Phyllis Orner

Psychosocial impacts on caregivers of people living with AIDS

Abstract Estimates show that by 2010 up to six million South Africans will be HIV-infected. Simultaneously, public health care resources are overstretched and communities and families are taking more responsibility for providing care. However, little work in South Africa has investigated the possible psychosocial impacts on caregivers. This study investigates psychosocial impacts at household level with reference to gender, programme, and policy implications. Forty-five in-depth interviews were held with primary caregivers of people living with AIDS (PWA). Participants were recruited using purposive and snowball sampling. Forty-three respondents were women, signifying that gender is an important issue in this context. Data were analysed using a grounded theory approach. Care giving placed considerable demands on caregivers, which was exacerbated by insufficient support, dire poverty and the added responsibilities of caring for other household members. Lack of basic resources was common and chronic, and care giving impacted negatively on employment and social life. Stigma and prejudice towards caregivers was common and exacerbated stress levels. Assessment of support received from various sources ranged widely. The lack of support was often debilitating. Respondents who felt supported linked this support to improved psychosocial status. Recommendations for policy on home-based care are outlined.

Clients’ perspectives on HIV/AIDS care and treatment and reproductive health services in South Africa

Abstract Qualitative research was conducted with HIV-positive women and men of reproductive age attending HIV/AIDS care and treatment services at a public health clinic in Cape Town, South Africa. Focus group discussions were held with women (n = 4) and men (n = 4), and in-depth interviews were held with four men to explore perceptions and experiences of HIV/AIDS care and treatment and sexual and reproductive health (SRH) care. Respondents praised their HIV/AIDS care and treatment, reflected on how it improved their quality of life and contrasted this with suboptimal care at other public health facilities, including SRH services. Women wanted integrated services, especially for contraception and to reduce stigma. HIV-positive mens lack of experience with SRH services and antipathy towards attending “womens” health services were highlighted. Challenges to involving men in HIV/AIDS care and treatment and SRH services and measures to address this were identified.

'Even if you're positive, you still have rights because you are a person': human rights and the reproductive choice of HIV-positive persons.

Global debates in approaches to HIV/AIDS control have recently moved away from a uniformly strong human rights-based focus. Public health utilitarianism has become increasingly important in shaping national and international policies. However, potentially contradictory imperatives may require reconciliation of individual reproductive and other human rights with public health objectives. Current reproductive health guidelines remain largely non prescriptive on the advisability of pregnancy amongst HIV-positive couples, mainly relying on effective counselling to enable autonomous decision making by clients. Yet, health care provider values and attitudes may substantially impact on the effectiveness of non prescriptive guidelines,particularly where social norms and stereotypes regarding childbearing are powerful, and where providers are subjected to dual loyalty pressures, with potentially adverse impacts on rights of service users. Data from a study of user experiences and perceptions of reproductive and HIV/AIDS services are used to illustrate a rights analysis of how reproductive health policy should integrate a rights perspective into the way services engage with HIV-positive persons and their reproductive choices. The analysis draws on recognised tools developed to evaluate health policies for their human rights impacts and on a model developed for health equity research in South Africa to argue for greater recognition of agency on the part of persons affected by HIV/AIDS in the development and content of policies on reproductive choices. We conclude by proposing strategies that are based upon a synergy between human rights and public health approaches to policy on reproductive health choices for persons with HIV/AIDS.

Delays in seeking an abortion until the second trimester: a qualitative study in South Africa

BackgroundDespite changes to the South African abortion legislation in 1996, barriers to women accessing abortions still exist. Second trimester abortions, an inherently more risky procedure, continue to be 20% of all abortions. Understanding the reasons why women delay seeking an abortion until the second trimester is important for informing interventions to reduce the proportion of second trimester abortions in South Africa.MethodsQualitative research methods were used to collect data. Twenty-seven in-depth interviews were conducted in 2006 with women seeking a second trimester abortion at one public sector tertiary hospital and two NGO health care facilities in the greater Cape Town area, South Africa. Data were analysed using a grounded theory approach.ResultsAlmost all women described multiple and interrelated factors that influenced the timing of seeking an abortion. Reasons why women delayed seeking an abortion were complex and were linked to changes in personal circumstances often leading to indecision, delays in detecting a pregnancy and health service related barriers that hindered access to abortion services.ConclusionUnderstanding the complex reasons why women delay seeking an abortion until the second trimester can inform health care interventions aimed at reducing the proportion of second trimester abortions in South Africa.

