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African Journal of Primary Health Care & Family Medicine

On-line version ISSN 2071-2936
Print version ISSN 2071-2928

Afr. j. prim. health care fam. med. (Online) vol.11 n.1 Cape Town  2019 



Implementation of postnatal care for HIV-positive mothers in the Free State: Nurses' perspectives



Lumka MangoejaneI; Mokholelana M. RamukumbaII

IMaternal, Child and Women's Health Unit, Free State Department of Health, Bloemfontein, South Africa
IIDepartment of Health Studies, University of South Africa, Pretoria, South Africa





BACKGROUND: Postnatal care (PNC) provides the opportunity for protecting the lives of women infected with human immune deficiency virus (HIV) and their babies. The prevention of mother-to-child transmission of HIV (PMTCT) guidelines provide a framework for implementation of PNC. There has been no empirical evidence on how the nurses at the clinic level implement these guidelines. In addition, there are reports that PNC has been neglected in South Africa.
AIM: The study aimed to explore the implementation of PNC for HIV-positive women, by explicating nurses' views regarding their practices
SETTING: The study was conducted in 2015 at three clinics at Mangaung Metro Municipality in the Free State.
METHODS: A qualitative, evaluative case study was conducted to provide a detailed account of the implementation of PNC, using 2015 PMTCT guidelines as a framework for evaluation. Eighteen key informants participated in three focus groups. Data were reviewed through direct thematic analysis.
RESULTS: Four themes emerged from data analysis, namely, guidelines as an empowering tool, implementation of HIV guidelines, perceived successes and challenges of postnatal HIV care, and measures to strengthen postnatal HIV care services. The study found that nurses interpreted and used guidelines to direct their practice. However, there were challenges and some successes.
CONCLUSION: It was concluded that nurses had a good understanding of the guidelines provided for their practices and implemented them with various levels of success. Effective management of HIV-infected women during the postnatal period requires well-designed multidisciplinary collaborations, adequate resources, continuous professional development programmes, a high level of competence and confidence.

Keywords: community health centre; HIV-positive women; nurses; primary healthcare; postnatal HIV care.




Maternal health remains a priority of global public health, and the disparities are growing between the developed and developing countries.1 One of the important health indicators for South Africa and other developing countries is maternal mortality. Measures of maternal mortality reflect women's access to and use of healthcare services.1 Primary healthcare (PHC) re-engineering is one of the measures to strengthen PHC through the district health system. Health systems should be strengthened in order to produce better health outcomes and to achieve long and healthy lives for all South Africans.2 To implement the PHC re-engineering, the National Department of Health has focused on three priorities or steams: the PHC ward-based outreach teams (WBOTs), strengthening school health services and district-based clinical specialist teams with initial focus on maternal and child health.3 Primary healthcare in South Africa faces many challenges such as inconsistencies in the quality of care delivered by health professionals, the burden of disease, health worker shortages, suboptimal supervision and support and underfunding in public health challenge innovations at the PHC level.4

The national consolidated guidelines for the prevention of mother-to-child transmission (PMTCT) and the management of human immune deficiency virus (HIV) in children, adolescents and adults provide a framework on how to respond to and to manage HIV-infected individuals.5 In an effort to reduce maternal and infant deaths, postnatal care (PNC) for women infected with HIV provides the opportunity for protecting the lives of both mothers and their babies by optimising HIV management. Antiretroviral treatment (ART) is often initiated by a professional nurse, and this is known as nurse-initiated and managed ART (NIMART). Nurses in the postnatal period are confronted with a variety of HIV-related situations. Some women are already on ART, while others' HIV status is not known, especially the 'unbooked cases'. There is also an issue of HIV-exposed infants who need to be properly managed to maximise effective management of HIV-positive women during this period. How the nurses provide care to these mothers and their infants is of paramount significance in the reduction of mortality in the postnatal period.

