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Postnatal care PNC provides the opportunity for protecting the lives of women infected with human immune deficiency virus HIV and their babies. There has been no empirical evidence on how the nurses at the clinic level implement these guidelines. A qualitative, evaluative case study was conducted to provide a detailed account of the implementation of PNC, using PMTCT guidelines as a framework for evaluation. Eighteen key informants participated in three focus groups.
Data were reviewed through direct thematic analysis. Four themes emerged from data analysis, namely, guidelines as an empowering tool, implementation of HIV guidelines, perceived successes and challenges of postnatal HIV care, and measures to strengthen postnatal HIV care services. The study found that nurses interpreted and used guidelines to direct their practice.
However, there were challenges and some successes. It was concluded that nurses had a good understanding of the guidelines provided for their practices and implemented them with various levels of success. Effective management of HIV-infected women during the postnatal period requires well-designed multidisciplinary collaborations, adequate resources, continuous professional development programmes, a high level of competence and confidence. Maternal health remains a priority of global public health, and the disparities are growing between the developed and developing countries.
Health systems should be strengthened in order to produce better health outcomes and to achieve long and healthy lives for all South Africans. The national consolidated guidelines for the prevention of mother-to-child transmission PMTCT and the management of human immune deficiency virus HIV in children, adolescents and adults provide a framework on how to respond to and to manage HIV-infected individuals. Nurses in the postnatal period are confronted with a variety of HIV-related situations.
There is also an issue of HIV-exposed infants who need to be properly managed to maximise effective management of HIV-positive women during this period. How the nurses provide care to these mothers and their infants is of paramount significance in the reduction of mortality in the postnatal period. Human immune deficiency virus care and management is integrated into routine care.
However, there was an increase in , with Human immune deficiency virus infection without complications is not classified as a high-risk factor. Community health centres provide comprehensive primary care services including deliveries. These facilities provide appropriate and accessible healthcare services to the communities. Women who test positive for HIV within 1 year after giving birth should be initiated on treatment irrespective of the CD4 count.
The study found that One study 9 identified that women were not given enough information during pregnancy and after birth, which affected their confidence in self-care and care of their babies. This implied the need to improve the quality of information given to women during PNC especially before discharge. There is evidence that women are motivated to address health issues during pregnancy and PNC.
A qualitative, evaluative case study design was used to provide a detailed account that involved description of implementation of PMTCT guidelines to postnatal HIV-positive clients. The heuristic quality of a case study, such as the ability to offer reasons for a problem, and providing the opportunity to evaluate what worked and what did not; made it most appropriate for this study. The researchers picked sites that yielded the most information and had the greatest impact on the development of understanding regarding implementation of PNC for HIV-positive mothers.
The population comprises nurses registered with the South African Nursing Council working at the PHC clinics, with various ethnic backgrounds. A non-probability, criteria purposive sampling method was used to select participants, which allowed selection of a homogenous group to enable focused enquiry. Nurses who were enrolled as nursing assistants working in the postnatal units were excluded from the study. Because this was an evaluative case study, the approach integrated elements of typical case, homogenous and criteria sampling.
The rationale for this approach was to describe and illustrate what is typical in the PNC unit serving HIV-positive mothers, to minimise variation by recruiting a homogenous group and use predetermined criteria to select nurses who have the necessary knowledge and experience of postnatal HIV care. Data were collected in October to November using a semi-structured interview guide. Three focus groups FGs with five to six participants in each were conducted at three clinics.
The participants were asked about their interpretation of the PMTCT guidelines, how they managed postnatal HIV-infected women, their achievements since implementing the guidelines, challenges and suggestions to address those challenges. The audio recordings were shared with M. The process continued until no new information emerged, and this stage signified data saturation.
The researchers explicated their beliefs about the phenomenon; these were written down and kept as a separate log, prior to data collection. The researchers remained open to data emerging from the participants by bracketing their thoughts and perceptions. The research analysis steps described in Creswell 19 were followed. These included transcription, immersion in data, coding, developing categories and comparison across categories. An inductive thematic analysis was used to review and identify common issues that recur, and these were summarised in narrative form.
Audio recordings were transcribed verbatim and typed using the Microsoft Word program. The period of immersion included reading of transcripts over and over again. Similar and different views from the different FGs were merged; this was followed by searching across the data sets to find repeated patterns of meaning. Data were then summarised using codes and compared to establish the relationships among the different categories.
