diagnosed with pre-eclampsia and eclampsia at gestational age >20 weeks in the department of obstetrics and gynecology, Kamla Nehru State Hospital for Mother and Child IGMC Shimla. Clinical signs and symptoms, neuroimaging findings were recorded for study purpose.Results: About 17.6% of severe pre-eclampsia and 100% of eclampsia had findings observed on cranial MRI. Headache and visual complaints were most frequently recorded. PRES was the predominant neuroradiographic finding in present study and occipital lobe was commonly affected region. No significant difference was observed regarding blood pressure parameters between MRI positive and negative subjects.Conclusions: Neuroimaging in antenatal with severe hypertensive disorders might aid in better understanding of the poorly explained phenomenon. In addition, this would be helpful in better management of the disorders along with their much-dreaded complications. Patients with hypertensive disorders of pregnancy should be subjected routinely to cranial imaging for the better perinatal outcomes.

Lactate dehydrogenase as surrogate marker of preeclampsia and eclampsia

Background: Hypertensive disorders of pregnancy is a spectrum of disorder which include chronic hypertension that antedates pregnancy and gestational hypertension or pre-eclampsia that is unique to human pregnancy. It is still a poorly understood condition. The clinical course is progressive and characterized by continuous deterioration that is arrested only by termination of pregnancy. Hence the disease must be detected in early stage and managed appropriately for improved maternal and fetal outcome.Methods: The study consists of 173 antenatal patients of gestational age 28 weeks and above. Study population was divided into two groups, Group 1 consists of 50 antenatal women of normotensive nature served as controls and group 2 consists of 123 antenatal women with confirmed hypertension. Venous blood samples were collected used for the estimation of lactate dehydrogenase enzyme.Results: Out of the total 173 patients 104 women delivered by C-section, 67 by normal vaginal delivery and 2 by assisted breech delivery. Among the women who delivered by caesarean 60 (57.69%) had serum LDH less than 600, 18 (17.30%) had serum LDH between 600 and 800 and 26 (25.00%) had LDH above 800. Among the women who delivered vaginally 61 (91.04%) had LDH less than 600, 1 (1.49%) had LDH between 600 and 800 and 5 (7.46%) had LDH above 800. Only 2 women delivered by assisted breech delivery one with LDH between 600 and 800 and another with S. LDH above 800.Conclusions: The study was done in search of a valuable marker for preeclampsia and Eclampsia which would reflect the severity of the disease and would predict the maternal and fetal outcome. Such markers can help in decision making and can influence the current management protocols in order to achieve a better maternal and perinatal outcome.

Clinicohaematological study of anaemia in antenatal patients

Background: According to WHO, approximately 75% of pregnant women in developing countries and 18% in developed countries are anaemic. In India prevalence of anaemia is reported to be 33%-89% and is one of the important causes of maternal morbidity and mortality. The present study was done with the objective to study the socio-demographic factors related to anemia and the distribution of different types of anaemia in antenatal patients.Methods: A prospective analytical study was done on 205 pregnant females who presented with anemia (Hb <11 gm/dl) in 1st, 2nd and early 3rd trimester (up to 30 weeks of gestation) in the department of obstetrics and gynecology of Swaroop Rani Nehru Hospital, Prayagraj from September 2017 to September 2018.Results: The rural background with lower socio-economic status comprised majority of the anemic patients (65.9%) with the major cause being iron deficiency anemia (68.8%). The patients mainly presented with anemia at late second or early third trimester (82.4%). Clinical signs like pallor, oedema and symptoms like palpitations and dyspnoea were more associated with severe anemia than mild and moderate anemia.Conclusions: Anemia prevention and prompt detection is the need of the hour with effective management. In India, major cause of anaemia are nutritional deficiencies which can be treated by proper diet and medications. The advises of routine iron supplementation during pregnancy, regardless of whether the mother is anemic or not, is strongly recommended by this study.

