On both occasions when Mary Atieno* gave birth in her home district of Suba, western Kenya, she knew that going to one of the health centres would be safer, but she was too afraid that the routine HIV test might reveal that she was HIV-positive.
"I normally just deliver at home with the help of traditional birth attendants, because when you go to these modern government hospitals they put you through certain tests which reveal even your HIV status," Atieno told IRIN/PlusNews.
"I fear this, because I have seen other women chased away by their husbands after testing positive to HIV." She still does not know her status.
HIV testing is routine in programmes for the prevention of mother-to-child transmission (PMTCT) of HIV, and most hospitals offer it as part of antenatal care. But many women in Kenya's western Nyanza Province say pre-natal HIV tests are a direct threat to their marriages.
"During my last pregnancy ... I was referred to the laboratory for tests after counselling. I was initially told to bring my husband for the test but he declined. After much prodding, he agreed to accompany me but refused to be tested; after the test, it turned out that I was positive," Jane Awino*, also from Suba, told IRIN/PlusNews.
"When my husband heard about it, he just turned violent and beat me senseless, and chased me from home together with the children, claiming I am a prostitute," she said. "But inside I knew I had never cheated on him."
Mediation attempts by community elders to salvage the marriage were fruitless, and Awino and her five children are now living with her mother.
Suba District medical officer Dr Aggrey Ouko said despite campaigns to bring more women to hospital for PMTCT services, the fear of an HIV diagnosis and its repercussions were keeping women away from antenatal care programmes.
"Men still believe that it is only women who can be a source of HIV in the family, and most of them turn very violent on realising their HIV status," he said. "It is interesting that even those men who are known to be in the business of inheriting widows still turn around to blame their wives for their predicament."
According to a 2005 study of PMTCT in Nyanza Province, 80 percent of clients did not return for follow-up counselling, regardless of their HIV status, and 95 percent did not disclose a positive HIV diagnosis to spouses and relatives for fear of stigma, discrimination and violence.
Need for women to be empowered
"Numerous organisations have carried out campaigns to empower women here, but the responses have not been very impressive because of the low level of education, and the importance women put on marriage," Ouko said.
Bretta Masinde, a social worker at a Suba-based NGO, said there was a need to involve men in PMTCT. "Most of these programmes alienate men, and this makes them see us, the social workers and the women, as enemies out to finish them," she said.
The issues of women's low self-esteem, dependence on men and the institution of marriage, needed to be addressed while girls were still young. "Women believe in it [the importance of marriage] so much that they would sacrifice their health to keep the marriages," Masinde said.
Nyanza has some of the country's highest school-dropout rates, and girls in the province start having sex earlier than those in the rest of the country.
HIV-prevalence in Nyanza is 15.3 percent, according to the 2007 Kenya AIDS Indicator Survey, more than twice the national average of 7.8 percent.