Content uploaded by Sonto Maria Maputle
Author content
All content in this area was uploaded by Sonto Maria Maputle on Apr 18, 2022
Content may be subject to copyright.
Full Terms & Conditions of access and use can be found at
https://www.tandfonline.com/action/journalInformation?journalCode=whiv20
Journal of HIV/AIDS & Social Services
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/whiv20
Grandmothers’ influence on the implementation
of PMTCT interventions within 6 weeks at rural
areas in Limpopo province: A qualitative study
F. C. Malindi, M. S. Maputle & L. H. Nemathaga
To cite this article: F. C. Malindi, M. S. Maputle & L. H. Nemathaga (2022): Grandmothers’
influence on the implementation of PMTCT interventions within 6 weeks at rural areas
in Limpopo province: A qualitative study, Journal of HIV/AIDS & Social Services, DOI:
10.1080/15381501.2021.2002751
To link to this article: https://doi.org/10.1080/15381501.2021.2002751
Published online: 18 Jan 2022.
Submit your article to this journal
View related articles
View Crossmark data
Grandmothers’influence on the implementation of
PMTCT interventions within 6 weeks at rural areas in
Limpopo province: A qualitative study
F. C. Malindi, M. S. Maputle, and L. H. Nemathaga
Department of Advanced Nursing, University of Venda, Thohoyandou, South Africa
ABSTRACT
Despite enormous interventions aimed at preventing mother-
to-child transmission of HIV; traditional, cultural practices and
mixed infant feeding remain prevalent. This study aimed to
determine the influence of grandmothers when continuing
with the prevention of mother-to-child transmission interven-
tions within 6 weeks after delivery. Qualitative, explorative,
descriptive, and contextual designs were used. The population
comprised of fifteen grandmothers of HIV-exposed babies.
Data were collected through unstructured face-to-face inter-
views and analyzed through the open coding method. Three
themes emerged showing knowledge deficit related to MTCT
risks when using traditional practices; cultural and religious
practices influencers to traditional diagnoses and management
and mixed feeding practices predispose babies. Total elimin-
ation of MTCT of HIV in rural context calls for targeted educa-
tion for grandmothers. Knowledge of traditional and cultural
practices that perpetuate MTCT could assist in developing the
contextual health education content to change grandmothers’
beliefs on infant feeding, prevention, and management of
childhood illnesses.
ARTICLE HISTORY
Received 15 July 2021
Revised 13 October 2021
Accepted 1 November 2021
KEYWORDS
HIV exposed babies;
traditional practices;
grandmothers; within 6
weeks; PMTCT
interventions; influence
Introduction
South Africa is amongst the 22 countries that have pledged to eliminate
mother-to-child transmission (MTCT) of HIV by utilizing the prevention
of mother-to-child transmission (PMTCT) Option Bþ, which supports the
provision of lifelong antiretroviral therapy to HIV-positive pregnant and
lactating women without considering their CD4 count and infant feeding
method of choice (Goga et al., 2016; World Health Organization, 2020).
The estimated MTCT rate in East and Southern Africa is 8% (United
Nations Children’s Fund, 2017). In South Africa, the MTCT rate at 6 weeks
reduced from 3.6% in 2011 to 1.5% in 2016, with a post-6-week transmis-
sion rate of 3.1%. Despite all the interventions aimed at preventing
CONTACT M. S. Maputle sonto.maputle@univen.ac.za Department of Advanced Nursing, University of
Venda, South Africa. Private Bag X5050, Thohoyandou, 0950, South Africa.
ß2022 Taylor & Francis Group, LLC
JOURNAL OF HIV/AIDS & SOCIAL SERVICES
https://doi.org/10.1080/15381501.2021.2002751
mother-to-child transmission (MTCT) of HIV, cultural practices and mixed
infant feeding remain prevalent (Goosen et al., 2014; Mlambo &
Peltzer, 2020).
Traditionally grandmothers are regarded as being knowledgeable, and
expert in caring for a newborn in the family. They are given a platform to
oversee rendering traditional practices to protect the baby against child-
hood illness by performing (muthuso) traditional immunization, removal of
(gokhonya), and mixed feeding introductions of solids (tshiunza). Usually,
the women gave birth at the clinic or hospital where they are given instruc-
tions by midwives to implement PMTCT interventions and to continue
when they are at home. It is noted that traditional practices and PMTCT
intervention usually clash. The traditional practices were regarded as being
important for the wellbeing of the babies within 6 weeks. Midwives who
were rendering PMTCT programs were reported to implement PMTCT
interventions in all primary health care facilities, however, babies were still
at the risk of MTCT of HIV, especially within 6 weeks after delivery.