A study to determine the prevalence of urinary incontinence in antenatal women at a tertiary care centre in central India

Background: Urinary incontinence is a common condition in pregnancy and postpartum. There are more than a thousand articles on urinary incontinence (UI) in pregnancy but very limited literature from Indian subcontinent is available. Incidence and prevalence figures of UI in association with pregnancy vary substantially. Not many reviews have focused solely on incidence and prevalence of UI in association with pregnancy. Prevalence of UI in pregnancy ranges from 32% to 64%.Methods: A cross sectional observational study was conducted in the department of obstetrics and gynecology, MGM Medical College and M.Y. Hospital, Indore over the period of 6 months on 1000 pregnant women who were following antenatal care (ANC) clinic. Pregnant women, who were severely sick, diagnosed with kidney or urinary infection and vaginal infections women were excluded from the study. The data were collected using a structured questionnaire. After the purpose of the study was explained, written consent was obtained from each voluntary participant. This study was approved by institutional ethical committee. The data was recorded in predesign coded case report form and statistical analysis was performed using the STATA 12.1.Results: In the present study the prevalence of urinary incontinence reported is 16.4% of women during pregnancy.Conclusions: In this study the prevalence of UI during current pregnancy was found to be lower compared to previous studies conducted. The previous history of surgery, constipation, obesity and respiratory problems were found to be significantly associated with UI during pregnancy.

HIV in pregnancy: a 9 year study of the seroprevalence, sociodemographic factors and pregnancy outcomes of seropositive women at a tertiary care hospital in Mumbai, Maharashtra, India

Background: HIV can cause considerable morbidity and mortality in those affected. An effective PPTCT programme helps in reducing the spread of HIV by vertical transmission and improving the life of the women and her baby.Methods: A retrospective study was done at a tertiary care hospital, including pregnant women registered and delivered at the hospital during a period of 9 years from January 2010 to December 2018. Pretest counseling, HIV testing, Post-test counseling were done and antiretroviral prophylaxis given as per the NACP guidelines. Sociodemographic characteristics, obstetric and maternal-foetal outcome of seropositive women and efficacy of PPTCT services were analyzed.Results: Out of the 58,205 antenatal mothers included, 55,256 (94.93%) accepted HIV testing. 171 of these tested positive (0.31%). 70 spouses of the 171 seropositive women tested positive, 53 tested negative and 48 did not undergo the HIV test. Majority of seropositive women were primigravidas; housewives from urban areas, from low income and educational background and with no history of any contraceptive use. 7.6% had an MTP, 1.75% a spontaneous abortion and 0.58% an ectopic pregnancy. Of the 154 births, 35.71% underwent caesarean sections. There were 96.7% live births in our study and the perinatal mortality rate was 5.19%. After 2013, all mother-baby pairs were given ARV prophylaxis.Conclusions: Utilization of PPTCT services has increased through the years, decreasing the vertical transmission and seroprevalence rate. Increasing the acceptance rates of HIV testing, both by patients and partners may further help in curbing the spread of this condition.

Knowledge of gestational diabetes mellitus among antenatal women in rural area of Maharashtra

Background: Gestational diabetes mellitus (GDM) is a growing epidemiological problem. GDM is defined as glucose intolerance during pregnancy. Treatment of GDM is important to avoid maternal and fetal complication. The objective of this study is to assess the knowledge about gestational diabetes mellitus among antenatal mothers from rural area.Methods: A descriptive cross-sectional study was done among 193 antenatal mothers in rural hospital, Murud. A study was done between July 2018 to August 2018. A pretested questionnaire was used to assess knowledge about GDM among all antenatal mothers.Results: Among the participants, 48.19% were in the age group 21-25 years and 90.15% antenatal mothers were literate. 80% heard about diabetes mellitus and 38% mothers knows that diabetes can occur first time in pregnancy. Only 28.50% mothers heard about GDM from different source of information.Conclusions: The study shows average knowledge about gestational diabetes mellitus among antenatal mother.

