'Striving for motherhood': understanding the socio-cultural context of realizing childbearing among women in Kenya

PMTCT allows people living with HIV to actualize childbearing. However, it also complicates motherhood, as the medical consequences and public health implications of non-adherence to PMTCT service recommendations disrupt socio-cultural expectations of childbearing and parenthood. This thesis aimed to study childbearing and adherence to PMTCT interventions focusing on how women living with HIV realize motherhood in Kenya. We sought to answer how women on ART experience motherhood and how motherhood aggravate adherence to PMTCT services.

Methods: A quantitative cross sectional study (I) with a questionnaire survey conducted among pregnant women at their first visit to antenatal clinic to study consent to HIV testing and three qualitative studies analyzed with content analysis (II and IV) and narrative structuring (III) were included. Qualitative interviews were performed with women living with HIV who were pregnant, recently delivered and those actively planning a pregnancy to explore views and experiences when seeking a pregnancy (II), the reasoning and deciding about adherence to PMTCT (III) and how motherhood interferes with HIV treatment (IV).

Results: ‘Striving for motherhood’ was the overriding theme describing the desire of women on ART to be parents while negotiating the challenges of living with HIV (I- IV). Children improve women’s position in society and are a sign of a happy and fulfilled life (II-IV). Of 900 pregnant women surveyed at their first visit to antenatal care clinic, only 17% understood that HIV testing is optional (I). Making an informed decision to decline HIV testing was associated with knowing that testing was optional (OR=5.44, 95%CI 3.44-8.59), not having a stable relationship with the child’s father (OR=1.76, 95%CI 1.02-3.03), and not having discussed HIV testing with a partner before the ANC visit (OR=2.64 95%CI 1.79-3.86). Socio-economic affluence and residence influence behaviors such as no condom use, non-disclosure of HIV infection, use of traditional medicine simultaneously with ART, home delivery and stigma and discrimination from partners, family and community, all of which undermine adherence to PMTCT services (II-IV). Structural shortcomings in PMTCT result in the lack of antiretroviral HIV medicines, practice of mixed infant feeding and missed appointments (I, III, IV).

Conclusion: Motherhood is achieved at the cost of striving to balance socio-cultural expectations of childbearing that also conceals their HIV infection at the cost of non- adherence to PMTCT recommendations. Being infected with HIV does not remove the desire of motherhood and related socio-cultural demands. It is important to acknowledge the significance childbearing among women infected with HIV to improve adherence. Women with chronic illness such as HIV-infection who are dependent on continuous medication and health check-ups struggle to balance the desire for children with the needs related to their illness and the expectations of being a ‘good mother’.

List of scientific papers

I. Opondo Awiti Ujiji, Birgitta Rubenson, Festus Ilako, Gaetano Marrone, David Wamalwa, Gilbert Wangalwa, Anna Mia Ekström. Is ‘Opt-Out HIV Testing’ a Real Option among Pregnant Women in Rural Districts in Kenya? BMC Public Health. 2011;11:151.
https://doi.org/10.1186/1471-2458-11-151

II. Opondo Awiti Ujiji, Anna Mia Ekström, Festus Ilako, Dorcas Indalo, Birgitta Rubenson. "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. BMC Women’s Health. 2010;10:13.
https://doi.org/10.1186/1472-6874-10-13

III. Opondo Awiti Ujiji, Anna Mia Ekström, Festus Ilako, Dorcas Indalo, David Wamalwa, Birgitta Rubenson. Reasoning and Deciding PMTCT- Adherence during Pregnancy in HIV-infected Women in Kenya. [Accepted]
https://doi.org/10.1080/13691058.2011.583682

IV. Opondo Awiti Ujiji, Anna Mia Ekström, Festus Ilako, Dorcas Indalo, Abigael Lukhwaro, David Wamalwa, Birgitta Rubenson. ‘Keeping healthy in the backseat’. How motherhood interrupted HIV-treatment among recently delivered women. [Accepted]
https://doi.org/10.2989/16085906.2011.593378