The Free State Province has 232 PHC clinics that render maternal and child health services as a PHC core package. Human immune deficiency virus care and management is integrated into routine care. Professional nurses are trained on NIMART to scale up initiation of women on ART. Uptake of ART among HIV-infected pregnant women is above 80%.6 Postnatal care is provided in all facilities, but at 6 weeks utilisation has been found to be low. However, there was an increase in 2014, with 81.3% of women receiving PNC within 6 days after giving birth6 as compared to 79.7% in 2011. In spite of all these efforts, non-pregnancy-related infections, including HIV and AIDS, still remain the top causes of maternal deaths in the Free State.7 Women with low-risk pregnancy receive antenatal care at the primary health clinics and deliver in the maternity-obstetric-unit. Human immune deficiency virus infection without complications is not classified as a high-risk factor. Postnatal follow-up is provided at a PHC setting nearer to patients' place of stay. Community health centres provide comprehensive primary care services including deliveries. These facilities provide appropriate and accessible healthcare services to the communities.

The 2015 PMTCT consolidated guidelines stipulate that women who test negative should be retested after every 3 months, as it has been discovered that about 4% of women who initially tested negative later test positive for HIV. Women who test positive for HIV within 1 year after giving birth should be initiated on treatment irrespective of the CD4 count.4 An investigation of PNC services to HIV-positive mothers and their HIV-exposed infants in Swaziland8 found gaps in the implementation of policies and the quality of PNC. The study found that 11.3% of HIV-positive women were not given information on the importance of co-trimoxazole prophylaxis, which put them at risk of developing opportunistic infections. One study9 identified that women were not given enough information during pregnancy and after birth, which affected their confidence in self-care and care of their babies. This implied the need to improve the quality of information given to women during PNC especially before discharge. There is evidence that women are motivated to address health issues during pregnancy and PNC.10 Therefore, the postnatal period presents an important intervention opportunity. The study sought to explore implementation of PNC to HIV-infected women in the Free State by explicating nurses' views regarding their practices. The 2015 PMTCT consolidated guidelines were used as a framework.

There are reports that PNC has been neglected in South Africa.11 Performance on PNC within 6 days has varied across provinces, with the Free State having performed higher than other provinces at 79.7%.12 Interventions to prevent mother-to-child transmission are critical to reduce infant HIV infections and child mortality.



Study design

A qualitative, evaluative case study design was used to provide a detailed account that involved description of implementation of PMTCT guidelines to postnatal HIV-positive clients. Qualitative research is an enquiry that seeks to explore human experience of the studied phenomenon for understanding of the participants' actions.13 It allowed the researchers to build a holistic picture of the implementation of PNC in a natural setting.14 In qualitative methods, the researcher can increase the depth of understanding that he or she may gain from the experience through exploration.15 The evaluative case study was the preferred study design as it allowed examination of specific instances such as interpretation and implementation of HIV national guidelines, thus illustrating the complexities of the situation of managing HIV in PNC. The heuristic quality of a case study, such as the ability to offer reasons for a problem, and providing the opportunity to evaluate what worked and what did not; made it most appropriate for this study.16 This type of research design is most valuable in exploratory research.17

Study setting

The study was conducted in the three community health centres in Mangaung Metro Municipality, which provide comprehensive PHC services including maternal, child and women's health. The researchers picked sites that yielded the most information and had the greatest impact on the development of understanding regarding implementation of PNC for HIV-positive mothers.

Participants and sampling

The population comprises nurses registered with the South African Nursing Council working at the PHC clinics, with various ethnic backgrounds. A non-probability, criteria purposive sampling method was used to select participants, which allowed selection of a homogenous group to enable focused enquiry. Nurses who were enrolled as nursing assistants working in the postnatal units were excluded from the study. Because this was an evaluative case study, the approach integrated elements of typical case, homogenous and criteria sampling.18 The inclusion criteria were nurses trained in ART and working with postnatal HIV-infected mothers. The rationale for this approach was to describe and illustrate what is typical in the PNC unit serving HIV-positive mothers, to minimise variation by recruiting a homogenous group and use predetermined criteria to select nurses who have the necessary knowledge and experience of postnatal HIV care. This method allowed an in-depth understanding of the implementation of PNC using PMTCT guidelines as a point of reference.13 The PMTCT guidelines were used to frame data collection, as nurses' practice in HIV management is largely controlled by HIV policy.