Seroprevalence of Human Immunodeficiency Virus among Antenatal Women in a Tertiary Care Hospital, India

Introduction: Human immunodeficiency virus (HIV) infection israpidly increasing in world as well as in India since thedetection of first acquired immune deficiency syndrome (AIDS)case in Chennai in 1986. Having seroprevalence rate of lessthan 1%, India is considered as low prevalence country but dueto large population this low prevalence convert in a hugesubset of HIV positive people. Unfortunately India shares onethird of total HIV positive cases of the world. Estimating the HIVseroprevalence in a low risk population of pregnant womenprovides vital information for the successful implementation ofAIDS control program and also for monitoring trend of HIV ingeneral population. Therefore, screening of pregnant women inearly pregnancy may help in prompt counselling and therapy,thereby bringing down the mother to child transmission of HIVinfection.Objective: To determine the rate and trends of seroprevalenceof HIV among antenatal women.Materials and Methods: It is a retrospective study conductedat PPTCT centre, Rajendra Institute of Medical Sciences(RIMS), Ranchi, a tertiary care referral hospital in Jharkhandstate of India from January 2014 to December 2016.The testswere done as per NACO guidelines using COMBAIDS-RSAdvantage-ST, HIV-1/2 TRISPOT and MERISCREEN HIV 1-2WB tests.Results: 19266 antenatal women were included in this study.Out of this 57 women were detected to be positive for HIV,accounting for 0.32% prevalence rate. HIV seroprevalenceamongst antenatal women is 0.32% which is in agreement withthe national projection (0.29% as per NACO annual report2014-2015). HIV seroprevalence rates showed a decreasingtrend from 0.32% in 2014 to 0.16% in 2016.Conclusion: Every antenatal woman should be screened forHIV. Appropriate antenatal screening, interventions andpreventive strategies might bring down the mother to childtransmission of HIV.

Incidence of Significant Bacteriuria among Pregnant Women in a Teaching Hospital of Rural Setup

Aim This study was carried out to determine the prevalence of asymptomatic bacteriuria in pregnant women attending a teaching hospital in rural setup. Materials and Methods A total of 600 women were recruited for this study. A total of 200 antenatal women were clinically identified to have no signs and symptoms of UTI, 200 antenatal women were having signs and symptoms of UTI, and 200 were non-pregnant women that were studied as controls. Clean catch midstream urine samples were collected from each patient into a sterile universal container from Gynecology and obstetrics department and general medicine department. The urine samples were examined microscopically and by the cultural method. Identification of isolates was carried out by a standard microbiological technique. Result A total of 272 (45.3%) were positive for significant bacteriuria. There was a significant difference in the prevalence of asymptomatic bacteriuria with respect to age (P< 0.0001). Trimester did not show any significant difference (P = 0.2006) in the prevalence of asymptomatic bacteriuria. Escherichia coli was the most predominant organism followed closely by Klebsiella species. Nitrofurantoin, ampicillin, and levofloxacin were mostly used antibiotics. Conclusion Asymptomatic bacteriuria is not uncommon among antenatal patients in the population studied. Routine urine cultural test should be carried out on all antenatal patients in order to identify any unsuspecting infection. This measure will go a long way in reducing maternal and obstetric complications associated with pregnancy.

Clinical and Immunohaematological Course of 64 Cases Of Antenatal Rh D Alloimmunisation At A Tertiary Care Centre In India.

