Being perceived as 'a real woman' or following one's own convictions: a qualitative study to understand individual, family, and community influences on the place of childbirth in Busia, Kenya.

Despite potentially playing a key role in improving maternal and child health, including the prevention of mother-to-child transmission (PMTCT) of HIV, health facility delivery rates remain low in Kenya. Understanding how place of childbirth is determined is therefore important when developing interventions to improve safe motherhood and childbirth outcomes. As part of a qualitative study, we conducted 25 in-depth interviews with mothers (13) and healthcare staff (12) and held 10 focus group discussions with traditional birth attendants (6) and female relatives (4) in Busia, rural Kenya. Our findings show that mothers prefer facility delivery; however, the choice is not theirs alone but involves both their family and the community. Furthermore, facility delivery poses a risk of being viewed as disloyal to tradition and not 'a real woman', which causes a strained relationship between healthcare staff, family and the community. Our interpretation of the findings is that mothers feel trapped between loyalty to sociocultural norms and awareness of the benefits of facility delivery. Also, we believe healthcare staff's disinclination to recognise certain traditional birth attendant services as a potential asset poses a barrier to increased facility deliveries. Interventions to link traditional birth attendants with formal healthcare combined with sociocultural sensitivity training for healthcare staff may increase facility delivery and PMTCT.

Reasoning and deciding PMTCT-adherence during pregnancy among women living with HIV in Kenya.

This study explores type identities among rural and urban slum women on antiretroviral therapies who become pregnant. Narrative structuring was chosen to develop type narratives that illustrate how rural and urban women handle their HIV-infection and how they reason and decide about PMTCT-adherence during pregnancy and childbirth. Women in rural areas described their lives as 'secure and family controlled'. This gave the women security and predictability in life, but also meant that it was difficult to keep secrets about HIV infection. For women in the urban slum area the narratives were a tale of the uncertain and hard to predict reality in the slum, but also about self-reliance and decisiveness. They portrayed themselves as 'vulnerable and striving to survive' thus managing a tough situation without long-term solutions. We conclude that pregnancy poses different social challenges in rural and urban areas affecting how women choose to manage their adherence to PMTCT, which is also affected by HIV stigma and lack of disclosure.

'Keeping healthy in the backseat': How motherhood interrupted HIV treatment in recently delivered women in Kenya.

Although there is a large body of literature related to the experiences of motherhood and aspects of the change that it brings about, how the experience of motherhood affects the healthcare of women with chronic illness is less documented. This study explores how motherhood in newly delivered HIV-infected mothers in Kenya interrupted their antiretroviral treatment (ART). Qualitative interviews were performed with 26 mothers on ART in a rural or urban area. The data were organised and interpreted using content analysis. The study found that adherence to ART was influenced by contextual differences in socio-cultural expectations and family relationships. Urban life enabled women to make decisions on their own and to negotiate challenges that were often unpredictable. Women in rural areas knew what was expected of them and decisions were normally not for them to make alone. The women in Busia and Kibera had difficulties combining adherence with attaining the socio-cultural definition of good mothering. Lack of support from health providers and weak healthcare systems contributed to inadequate stocks of HIV drugs and inaccessibility of HIV-related care. From the data, we developed the main theme 'keeping healthy in the backseat' and the two sub-themes 'regaining self-worth through motherhood' and 'mother first - patient later.' We suggest that motherhood is context-specific and follows socio-cultural practises, which made it difficult for the women in Kenya to follow ART instructions. There is a need to reassess HIV-related services for mothers on ART in order to give them a better chance to stay on treatment and satisfy their aspiration to be 'good mothers.' Context-specific HIV-treatment policies are necessary for ensuring adherence and successful treatment outcomes.

"I will not let my HIV status stand in the way." Decisions on motherhood among women on ART in a slum in Kenya- a qualitative study.

BACKGROUND: The African Medical Research Foundation antiretroviral therapy program at the community health centre in Kibera counsels women to wait with pregnancy until they reach the acceptable level of 350 cells/ml CD4 count and to discuss their pregnancy intentions with their health care providers. A 2007 internal assessment showed that women were becoming pregnant before attaining the 350 cells/ml CD4 count and without consulting health care providers. This qualitative study explored experiences of intentionally becoming pregnant among women receiving highly active antiretroviral therapy (HAART). METHODS: Nine pregnant women, six newly delivered mothers and five women wanting to get pregnant were purposefully selected for in-depth interviews. Content analysis was used to organize and interpret the women's experiences of becoming pregnant. RESULTS: Women's choices for pregnancy could be categorized into one overarching theme 'strive for motherhood' consisting of three sub-themes. A child is thought of as a prerequisite for a fulfilled and happy life. The women accepted that good health was required to bear a pregnancy and thought that feeling well, taking their antiretroviral treatment and eating nutritious food was enough. Consulting health care providers was perceived as interfering with the women's decisions to get pregnant. Becoming pregnant as an HIV-infected woman was, however, complicated by the dilemmas related to disclosing HIV infection and discussing pregnancy intentions with their partners. CONCLUSIONS: Motherhood is important to women on antiretroviral treatment. But they seemed to lack understanding of the relationship between a high CD4 cell count and a low chance of transmission of HIV to offspring. Better education about the relationship of perceived good physical health, low CD4 cell count and the risk of mother to child transmission is required. Women want to control the domain of childbearing but need enough information to make healthy choices without risking transmission.