Opinion of Doctors on discrimination of women patients suffering from

Hepatitis C during pregnancy at public and private hospitals of Islamabad

Abstract:
Background: Hepatitis C is viral disease that affects the liver in humans;
globally it is very prevalent disease and a frequent cause of death. This study
explored the HCV screening pattern during pregnancy and to establish national
guidelines for HCV screening in the light of international guidelines during
pregnancy based on suggestions of experts.
Methodology: A mix method cross sectional survey was conducted including
gynecologist and obstetricians professionals working in the different government
and private medical institutions. Sixty-four professionals were selected for
quantitative part while fifteen were selected for the qualitative part. In dept
interviews were conducted and using a questionnaire quantitative data was
collected. Data was presented in the narrations, graphs and tables. Frequencies
and proportions were calculated.
Results: Among the study participants 85.9% experts agreed that we can follow
international guidelines for HCV screening in our settings. The majority of the
experts provided that National screening guidelines should be based on risk factor
based. It was observed by the expert opinion that there is social and mental
stigma among the pregnant females positive for HCV i.e. Feel badly labeled
73.4%, Discrimination during antenatal visits 29.7%, Discrimination during
delivery 56.2%, Not sure about breast feeding 81.2%, Problem facing during baby
care 50%, Personal relationship problems 65.6%, Problems at family level 59.3%,
Social discrimination 73.4%, Mental stress 79.6% and Discrimination at job/work
place 48.4%. Study participants provided that universal screening during
pregnancy is necessary because of the various reasons including safety of the
health care providers and to aware the health care providers about the safety
measures during handling of a HCV positive case, Prevent the vertical
transmission and it will provided the estimate about the HCV burden among the
population especially among the pregnant population.

Conclusion: Study concluded that there is social and mental stigma among the
pregnant females positive for HCV.

Key words: Stigma, Negligence in treatment, women health, infectious diseases,

Hepatitis infection.
Introduction:

Globally HCV prevalence among pregnant women ranges from 0.15% to 2.4%. In
Pakistan 3% population is suffering due to hepatitis C virus (HCV). HCV among
pregnant population was 3.3% to 29.1%. Screening of some potential diseases
during early pregnancy has led to the improvement of the health of mothers and
newborns (1,2). Persistent HCV infection is responsible for liver cirrhosis, cancer,
liver dysfunction and finally increases the fatality rate. HCV remained responsible
for the maximum deaths among HIV positive patients who are receiving antiviral (3,
4). The identified risk factors associated with HCV infection among pregnant
population include use of contaminated syringes , blood exchange, Co-morbidity and
unsafe sexual contact, (5). Throughout the World, the prevalence of HCV among
pregnant women range between 0.15% and 2.4%. US, Europe and Egypt reported
HCV among pregnant ladies as 8.6% (6).

Mother to infant spread of HCV was reported around 10% and the crude rate
remained as 5.6%. Worldwide during pregnancy diagnostic is not appreciated by The
Canada Public Health Department and center for disease control (CDC) America (7).
No known stop method in the world is available to prevent the spread of HCV from
infected mothers to their newborn but it is recommended that high proportion of HCV
positive women may be decreased with appropriate management (8). Pregnancy,
however, may be an important time to screen for HCV infection. Many women will
already have reached their peak likelihood of becoming infected by the time they
become pregnant, making the yield of testing near its maximum. Screening at this
point in a woman’s life can also provide early diagnosis and treatment that may offset
the future burden of HCV on the health care system. Further, testing for HCV during
pregnancy may help to identify infected newborns, allowing for appropriate follow-
up. In CDC guidelines HCV screening among pregnant women is not recommended.
But in Pakistan diagnostic of HCV among the pregnant females has been advised at
every health care center. But prevention of the spread of HCV from the infected
mothers to their newborn is still not known (9). The current study is designed to probe
into the reasons for this screening in Pakistan and to get suggestions for national
guidelines.

