Ethical considerations in maternity services to HIV positive pregnant women - Essay Example

Ethical considerations in maternity services to HIV positive pregnant women Ethics are a very important part of care service provision and from its inception, this project's aim was to gain equity in access to and safety of care. The author's view of ethics is as follows; Ethics is a generic term used to refer to the several different ways of examining and understanding moral life. The health care service has morality standards of conduct that are generally acknowledged and accepted by the majority of health care professional. These standards include; Respect for autonomy Beneficence Non maleficence Justice Confidentiality Unfortunately within the current climate of limited and finite resources available for health care provision, it is very easy to overlook our moral responsibilities whilst focusing on balancing books and meeting targets. Because they form a small percentage of the whole, HIV positive pregnant women were being overlooked. The rarity of HIV amongst pregnant women meant knowledge of its management in pregnancy amongst midwives was limited. HIV positive pregnant women, although a minority in most of the hospitals, require special care with much of ethical considerations in order to help them to deliver a child avoiding the chances of vertical transmission as far as possible. This requires awareness not only for the patient but also for the people especially midwives who are dealing with them. It is reported that only about 50% of the people in Africa returns to hospital for any such care after diagnosing positive for HIV and only about 23% are taking antiretroviral therapy which is meant to keep the viral load to a safer minimum level (Carter, 2008). Worldwide statistics revealed that only one-third of the HIV positive pregnant women take the services rendered (World vision UK, 2008). Their unwillingness to access antenatal classes meant that their knowledge of how to prepare for labour delivery and the postnatal period was very poor. Developing the specialist antenatal class aimed to improve this by providing standard antenatal class information as well as information regarding HIV, its impact on pregnancy, delivery and postnatal care and what choices were available. Due to the nature of HIV, choice of mode of delivery is limited and it could be argued that it is not true choice as the planned mode of delivery is dependant on viral load at thirty-six weeks. Most of the women prefer a vaginal delivery. But the doctors would recommend only caesarean, if the viral load is higher than 1,000 copies/ml at the time of delivery or at 36 weeks. During the pregnancy period, if the patient has taken only AZT and no other medications and if she has not received the special prenatal care for HIV positive women, then also doctors would suggest caesarean (Delivery Options for HIV Positive Pregnant Women, 2008). Therefore the patient has to undergo antiretroviral therapy much before the due date so that the viral load could be reduced by the due date and can have a safe vaginal delivery. She also has to take the required medications and prenatal care in order to have a vaginal delivery. So even if a woman wanted to have a vaginal delivery, if her viral load remained high at 36 weeks, the obstetrician would recommend that she has an elective LSCS. This is a simplification of autonomy. It's the author's belief that to ensure true autonomy, regardless of the limited choices available, HIV positive women had to be provided with all information necessary to help them make a conscious choices to follow recommended actions. Most of the HIV positive women would be hiding the facts about the disease from their relatives, friends and even from their family members. So they may not come forward asking for the services. It is also not possible to compel them to take services. But an appropriate counselling would help them to understand the importance of these services for them as well as for their child. So these services has to be offered while respecting the autonomy. It is often forgotten that respecting autonomy also involves respecting choices that go against our recommendations as health care professionals. In empowering women through the provision of information, it was hoped that there would be a shift in the nature of the patient / health professional relationship making it more of a partnership where women felt they could ask questions and discuss available treatment choices and less of a paternalistic one which it appeared to be. Offering such a situation would be highly beneficial to them, thus it serves beneficence also. Confidentiality is very important while dealing with HIV positive women. Most of the HIV women prefer to have a vaginal delivery because they do not want their family to know that they are HIV positive. It is also not possible to breast feed the child since that is having a greater risk of vertical transmission. If it is LSCS and there is no breast-feeding, people would sense that some problem is there. If it is normal delivery, then some reason could be told about absence of breast-feeding. Because of the stigma associated with condition, women would not disclose these facts even to their closest family members. They could