The researchers examined the interpretations and implementation of PNC to identify themes. Themes were consolidated to develop meanings. The researchers used audit trails, member checking and bracketing to enhance the confirmability of the research results. The first author sought confirmation from participants that the interpretations were their true reflections. Credibility was promoted through prolonged interaction, remaining in the field until saturation of data was attained.
Reflexivity and bracketing were used to set aside views, existing knowledge and preconceived ideas about care of HIV-positive women during the postnatal period. The research design, methods and their implementation, data collection process and procedures used by the researcher in the study were described in detail. The researchers selected information-rich participants such as nurses who had been trained in HIV and who managed HIV-positive women in postnatal clinics.
Data were collected until data saturation occurred. The thick descriptions of data were generated on the premise that, in similar contexts and conditions, the results could be transferable. Permission and informed consent from the nurses were obtained prior to the commencement of the study. The purpose of the study was explained prior to data collection.
All participants were above 18 years and were eligible to give informed consent. They were made aware that they were not forced to participate in the study and that they had the right to withdraw at any time, not answer questions that they felt violated their privacy and withhold information without being penalised. The participants consented to the use of a digital audio recorder. The transcripts and recordings were kept in a safe place using passwords to protect the electronic files.
Paper files were stored in a locked cupboard to prevent unauthorised access. Codes were used instead of names to ensure anonymity. Four major themes emerged from the data. These were: The first two themes were related to the views of the participants regarding interpretation of the guidelines and implementation of postnatal HIV care. The third theme was based on the recommendations on how to strengthen services provided to HIV-infected women.
Participants described guidelines as a general framework for the management of HIV-infected women and their babies. They understood the guidelines as a tool that enabled them to initiate treatment to HIV-positive clients at the point of diagnosis. However, it appeared that the guidelines were not detailed enough as in some instances they used their nursing background to offer specific care.
This is supported by the quote that follows:. During implementation, we adopt them to suit specific scenarios. At times, we have to go out of the parameters of the guidelines and use our nursing knowledge to give care, because I understand guidelines to be broad. Participants explained that in general, the guidelines are more comprehensive and there is more focus on women in that the services have been expanded to include cervical cancer screening 6 weeks post-delivery and then yearly, screening for tuberculosis TB , family planning and the management of sexually transmitted infections.
The following statement represents their views:. The guidelines were also interpreted as an attempt to minimise missed opportunities by not only focusing on PNC but also tracking the history of the woman from antenatal care and include those who tested HIV negative during pregnancy. Participants showed understanding of the treatment cascade by indicating that HIV-positive women who were not diagnosed during antenatal care or given prophylaxis were at risk of developing opportunistic infections during the postnatal period:.
Previously HIV-negative women were retested at 32 weeks irrespective of when the initial test was done; now it is after every three months to minimise missed opportunities. There is a chance for follow-up from pregnancy. Nurses indicated that they followed guidelines, offered comprehensive care to these mothers and encouraged breastfeeding within an hour of delivery. All assessments and screening were carried out on mothers to ensure quality care.
Human immune deficiency virus-positive women were discharged within 6 hours if there were no complications. The repeat test was performed after 10 weeks. As stated by a participant:. In case the mother is diagnosed during labour we also give the baby AZT [ azidothymidine ], which she will take together with nevirapine. We advise the mother that the baby must drink AZT until the nurse discusses the PCR [ polymerase chain reaction ] results with her. What featured frequently was the various aspects of health education and counselling that nurses provided.
The emphasis was on self-care, adherence to treatment for herself and the baby, contraception and child spacing, nutrition, safe infant feeding and monitoring of danger signs. However, they also expressed limitations and inadequacy with counselling services that they offered. It is generally expected that nurses at these facilities will provide counselling on various issues such as HIV and couple counselling. However, they are faced with a high workload of managing HIV-positive mothers and their exposed babies and have to rely on lay counsellors for counselling.
Statements by participants:. At six days, they are counselled on infant feeding; they are done breast examination to check for signs of infection as it may increase the chances of mother-to-child transmission of HIV. According to the nurses, the 6-week visit entails growth monitoring of the baby, prescribed medication and feeding. Mothers are monitored for disease progression by having a CD4 count and World Health Organisation clinical staging. Human immune deficiency virus -infected breastfeeding women are initiated on fixed-dose combination or zidovudine immediately irrespective of the CD4 count.
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