Methods:

This was a cross sectional study design with mixed method approach involved the
consultant Gynecologists from the Government and autonomous medical
institutions of Islamabad (Federal Government Hospital, Pakistan Institute of
Medical Sciences, Capital Hospital, KRL General Hospital, PAEC Hospital,
Social Security Hospital). Sixty-four consultants were invited for the interview of
pretested, validated and piloted questionnaire for to complete the quantitative part
of this research and fifteen were invited for in-depth interviews till the saturation
level achieved. Both findings were triangulated and results were finalized as per
the objectives. Data was collected by contacting the selected participant and venue
and time for meeting was decided. A questionnaire was offered to fill in with set of
questions. On qualitative aspect experts were be asked set of questions under sub
headings of main list and offered open ended questions and expected time was
between 15 to 30 minutes. Note taker has assisted the research. Departmental
permission for the current study was taken by writing a permission letter of health
serviced academy comprising type of study, purpose, time and expected duration
of study and issues of confidentiality. Informed individual consent was taken,
stating the purpose, nature of study.

Results:

A total of 64 experts were participated in the current study. All the participants
were either Gynecologist or obstetrician professionals with minimum experience
of 3 years. Among the total participants 73.4% (47) agreed that pregnant women
positive for HCV feel themselves badly labeled while 25% (16) experts disagree
with this statement and 1.5% (01) does not have any idea in this regard . Study
participants 81.2% (52) experts agreed with the statement that HCV positive women
remain ambiguous/ unsure about the breast-feeding. Among the total experts 65.6%
(42) provided that they are aware about the personal relationships problems facing by
the pregnant women positive for HCV. Majority 73.4% told that they agreed with the
statement that HCV positive pregnant women face various discriminations. Mainly
79.6% (51) told that they are aware about the mental stress faced by pregnant women
positive for HCV during pregnancy and after delivery phases. Among the total
experts 85.9% (55) experts agreed with the statement that we can follow international
guidelines for HCV screening in our settings. Almost 92.1% (59) experts
recommended universal HCV screening of pregnant women. Out of the total experts
85.9% (55) experts told that there is a requirement of the National guidelines for HCV
screening among the pregnant women. (Table-2)

Table 1: Expert’s view on different opinions

Variables Agree Disagree Strongly No idea

agree

N % N % N % N %

Discrimination during 19 29.7 32 50 9 14.1 4 6.2

antenatal visits

Ambiguous/unsure about 52 81.2 4 6.2 1 1.6 7 10.9

breast feeding

Problems during baby 42 65.6 5 7.8 0 0 17 26.6

care
Discriminations face 47 73.4 3 4.7 1 1.6 13 20.3
socially

Discriminations at 31 48.4 17 26.6 1 1.6 15 23.4

job/workplace

Screening of pregnant 42 65.6 7 10.9 3 4.7 12 18.8

women as per guidelines

Risk factor based HCV 41 64.1 17 26.6 3 4.7 3 4.7

screening in pregnant
women

Out of the total experts 85.9% (55) experts told that there is a requirement of the
National guidelines for HCV screening among the pregnant women. 14.1% (9)
provided that there is no need for the guidelines at National level we can follow
international guidelines (Figure 1).

Figure 1: Experts opinion regarding requirement of national guidelines for HCV

screening among the pregnant women (n=64)

100.00%
90.00% 86%
80.00%
70.00%
Percentage (%)

60.00%
50.00%
40.00%
30.00%
20.00% 14%
10.00%
0% 0%
0.00%
Agree Disagree Strongly No Idea
Disagree
Do we need national guide lines for HCV screening?

Qualitative findings:

The qualitative research question for this study was to establish national guidelines for
HCV screening in the light of international guidelines during pregnancy - suggestions
of experts’ forum (Gynecologist and obstetricians professionals, Islamabad).

1. Screening HCV during pregnancy: The experts provided that universal

screening during pregnancy regarding HCV is necessary because of the safety of the
health care providers and to aware the health care providers about the safety measures
during handling of a HCV positive case.

2. Universal HCV Screening during breast-feeding: The maximum of the

participants said that it’s the best time to screen the females if she got positive for
HCV she will administered the treatment because after delivery interferon therapy is
safe.

3. Risk factor based screening: Majority of the experts were agreed with this theme.
One of the participants pointed out that this is very important for pregnant lady and
her baby. The remaining participants disagree with the theme and provided that we
should screen all the pregnant ladies and three should be universal screening
mechanism that must screen all females presenting in the hospital with pregnancy.

4. Replication of international guidelines as National guidelines: The maximum of

the experts provided that we couldn’t replicate the international guidelines as National
guidelines because in our country we have the different circumstances and have
different cultures and believes.