not be blamed for that because most of their forerunners who have disclosed about the disease to the family members ultimately got isolated and ill-treated by the family as well as the society, mainly because the public is not much aware of the disease and how it is transmitted. So the HIV positive women are not in a position to get a support either from family or friends in this highly traumatized situation. It is therefore the responsibility of the healthcare professional to give them all the needed support without being asked for. So throughout the period of service, strict confidentiality is maintained. Setting up the antenatal class had to be done bearing in mind the women's need for confidentiality. By attending the class women would be choosing to disclose their diagnosis to others. To ensure true choice in this decision, women were made aware of what the programme for the day would be, and who would be attending. Considering the fact that the majority of HIV women accessing maternity services have not disclosed their diagnosis to people other than their partners, attending the class was a big step for them. Once the decision to attend the class has been made, it is still the responsibility author's responsibility to ensure that confidentiality was maintained from those not attending the class. To achieve this, there was no advertisement of the class at the venue or anywhere else. Frequent screening of the conditions is highly essential for the HIV positive pregnant women because, HIV together with pregnancy would expose them to different types of infections because of the suppressed immune system (Temmerman, 1994). A large percentage of HIV positive women accessing maternity services were already disadvantaged due to low income and yet they were required to attend hospital more frequently. Moreover they will be forced to disclose the reason behind the frequent visits to at least the close family members. Most of them are employed and therefore will not be in a position to take frequent leaves from the job without giving a proper reason. If the diagnosis has been made recently, the emotional stress would be very high and there would be tendency to avoid medical visits. Reducing the number of appointments required would not only reduce the financial strain but also mean less need to explain such frequent attendances to their employer, family and friends. For those who are not in a position to buy milk for the child mainly due to lack of social security benefits, are provided with free formula milk up to 9 to 12 months. This would also prevent temptation of the mother to breast feed the child. Even then there would be pressures from the family members to feed the child. The patient is to be well prepared for such situations well in advance and sufficient support is to be given. The primary healthcare professionals in direct contact with HIV positive pregnant women are the midwives and nurses. But very often these people are not given any training to handle these highly depressed patients. They are not even consulted while preparing plans for such patients. It is necessary to develop a highly expertise medical team to handle such women, who are well aware of all the psychosocial conditions and the medical history and future plans for each and every HIV positive pregnant women. The team has to be given clinical training, leadership training as well as salary support to motivate them to support these patients (Raisler and Cohn, 2009). The HIV positive women who come to know that they are HIV positive during the early screening go into a highly traumatic psychological condition in which they even forget the baby growing in their womb. They are facing the fact that they would die soon and this is a very difficult condition to handle even by well-experienced health care professionals. The awareness programme for service providers take all these factors into account and they are trained in such a way so as to handle the situation in the best possible way resulting less harm to both mother and baby. The antenatal class has been found highly effective in dealing such conditions. The class is a place where women with similar problem could gather. So they enjoyed much freedom of their expression and need not have to hide anything. Thus the place gave them a situation in which they could share their mental trauma and gather confidence. This would help them to share their difficulties and problems much better than individually. In this way the overall confidence of the person is increased to a considerable extent. The Antenatal/Delivery Pathway document developed in the project also includes many ethical considerations. As per the document, the easiness with which HIV positive women could contact healthcare professionals are improved in such a way that whenever they want to contact some of these professionals arrangements are made. Before commencing the treatment the psychological and social conditions of the patient are well studied to prevent interventions of these factors in the treatment. The hospital appointments dates are synchronized so as to reduce frequent visits to hospital. The midwives and other healthcare people associated with the patients are well aware of the confidentiality required to be kept for the autonomy, beneficence