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Background: In preventing the transfer of HIV to their children, the Ministry of Health in Mozambique recommends all couples follow medical advice prior to a pregnancy. However, little is known about how such women experience pregnancy, nor the values they adhere to when making childbearing decisions. This qualitative study explores perceptions and decision-making processes regarding pregnancy among HIV positive women in rural Maputo Province. Methods: In-depth interviews and five focus group discussions with fifty-nine women who had recently become mothers were carried out. In addition, six semi-structured interviews were held with maternity and child health nurses. The ethnographic methods employed here were guided by Bourdieu’s practice theory. Results: The study indicated that women often perceived pregnancy as a test of fertility and identity. It was not only viewed as a rite of passage from childhood to womanhood, but also as a duty for married women to have children. Most women did not follow recommended medical advice prior to gestation. This was primarily due to perceptions that decision-making about pregnancy was regarded as a private issue not requiring consultation with a healthcare provider. Additionally, stigmatisation of women living with HIV, lack of knowledge about the need to consult a healthcare provider prior to pregnancy, and unintended pregnancy due to inadequate use of contraceptive were crucial factors. Conclusion: Women’s experiences and decisions regarding pregnancy are more influenced by social and cultural norms than medical advice. Therefore, education concerning sexual and reproductive health in relation to HIV/AIDS and childbearing is recommended. In particular, we recommend maternal and child healthcare nurses need to be sensitive to women’s perceptions and the cultural context of maternity when providing information about sexual and reproductive health.
This qualitative study is part of a broader research programme entitled Perceptions and practices regarding pregnancy care and infant feeding among HIV positive women in rural Mozambique. Applying a grounded theory approach, [30] the research was conducted in the Namaacha and Manhiça rural districts of the Maputo province, located in the south of Mozambique. In 2017, the population of Namaacha district was 48,933 [31] and serviced by ten healthcare facilities. Approximately 208,466 inhabitants lived in Manhiça district in 2017 [31] with 14 healthcare facilities and one rural hospital. These investigation sites were relevant for this study because of having the highest prevalence of HIV/AIDS in the country – accounting for 26% of all pregnant women living with HIV [32]. Recruitment and interviews of study participants took place between January and March 2015 in six healthcare facilities that implemented a prevention of mother-to-child transmission of HIV (PMTCT) program. Three healthcare facilities were selected in each district; one located at the centre and two in neighbourhoods. The centre of the district is relatively urbanised, while the neighbourhood settings are more rural. These differences were considered for purposes of analysis. The study applied purposive sampling to select both HIV positive women and maternal child health (MCH) nurses. A total of 59 HIV positive women who had given birth and were breastfeeding were selected. Twenty-five (25) were located in Namaacha district and thirty-four (34) in Manhiça district, and one MCH nurse was selected in each healthcare facility. These participants were especially important in accessing women’s decision-making practices regarding pregnancy. In selecting participants, the main researcher had previously visited the selected healthcare facilities with the ethical clearance, the objectives, and the research design. The MCH nurses working at maternal and child health service were introduced to the main researcher by the director of each healthcare facility. In the central healthcare facilities, the maternal and child service is composed of four departments: antenatal, postnatal, a general paediatric department, and a child at risk clinic (CRC). There was one nurse in each department. The healthcare facilities located in the more rural neighbourhoods had three departments: antenatal, postnatal and general paediatric departments. In these facilities, the general paediatric department offered services to all mothers and their infants regardless of their HIV status. It also served as a CRC. However, only one nurse was available to cover the three departments. In both facilities, a mother living with HIV had to first queue for postnatal service, secondly for general paediatric and lastly for the CRC. Nurses helped to identify the queues for mothers who were waiting to receive services at the CRC. Some mothers whose infants were less than one month old were assigned one appointment per week. Infants older than one month were assigned one appointment per month. To access participants, all mothers at the CRC were approached, our identity was disclosed, and the objectives and benefits of the study were explained. Those who agreed to participate were interviewed. Of those who were approached, a total of eleven participants refused to participate. The most common reason cited was an unwillingness to share their experience of previous pregnancy and childcare. Participants chose the place and time for the interview. The majority chose to be interviewed in the healthcare facility, the remainder made appointments at their homes. Interviews held in the healthcare facility took place under a tree, a convenient distance from the clinic consultation space, after the participants had attended all their consultations. The interviews lasted between 50 and 60 min. An audio recording was made following participants’ approval; some participants (n = 20) were uncomfortable with this technique. In all, 59 in-depth interviews were performed. The interviews ceased when saturation [33] was achieved. The majority of participants were between 18 and 34 years, married or living with a partner. Most participants were farmers and had more than one child. Some participants lacked formal education (Table 1). The study also included five focus group discussions (FGDs) with HIV positive women. Three were conducted in Manhiça district and two in Namaacha district. Participants of these FGDs were recruited at the CRC. Each FGD lasted 60–90 min with 6–10 participants. Demographic characteristics of the study participants The inclusion criteria for both participants in individual interviews and FGDs were: a) being 18–49 years old and living with HIV, b) having an infant between 0 and 2 years old, c) attending the CRC and d) agreeing to participate in the study. Both individual in-depth interviews and FGDs were conducted in Portuguese – the national language – for those who could read and write it. Tsonga, the local vernacular language, was used for those who could not understand Portuguese. In addition, and after all interviews with HIV positive women had been undertaken, six semi-structured interviews with MCH nurses working in the PMTCT program were conducted. To access these participants, we selected MCH nurses working in the CRC. The objectives of the study were explained and interviews were requested. Participants scheduled the interviews, which lasted approximately 45 min, in their offices at the healthcare facility. The inclusion criteria included: a) being a MCH nurse working in a CRC; and b) agreeing to participate in the study. MCH nurses were aged between 23 and 35 years old, married or living with a partner, and all had children. All MCH nurses had attended a maternal child nurse course at the National Institute of Health Sciences.
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