5. Suggestions for National Guidelines for HCV Screening: The majority of the
experts provided that National screening guidelines should be based on risk factor
based. The pregnant ladies with risk factors must be screened for the HCV because
the incidence of the HCV is increasing day by day and it is mandatory to screen at
least risk factor based pregnant ladies.

Discussion:

According to CDC guidelines the screening of pregnant women regarding HCV is not
advised during pregnancy because at that time females cannot be administer treatment
(10)[33]. In the current study the expert opinion regarding the universal screening
during pregnancy because of the various reasons including safety of the health care
providers and to aware the health care providers about the safety measures during
handling of a HCV positive case, HCV screening is important during pregnancy to
prevent the vertical transmission. According to current study it was also concluded
that normally people don’t come for screening and it’s the best time to screen the
females when they are pregnant because during pregnancy they must have to come for
antenatal visit and it’s the chance to screen all pregnant females and it will provided
and estimate about the HCV burden among the population especially among the
pregnant population. According to current study it was observed that HCV screening
is necessary because to prevent transmission of HCV mother to baby.

According to another published study provided that among the pregnant women
around 8% there are chances of the spread of Hepatitis C from infected mothers to
their offspring but exact phase of that spread is still unknown (11). In the current
study according to the experts is was recommend that universal screening during
breast feeding is necessary because if she got positive for HCV she will administered
the treatment furthermore screening is recommended to stop the vertical transmission
and for proper management of the positive cases to avoid further spreading of the
disease. Some already done researches provided that there is possibility of the
presence of HCV in the breast milk but quantity remain very low as compared with
the quantity in the blood. The importance of these findings is not yet clear and while
there is a theoretical risk of transmission, no case has yet been reported (12).

According to current study the majority of the experts provided that universal
screening will not be a burden on the government instead it will be the beneficial in
long run. Similarly experts said that universal screening regarding HCV will be a big
financial burden for the patients and this is responsibility of the stat to provide a
universal screening. Experts also provided that we should screen all the pregnant
ladies and three should be universal screening mechanism that must screen all females
presenting in the hospital with pregnancy. According to some published studies it was
observed that screening on the basis of determinants regarding is better than the
universal screening method. By using determinant based we can miss the person who
mislead the question or recall bias can occur. It has been provided that determinant
based screening will pick 85% of the cases (13). Delay in diagnosis and treatment
will results in the cases with more complications some of those may develop
condition and are not curable by this there will be more burden of the case on the
hospitals and economic burdened ultimately the disease burden will grow (14).

According to current study the majority of the experts provided that we cannot
replicate the international guidelines as National guidelines because in our country we
have the different circumstances and have different cultures and believes. But few
experts provided that we can follow the international guidelines with a few
modifications according to our circumstances and according to our problems. At
international level it was found that there are contradictions regarding the screening of
the pregnant women for HCV for example in America diagnosis of all the expecting
females remained only 1% (15)[38]. In UK patients not seemed to oppose the concept
of HCV diagnostic when population were given option of screening for all 84%
women were willing and 92% women were against (16). At Vienna a comparative
study of universal and targeted HCV screening policy was provided that screening of
all will not provide HCV cases then determinant based screening. 21% women
provided that determinant based screening will not be beneficial(17) [40]. In another
study in Egypt risk based study of screening pregnant women for HCV it was
concluded that universal base screening was 100 % accepted and risk base screening
missed about 03 % chronically infected women (18). India published a study and
according to that approximately 62 % women with no known determinants when
screened they were positive for HCV (19).

It was observed by the expert opinion that there is social and mental stigma among the
female positive for HCV. The current study has highlighted that 73.4% experts
agreed that pregnant women positive for HCV feel them badly labeled, 29.7% experts
agreed that pregnant women positive for HCV face discriminations during antenatal
visits in the hospitals. Among the total experts 65.6% provided that they are aware
about the personal relationships problems facing by the pregnant women positive for
HCV and have discriminations at social and family level. According to published
study it was concluded that many women were not clear about transmission of HCV
and due to that there is problems in the family including those with husband, other
members and children. Women are worried about to the transmission of HCV and
their ability to carry out their social roles (20). Another study provided that problems
regarding Hepatitis C among the people is not because of the medical issues but
various other psychological determinants are also there. Those factors are also playing
significantly. And it was found that among the HCV positive females and level of
depression is higher as compared with the negative females (21). In another research
it was found that the most shocking results were with broken marriages or major
stressors on disturbance of sexual contacts were reported among 17% of the
participants (22).

