“I will leave the baby with my mother”: Long‐distance travel and follow‐up care among HIV‐positive pregnant and postpartum women in South Africa

Abstract

IntroductionIt is common in urban African settings for postpartum women to temporarily return to family in distant settings. We sought to explore mobility among peripartum HIV‐positive women to understand the timing and motivation of travel, particularly vis‐à‐vis delivery, and how it may affect healthcare access.MethodsUsing the same mobility measurements within three different studies, we examined long‐distance travel of mother and infant before and after delivery in three diverse clinics within greater Johannesburg, South Africa (n = 150). Participants were interviewed prior to delivery at two sites (n = 125) and after delivery at one (n = 25). Quantitative and qualitative results are reported.ResultsAmong 150 women, median age was 29 years (IQR: 26 to 34) and 36.3% were employed. Overall, 76.7% of the participants were born in South Africa: 32.7% in Gauteng Province (Johannesburg area) and 44.0% in other South African provinces, but birthplace varied greatly by site. Almost half (44.0%) planned to travel around delivery; nearly all after delivery. Median duration of stay was 30 days (IQR: 24 to 90) overall, but varied from 60 days at two sites to just 7 days at another. Participants discussed travel to eight of South Africa's nine provinces and four countries. Travel most frequently was to visit family, typically to receive help with the new baby. Nearly all the employed participants planned to return to work in Johannesburg after delivery, sometimes leaving the infant in the care of family outside of Johannesburg. All expressed their intent to continue HIV care for themselves and their infant, but few planned to seek care at the destination site, and care for the infant was emphasized over care for the mother.ConclusionsWe identified frequent travel in the peripartum period with substantial differences in travel patterns by site. Participants more frequently discussed seeking care for the infant than for themselves. HIV‐exposed children often were left in the care of family members in distant areas. Our results show the frequent mobility of women and infants in the peripartum period. This underscores the challenge of ensuring a continuity of HIV care in a fragmented healthcare system that is not adapted for a mobile population.

Qualitative exploration of perceived benefits of care and barriers influencing HIV care in trans Nzoia, Kenya

“…Health system barriers noted in this study such as limited and unprofessional providers at healthcare facilities, and long travel distance to care have been identified in other research [12,14,15,18]. This study reported some communities were up to 20 km away from the health facilities.…”

“…Health system barriers consist of structural, process, and relational issues. Shortages in healthcare personnel [12,14,17], long distance to health facilities [4,11,15,18] and poor interactions with patients are commonly reported barriers to HIV care [5,11,12,14]. Other health systems barriers have included frequent appointments [11,19,20], unfriendly health staff with a breakdown of patient-provider trust [5,7,11,14], and poor reimbursement for services by government and other financial support programs [9,14,16,17].…”

CareConekta: study protocol for a randomized controlled trial of a mobile health intervention to improve engagement in postpartum HIV care in South Africa

“…South Africa's population is highly mobile; the most typical pattern is of circular, within-border migration between rural and urban areas, with the mobile individual keeping strong ties to the rural areas by sending remittances to their family and returning to the rural area for holidays and family events, and upon retirement, illness, or during lapses in employment [26]. Postpartum women in South Africa are likely to be a particularly mobile group, due to a tradition of returning to one's rural home after delivery to receive care from family members [12,[27][28][29]. Our recent formative work at three sites in Johannesburg found that among 150 peripartum, HIV-positive women interviewed, 44% planned to travel around delivery -typically after delivery -to stay with family, sometimes leaving the infant in the care of family while the mother returned to work in Johannesburg [29].…”

“…Postpartum women in South Africa are likely to be a particularly mobile group, due to a tradition of returning to one's rural home after delivery to receive care from family members [12,[27][28][29]. Our recent formative work at three sites in Johannesburg found that among 150 peripartum, HIV-positive women interviewed, 44% planned to travel around delivery -typically after delivery -to stay with family, sometimes leaving the infant in the care of family while the mother returned to work in Johannesburg [29]. With unlinked medical records and no way of tracking mobility, it is difficult to intervene appropriately to ensure continuity of HIV care for mother and infant.…”

Bringing population mobility into focus to achieve HIV prevention goals

“…Two articles in this volume examine women's migration in the context of pregnancy. Clouse and colleagues present findings from a mixed methods study to identify drivers and types of mobility among pregnant and postpartum women living with HIV in the Johannesburg area in South Africa. They examine long‐distance travel of mothers and infants before and after delivery, finding that the frequent mobility in the peripartum period “underscores the challenge of ensuring a continuity of HIV care in a fragmented health care system that is not adapted for a mobile population.” In another setting in South Africa (Cape Town), Phillips and colleagues also examined the mobility of women attending an integrated antenatal‐ART clinic.…”