Data collection

Data were collected in October to November 2015 using a semi-structured interview guide. Three focus groups (FGs) with five to six participants in each were conducted at three clinics. The procedures followed included setting rules, keeping discussions confidential and respect for each participant's viewpoints.18 The first author collected data using digital audio recorder. The participants were asked about their interpretation of the PMTCT guidelines, how they managed postnatal HIV-infected women, their achievements since implementing the guidelines, challenges and suggestions to address those challenges. The audio recordings were shared with M.M.R. to determine the need for additional data. The process continued until no new information emerged, and this stage signified data saturation. The researchers explicated their beliefs about the phenomenon; these were written down and kept as a separate log, prior to data collection. The researchers remained open to data emerging from the participants by bracketing their thoughts and perceptions.

Data management and analysis

The research analysis steps described in Creswell19 were followed. These included transcription, immersion in data, coding, developing categories and comparison across categories. An inductive thematic analysis was used to review and identify common issues that recur, and these were summarised in narrative form. Audio recordings were transcribed verbatim and typed using the Microsoft Word program. The transcription of data occurred after each FG interview, followed by a short description of each group's data and preliminary analysis. The period of immersion included reading of transcripts over and over again. Similar and different views from the different FGs were merged; this was followed by searching across the data sets to find repeated patterns of meaning. Data were then summarised using codes and compared to establish the relationships among the different categories. The researchers examined the interpretations and implementation of PNC to identify themes. Themes were consolidated to develop meanings.

Trustworthiness of the study

The researchers used audit trails, member checking and bracketing to enhance the confirmability of the research results. Continuous checks were built into the data collection process by using participants' verbatim accounts and using the audio recorder and member checks to ensure confirmability. Notes obtained from the fieldwork were reviewed and the voice recording was listened to repeatedly, ensuring that the data represented participants' views and actual practice. The first author sought confirmation from participants that the interpretations were their true reflections.

Credibility was promoted through prolonged interaction, remaining in the field until saturation of data was attained. Reflexivity and bracketing were used to set aside views, existing knowledge and preconceived ideas about care of HIV-positive women during the postnatal period.

The research design, methods and their implementation, data collection process and procedures used by the researcher in the study were described in detail. The researchers selected information-rich participants such as nurses who had been trained in HIV and who managed HIV-positive women in postnatal clinics. Data were collected until data saturation occurred. The thick descriptions of data were generated on the premise that, in similar contexts and conditions, the results could be transferable.

Ethical considerations

Ethical approval was obtained from the University of South Africa Health Studies Higher Degrees Committee, College of Human Studies (HSSHD/ 401/2015), and the Free State Department of Health. Permission and informed consent from the nurses were obtained prior to the commencement of the study. The purpose of the study was explained prior to data collection. All participants were above 18 years and were eligible to give informed consent. They were made aware that they were not forced to participate in the study and that they had the right to withdraw at any time, not answer questions that they felt violated their privacy and withhold information without being penalised. The participants consented to the use of a digital audio recorder.

The transcripts and recordings were kept in a safe place using passwords to protect the electronic files. Paper files were stored in a locked cupboard to prevent unauthorised access. Codes were used instead of names to ensure anonymity.



Four major themes emerged from the data. These were: guidelines as an empowering tool, current HIV care practices, successes of postnatal HIV care, challenges and measures to strengthen postnatal HIV care services (see Table 1). The first two themes were related to the views of the participants regarding interpretation of the guidelines and implementation of postnatal HIV care. The third theme was based on the recommendations on how to strengthen services provided to HIV-infected women. The PMTCT national guidelines provided the framework for the interpretation and conclusions.