Conclusion: Study concluded that there is social and mental stigma among the
pregnant females positive for HCV. There should be strict criteria of blood
screening before blood transfusion during delivery and instruments must be
sterilized before any sort of procedure.

References:

1. Cooke GS, Lemoine M et al. “Viral hepatitis and the Global Burden of
Disease: a need to regroup”. J Viral Hepat 2013;20:600-601.

2. Mohd Hanafiah K, Groeger J, Flaxman AD, Wiersma ST. Global

epidemiology of hepatitis C virus infection: new estimates of age-specific
antibody to HCV seroprevalence. Hepatology 2013;57:1333-1342.

3. Lauer GM, Walker BD. Hepatitis C virus infection. N Engl J Med

2001;345:41-52.

4. Causes of death in HIV-1-infected patients treated with antiretroviral therapy,

1996-2006: collaborative analysis of 13 HIV cohort studies. Clin Infect Dis
2010;50:1387-1396.

5. Silverman NS, Jeukin BKet al,. “Hepatitis C Virus in pregnancy:

Seropervaleuce and risk factors for infection”. Am Obstet
Gynaecol.1993;169(3):583–587. 

6. Costa ZB, Machado GC et al. “Prevalence and risk factors for Hepatitis C and
HIV-1 infections among pregnant women in Central Brazil”. BMC Infect Dis
2009; 9: 116.

7. Kimberly A, Workowski, Stuart Berman. Sexually Transmitted Diseases

Treatment Guidelines, 2010. department of health and human services Centers
for Disease Control and Prevention, 2010.
8. Gibb DM, et al. Mother-to-child transmission of hepatitis C virus: evidence
for preventable peripartum transmission. Lancet 2000; 356: 904–907.

9. Horne C. Knowledge update on screening for hepatitis C virus in pregnancy

2011. 1-10].
10. Miriam J. Alter, Margolis HS. “Recommendations for Prevention and Control
of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Diseas”.
Atlanta, Georgia: Centers for Disease Control and Prevention (CDC) Atlanta,
Georgia, 1998.

11. Mona R Prasad,  Jonathan R. Honegger et al., “Hepatitis C Virus in

Pregnancy”. Am J Perinatol”. Author manuscript, 2013.

12. Kage M, Ogasawara S, Kosai KI, et al. “Hepatitis C virus RNA present in
saliva but absent in breast-milk of the hepatitis C carrier mother”. J
Gastroenter Hepatol 1997;12:518-21.

13. Coffin PO, Stevens AM, et al. “Patient acceptance of universal screening for
hepatitis C virus infection”. BMC Infect Dis. 2011;11:160. 

14. Wong JB, McQuillan GM, McHutchison JG, Poynard T. “Estimating future
hepatitis C morbidity, mortality, and costs in the United States. Am J Public
Health”. 2000;90(10):1562–9.

15. Plunkett BA, Grobman WA. “Routine hepatitis C virus screening in

pregnancy: a cost-effectiveness analysis”. American journal of obstetrics and
gynecology. 2005;192:1153. 

16. Ward C, Tudor-Williams G et al., “Prevalence of hepatitis C among pregnant

women attending an inner London obstetric department: uptake and
acceptability of named antenatal testing”. Gut. 2000;47:277–80.

17. Diab-Elschahawi M1, et al., “Evaluation of a universal vs a targeted hepatitis

C versus screening strategy among pregnant women at the Vienna University
Hospital”.

18. El-Kamary SS1, Hashem M2, et al “Reliability of risk-based screening for

hepatitis C virus infection among pregnant women in Egypt”.

19. , Sharma A, Ashok K et al. “Prevalence and risk factors for hepatitis c virus
among pregnant women”. Indian J Med Res 2007;126:211-5.

20. Gillian Grundy  and Nicholas Beeching, “ Understanding social stigma in

women with hepatitis C” Nursing 2004, Standard. 19, 4, 35-39. 

21. Yesim Erima, Sefik Tagaya et al.,  “Depression and protective factors of

mental health in people with hepatitis C: A questionnaire survey, International
 Journal of Nursing Studies”, Volume 47, Issue 3, March 2010, Pages 342–
349.

22.  Kadushin G. “Gay men with AIDS and their families of origin: an analysis of
social support. Health Soc Work”. 1996;21:141–149.