"I managed to stand on my own. I saved my baby's life.": qualitative analysis of birth experiences from women living with HIV in Cape Town, South Africa

BackgroundThere is growing recognition of obstetric violence in health facilities across the globe. With nearly one in three pregnant women living with HIV in South Africa, it is important to consider the influence of HIV status on birth experiences, including potential experience of obstetric violence as defined by the Respectful Maternity Care Charter. This qualitative analysis aims to understand the factors that shape birth experiences of women living with HIV, including experiences at the nexus of HIV status and obstetric violence, and how women react to these factors.MethodsData were collected in a Midwife Obstetric Unit in Gugulethu, Cape Town, South Africa, through 26 in-depth interviews with women living with HIV at 6-8 weeks postpartum. Interviews included questions about labor and early motherhood, ART adherence, and social contexts. We combined template style thematic analysis and matrix analysis to refine themes and subthemes.ResultsParticipants described a range of social and structural factors they felt influenced their birth experiences, including lack of resources and institutional policies. While some participants described positive interactions with healthcare providers, several described instances of obstetric violence, including being ignored and denied care. Nearly all participants, even those who described instances of obstetric violence, described themselves as strong and independent during their birth experiences. Participants reacted to birth experiences by shifting their family planning intentions, forming attitudes toward the health facility, and taking responsibility for their own and their babies' safety during birth.ConclusionsNarratives of negative birth experiences among some women living with HIV reveal a constellation of factors that produce obstetric violence, reflective of social hierarchies and networks of power relations. Participant accounts indicate the need for future research explicitly examining how structural vulnerability shapes birth experiences for women living with HIV in South Africa. These birth stories should also guide future intervention and advocacy work, sparking initiatives to advance compassionate maternity care across health facilities in South Africa, with relevance for other comparable settings. Mistreatment of women during childbirth is a global concern, with known negative impacts on the birthing person and newborn. Women living with HIV are at risk for mistreatment in clinical settings due to persistent stigma and negative perceptions about HIV. Women living with HIV may be further at risk for mistreatment during labor and delivery based on stigma related to HIV status. This qualitative data analysis aims to understand the factors that shape birth experiences of women living with HIV, and how women react to those factors. Data were collected in a Midwife Obstetric Unit in Gugulethu, Cape Town, South Africa, through 26 interviews with women living with HIV at 6-8 weeks postpartum. Interviews included questions about labor and early motherhood experiences. We used a combination of qualitative data analysis techniques to understand and organize participant experiences. While some participants described positive interactions with healthcare providers, several described mistreatment including being ignored, disrespected, denied care, and denied informed consent. Participants also said that lack of healthcare facility resources and infrastructure issues influenced their birth experiences. Nearly all participants, even those who described mistreatment during childbirth, described themselves as strong and independent. These birth stories should guide future research and advocacy in South Africa.