A qualitative exploration of HIV-positive pregnant women's decision-making regarding abortion in Cape Town, South Africa

HIV-positive womens abortion decisions were explored by: (i) investigating influencing factors; (ii) determining knowledge of abortion policy and public health services; and (iii) exploring abortion experiences. In-depth interviews were held with 24 HIV-positive women (15 had an abortion; 9 did not), recruited at public health facilities in Cape Town, South Africa. Negative perceptions towards HIV-positive pregnant women were reported. Women wanted abortions due to socio-economic hardship in conjunction with HIV-positive status. Respondents were generally aware that women in South Africa had a right to free abortions in public health facilities. Both positive and negative abortion experiences were described. Respondents reported no discrimination by providers due to their HIV-positive status. Most respondents reported not using contraceptives, while describing their pregnancies as ‘unexpected’. The majority of women who had abortions wanted to avoid another one, and would encourage other HIV-positive women to try to avoid abortion. However, most felt abortions were acceptable for HIV-positive women in some circumstances. Data suggested that stigma and discrimination affect connections between abortion, pregnancy and HIV/AIDS, and that abortion may be more stigmatised than HIV/AIDS. Study results provide important insights, and any revision of reproductive health policy, services, counselling for abortion and HIV/AIDS care should address these issues.

Access to safe abortion: building choices for women living with HIV and AIDS

In many areas of the world where HIV prevalence is high, rates of unintended pregnancy and unsafe abortion have also been shown to be high. Of all pregnancies worldwide in 2008, 41% were reported as unintended or unplanned, and approximately 50% of these ended in abortion. Of the estimated 21.6 million unsafe abortions occurring worldwide in 2008 (around one in 10 pregnancies), approximately 21.2 million occurred in developing countries, often due to restrictive abortion laws and leading to an estimated 47,000 maternal deaths and untold numbers of women who will suffer long-term health consequences. Despite this context, little research has focused on decisions about and experiences of women living with HIV with regard to terminating a pregnancy, although this should form part of comprehensive promotion of sexual and reproductive health rights.In this paper, we explore the existing evidence related to global and country-specific barriers to safe abortion for all women, with an emphasis on research gaps around the right of women living with HIV to choose safe abortion services as an option for dealing with unwanted pregnancies. The main focus is on the situation for women living with HIV in Brazil, Namibia and South Africa as examples of three countries with different conditions regarding womens access to safe legal abortions: a very restrictive setting, a setting with several indications for legal abortion but non-implementation of the law, and a rather liberal setting.Similarities and differences are discussed, and we further outline global and country-specific barriers to safe abortion for all women, ending with recommendations for policy makers and researchers.

‘It hurts, but I don't have a choice, I'm not working and I'm sick’: decisions and experiences regarding abortion of women living with HIV in Cape Town, South Africa

Research was conducted with 36 women living with HIV in Cape Town, South Africa, regarding their decision-making about, and experiences with, abortion of unwanted pregnancies in the public health sector. Abortion intentions and decisions were explored by investigating influencing factors; knowledge of abortion policy and public health sector services; and abortion perceptions and experiences. Findings reveal that many women face censure both for becoming pregnant and terminating a pregnancy, including by family, partners, community members and healthcare providers. Data suggest that abortion may be more stigmatised than HIV despite South Africas liberal abortion law. Generally, however, study participants were satisfied with the abortion care received. Most would advise women living with HIV to think carefully about abortion, but to make a decision in their own best interests, including only seeking care early in pregnancy from an accredited clinic. Study implications include a need to integrate information and counselling on safe legal abortion within sexual and reproductive health services, especially in efforts to integrate sexual and reproductive health into HIV care, and to forge greater linkages between HIV and abortion services more generally to ensure continuity in follow-up of care for women.

O726 A qualitative exploration of HIV-positive pregnant women's decision-making regarding abortion in South Africa

Objectives: To evaluate the effect of antenatal care on maternal mortality at the University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria. Methods: A retrospective analysis of all maternal deaths at the University of Port Harcourt Teaching Hospital between August 1 2005 and July 31 2008. The case files of booked and unbooked parturients who died in the period under review were retrieved from the hospital records and analyzed using Epi Info 3.3. The chisquared test was used to evaluate differences in the mortality rates between the 2 groups. Results: A total of 94 maternal deaths occurred out of 8936 deliveries giving an overall maternal mortality rate of 1052/100,000 deliveries. This included 6 deaths from ectopic pregnancies and 5 deaths from abortions. The maternal mortality rate was significantly higher in unbooked mothers (7438/100,000) compared to booked mothers (247/100,000) p =0.001. The principal causes of death were eclampsia (39.7%) in the unbooked and obstetric haemorrhage (40.0%) in booked parturients. Sepsis occurred only in the unbooked women. Conclusion: Maternal mortality remains unacceptably high at the University of Port Harcourt Teaching Hospital especially amongst unbooked parturients and the causes of death are preventable. Encouraging antenatal care and improving skilled attendance at delivery are recommended to reduce maternal mortality at the University of Port Harcourt Teaching Hospital.