Guidelines as an empowering tool

Participants described guidelines as a general framework for the management of HIV-infected women and their babies. They understood the guidelines as a tool that enabled them to initiate treatment to HIV-positive clients at the point of diagnosis. They also believed that it was the government's approach to show its commitment to reducing the infection rate, increasing access to treatment and providing protocols for health professionals to manage HIV effectively. However, it appeared that the guidelines were not detailed enough as in some instances they used their nursing background to offer specific care. This is supported by the quote that follows:

'The guidelines are general and do not provide for individual care. During implementation, we adopt them to suit specific scenarios. At times, we have to go out of the parameters of the guidelines and use our nursing knowledge to give care, because I understand guidelines to be broad.' (FG2, 39 years old, nurse)

Participants explained that in general, the 2015 guidelines are more comprehensive and there is more focus on women in that the services have been expanded to include cervical cancer screening 6 weeks post-delivery and then yearly, screening for tuberculosis (TB), family planning and the management of sexually transmitted infections. The following statement represents their views:

'In the new provisions, the fourth prong of PMTCT puts an emphasis on holistic management of HIV-positive women, including health education on how to care for their babies and management of STDs.' (FG1, 30 years old, nurse)

The guidelines were also interpreted as an attempt to minimise missed opportunities by not only focusing on PNC but also tracking the history of the woman from antenatal care and include those who tested HIV negative during pregnancy. Participants showed understanding of the treatment cascade by indicating that HIV-positive women who were not diagnosed during antenatal care or given prophylaxis were at risk of developing opportunistic infections during the postnatal period:

'The change is about testing for HIV. Previously HIV-negative women were retested at 32 weeks irrespective of when the initial test was done; now it is after every three months to minimise missed opportunities. There is a chance for follow-up from pregnancy.' (FG3, 40 years old, nurse)

Implementation of HIV guidelines

Nurses indicated that they followed guidelines, offered comprehensive care to these mothers and encouraged breastfeeding within an hour of delivery. All assessments and screening were carried out on mothers to ensure quality care. Human immune deficiency virus-positive women were discharged within 6 hours if there were no complications. All HIV-exposed babies were tested for HIV and medication given accordingly. The repeat test was performed after 10 weeks. As stated by a participant:

'Babies born from HIV-positive mothers are given nevirapine syrup at birth according to the dosages in the guidelines. In case the mother is diagnosed during labour we also give the baby AZT [azidothymidine], which she will take together with nevirapine. We advise the mother that the baby must drink AZT until the nurse discusses the PCR [polymerase chain reaction] results with her.' (FG3, 30 years old, nurse)

What featured frequently was the various aspects of health education and counselling that nurses provided. The emphasis was on self-care, adherence to treatment for herself and the baby, contraception and child spacing, nutrition, safe infant feeding and monitoring of danger signs. However, they also expressed limitations and inadequacy with counselling services that they offered. It is generally expected that nurses at these facilities will provide counselling on various issues such as HIV and couple counselling. However, they are faced with a high workload of managing HIV-positive mothers and their exposed babies and have to rely on lay counsellors for counselling. Statements by participants:

'Mothers are informed on the importance of follow-up care at six days and six weeks. At six days, they are counselled on infant feeding; they are done breast examination to check for signs of infection as it may increase the chances of mother-to-child transmission of HIV.' (FG2, 39 years old, nurse)

'We have patient overload and proper counselling on various issues such as emotional and nutrition should be handled by appropriate professionals.' (FG1, 30 years old, nurse)

According to the nurses, the 6-week visit entails growth monitoring of the baby, prescribed medication and feeding. Mothers are monitored for disease progression by having a CD4 count and World Health Organisation clinical staging. Human immune deficiency virus -infected breastfeeding women are initiated on fixed-dose combination or zidovudine immediately irrespective of the CD4 count. Participants also believed that much could be done to increase confidence levels in ART initiation. The majority claimed that WBOTs are a resource used to trace and follow-up postnatal patients in communities. During the household visits they identify patients with complications and are referred to the facility for further management. Nurses indicated that all infants are given immunisations according to the Expanded Programme on Immunisation schedule. However, babies whose mothers have active TB are given isonicotinohydrazide prophylaxis; if the mother has been on TB treatment for less than 2 months, the Bacille Calmette-Guerin (BCG) vaccine is delayed until she has completed TB treatment. The nurses acknowledged that effective PNC requires