Background and Objectives: Incidence and outcome of Hemolytic disease of Fetus and New-born due to RhD alloimmunisation has changed in last few decades after the advent of RhIG and other diagnostic and therapeutic tools. But reports from different centres vary. In this study Rh D sensitised antenatal women were followed up at Medical college, Trivandrum and clinical &laboratory profile analysed. Objectives of the study are to describe the clinical &laboratory profile of Rh D alloimmunised pregnant ladies and to describe severity and treatment of Hemolytic Disease in their off springs. Materials and Methods: Cross sectional study done on 64 antenatal cases, positive for anti Rh D antibodies by ICT and followed up with serial titres and ultrasound. Cord blood values and Direct Coombs test were used to diagnose HDFN at birth. Data was analyzed in SPSS ver.17.catagorical data was expressed in percentages and continuous data was expressed with mean and standard deviation. Results: Out of 2,496 Rh D negative women tested with ICT, 78 (3.12%) were positive.54 RhD positive new-borns were DCT positive (93.1%).50.9% cases were unaffected or mild. Severe cases accounted for 10% only. Majority (50%) received no treatment and phototherapy was the major modality of treatment. Overall survival rate of affected new-borns was 92.18%. Out of 6 hydropic babies, 4 died in utero. Interpretations and Conclusions: Rh alloimmunisation is still prevalent among antenatal women, but majority of cases produces only mild disease in new-born. Survival rate in newborns is >90%. Hydropic babies have a higher death rate. Better strategies to prevent Rh D alloimmunization and introduction of interventions like IUT are warranted.

Prescribing pattern of iron preparations in antenatal women in a tertiary care hospital.

Iron deficiency anemia in pregnant women is a major health problem in India. According to WHO, anemia in pregnant women is described as Hb% < 11g/dl or hematocrit < 33% and all pregnant women are to be given a standard dose of 60mg and 120mg elemental iron for prophylaxis and treatment of anemia respectively. As per ICMR guidelines, the dosage has increased from 60 to 100mg for treatment of anemia. This study was done to study the prescribing pattern of iron preparations in antenatal women and to compare the elemental iron content in the drug. Fifty pregnant women were included in the study. Prescription analysis showed that 94% were given oral iron preparations and 6% were given I.V. injections. The commonly prescribed drugs were Ferrous Ascorbate(42%) and Sodium Feredetate(40%) containing elemental iron 100mg and 33mg respectively. The I.V. preparation used was mainly iron sucrose (6%). Since both the oral iron preparations were prescribed once daily, Ferrous Ascorbate should be preferred over Sodium Feredetate since the total elemental iron in Sodium Feredetate is not sufficient as per WHO and ICMR guidelines.

Utilization of the prevention of parent-to-child transmission of HIV (PPTCT) services in a tertiary care hospital, Odisha, India.

Aims: To assess seroprevalence of HIV among antenatal women and the extent of utilization of interventions to minimize the risk of mother-to-child transmission. Study Design: Descriptive cross-sectional study was carried out among antenatal women who attended integrated counseling and testing center (ICTC) of HIV. Sample sizes were determined from the number of pregnant women that attended ICTC. Place and Duration of Study: Data and samples were collected from a tertiary care hospital, Odisha, India during January 2009 to December 2012. Methodology: All pregnant women were counseled and tested for HIV by rapid test. All HIV-seropositive antenatal women (ANW) were linked to services and followedup for institutional delivery, single-dose nevirapine (sdNVP) prophylaxis, infant feeding options and testing of children at 18 months. Results: Out of 11,508 ANW registered and pretest counseled, 11,390 (98.97%) accepted HIV testing. Sixty women were found to be seropositive, thus showed seroprevalence rate of 0.53% (60/11,390). CD4 testing was carried out in all ANW and five (8.33%) were eligible for antiretroviral therapy (ART). Seven (11.67%) had opted for medical termination of pregnancy (MTP). All 48 ANW delivered institutionally, only 7 (14.58%) received cesarean delivery. Out of 46 live births, 5 (10.87%) ANW were on ART, 35/41 (85.37%) received sdNVP mother baby-pair prophylaxis and only 8/46 (17.39%) mother opted for replacement feeding. Twenty one children have reached 18 months till date and among them three (14.29%) were HIV-seropositive. All three were delivered vaginally, received sdNVP prophylaxis and were exclusively breast fed for 6 months. Conclusion: The HIV-seroprevalence rate among antenatal women was 0.53% and mother-to-child transmission (MTCT) rate was 14.29%. Reduction in MTCT rate needs pre or early antenatal HIV testing, prenatal antiretroviral medication, preference for cesarean delivery, 100% antiretroviral prophylaxis coverage and education on avoidance of breast feeding.