and non- maleficence of the patient. The results of the screening tests are to be compiled in such a way that it would be easy to assess the conditions and take appropriate decisions without any delay. There is also a HIV consultant who would closely monitor all the treatments. Help is also rendered for the patient to take a decision regarding the antiretroviral therapy well in advance so that confusions at the last minute could be avoided. After the delivery also, the care needed to be given to both mother and baby are well planned and well documented. All the aspects given in the document are explained to the women so that they also could follow each and every step in the required manner. Community leaders or the church leaders are people who have a profound influence in the life of blacks. It is highly necessary to include them also in the awareness programmes to help HIV positive people who are blacks to move forward in the life. This is especially true in the case of HIV positive pregnant women. If the church leaders also cooperate in the programmes organized for the benefit of both the patient as well as the new born, it would give a lot of confidence to patients. The project has highlighted the importance of the involvement of church leaders and has discussed the possibility to do so. Another important aspect that would affect treatment is the discrimination to blacks. Studies conducted in United States revealed that the percent of mortality due to AIDS is greater among the HIV positive blacks compared to HIV positive whites. It was also seen that HIV positive blacks experience greater satisfaction in the service they get when the service provider is of the same race rather than a white. (Cooper-Patrick et al., 1999). The difference is mainly in antiretroviral medications used (Moore et al., 1994). Studies conducted by King et al. (2004) revealed that blacks prefer to receive their medications and services from people of their race rather than from a white in order to have a better satisfaction and confidence. It is therefore necessary to include these minorities among the healthcare professionals of the hospital in order to ensure better care and considerations for HIV positive black pregnant women. This is necessary to stick on to morality standards of conduct especially 'justice' in order to ensure a better atmosphere for these patients. Any negative interactions between the patients especially HIV positive patients with their health service providers could seriously affect the health of these people (Bird et al., 2004) and in this case it would affect the new born also. Thus it could be seen that the HIV positive pregnant women requires a lot of ethical considerations in the health care services rendered to them. This is mainly because most of these patients are highly depressed and are not in a psychological condition either to think about them or about the unborn baby. Because of the stigma associated with the disease most of them would not disclose the matter of diagnosis even to the closest family members and therefore most of them would be unaware of the different services available to them. In order to handle such situation a medical team is developed with a set of guidelines known as Antenatal/Delivery Pathway document. This would enable the medical team to closely monitor each and every such patient and give proper counselling so that they are aware of all the services. The antenatal class provided is giving not only awareness, but also an environment of freedom of expression and sharing to these women. All these are done by keeping utmost confidentiality so as to respect autonomy of the patient. Efforts are taken to include church leaders also for the greater beneficence and confidence to these patients. It is also necessary to include blacks and other minorities in the medical team so as to avoid any chance of discrimination. References Bird ST Bogart LM Delahanty D L [2004] Health-Related Correlates of Perceived Discrimination in HIV Care. AIDS Patient Care and STDs. 18(1): 19-26. Cooper-Patrick L Gallo JJ; Gonzales JJ [1999] Race, gender, and partnership in the patient-physician relationship. JAMA. 282:583-589. King WD Wong MD Shapiro MF Landon BE and Cunningham WE [2004] J Gen Intern Med. 19(11): 1146-1153. Moore R D Stanton D Gopalan R Chaisson R E [1994] Racial differences in the use of drug therapy for HIV disease in an urban community. N Engl J Med. 330:763-768. Raisler J Cohn J [2009] Mothers, Midwives, and HIV/AIDS in Sub-Saharan Africa Journal of Midwifery & Women & apos;s Health, 50: 275-282 Temmerman, M Chomba EN Ndinya-Achola J Plummer FA Coppens M Piot P [1994] Maternal Human Imminodefiency virus - infection and pregnancy outcome. Obstet Gynecol. 83:495-501. Online references Carter, M. [2008] More HIV-positive pregnant women getting antiretrovirals, but still much more to do, says report. Accessed online at: http://www.aidsmap.com/en/news/AA3D6165-A438-4B59-AC63-DB7AFFB59B8C.asp Delivery Options for HIV Positive Pregnant Women [2008] Accessed online at: http://www.aidsinfo.nih.gov/contentfiles/DeliveryOptions_FS_en.pdf World vision UK [2008] World Vision makes government call on services for HIV positive mothers Accessed online at: http://www.worldvision.org.uk/server.phpshow=nav.2501 Read More