The grandparents’opinions, beliefs, and other cultural practices related
to prevention and curing childhood illness for both mother and the baby
were reported to predispose the baby to the risk of Mother-to-Child
Transmission (MTCT) of HIV. Babies were brought to the clinic by gran-
nies who did not know the HIV status of the baby and they may be adher-
ing to cultural ways of feeding such as giving water in the morning or
traditional medication in the place of breastfeeding. Gourlay et al. (Gourlay
et al., 2013), mentioned that family members and the strong roles of elders
and their beliefs influence the decision to use traditional medicines instead
of ARVs. Mixed feeding was also identified as a contributory factor that
expose the babies to MTCT. Sujatha (Sujatha, 2014) also concurred that
some traditional practices may put the babies at risk of MTCT of HIV.
This was also supported by Mnyani et al. (2020) that mixed infant feeding
and adherence to traditional practices or cultural factors remained preva-
lent in some rural South African districts. The expressed breast milk that
was stored in the refrigerator was not fed to babies by the grandmothers.
Brittain et al. (Brittain et al., 2015; van den Berg et al., 2015), also found
that the issue of expressing breast milk and store the milk in the refriger-
ator was also not acceptable by society since breastmilk has been assumed
to be a waste product. Since the grandmothers are perceived to be deci-
sion-makers about infant feeding and protecting the babies from childhood
illnesses, the research question was “What role do grandmothers play in
continuing with the implementation of interventions for the prevention of
MTCT in babies within 6 weeks of delivery”?The influence of grannies was
also identified as a barrier for family support to continue and sustain the
implementation of PMTCT interventions. Despite the PMTCT programme
2 F. C. MALINDI ET AL.
(interventions) rendered in all community health care facilities babies were
still admitted in different hospitals being affected with MTCT. Mothers’
records showed that midwives did their work of educating women on dis-
charge. It was not known as to whether grandmothers continue with the
implementation of PMTCT interventions within 6 weeks after delivery? The
purpose of this research was to determine the influence of grandmothers
continuing with PMTCT interventions within 6 weeks after delivery.
Methods
A qualitative approach and explorative, descriptive, and contextual designs
were used to explore grandmothers’influence on the implementation of
PMTCT interventions. The study was conducted in 2018 at the primary
health facilities in three selected districts in Limpopo: namely Capricorn,
Mopani, and Vhembe (as a subsection of the Ph.D. study). The three dis-
tricts were selected because of their different ethnic groups; namely, Venda,
Pedi, and Tsonga. Researchers wanted to determine differences and similar-
ities amongst the three ethnic groups that are found in Limpopo province.
Population and sampling
The population comprised all grandmothers/mothers-in-law of HIV-
exposed babies (within 6 weeks) who were bringing babies for a well-baby
clinic. Fifteen (15) grandmothers/mothers-in-law, 5 from each district, and
agreed to participate were purposely sampled.
Ethical considerations
Ethical standards were ensured by obtaining the ethical clearance (Ref:
SHS/16/PDC/05/1306), from the University of Venda Ethics Committee,
permission to conduct the study from the Limpopo Provincial Department
of Health, the District Managers of the districts, the hospital CEOs and the
participants. Participants coded as Participant numbers from a specific dis-
trict. Participants gave verbal and written, informed consent, and were
informed of their right to withdraw from the study without any penalty.
Ethical principles of fairness, privacy, confidentiality, anonymity as well as
participants’rights to voluntarily participate in the study were adhered to.
Data collection
Data were collected from June to September 2019 from the grandmothers
who were bringing babies to the well-baby clinic. Unstructured face-to-face
interviews were used to gain a detailed narrative of participants on the
JOURNAL OF HIV/AIDS & SOCIAL SERVICES 3
implementation of PMTCT interventions within 6 weeks after delivery.
Data was collected after the baby had attended the well-baby clinic in the
quiet room of the facility. The question asked was “Can you share with me
how do you continue with PMTCT interventions to your grandson/daughter
within the 6 weeks after delivery”? Probing was done focusing on infant
feeding practices; giving of traditional medication, over-the-counter medi-
cation, and the issue of giving the baby expressed breastmilk and general
beliefs on prevention of childhood illnesses). The interviews were con-
ducted by researchers in participants’local language (Tshivenda, Sepedi,
and Xitsonga), and each lasted between 30 and 45 min. Permission to use
the voice recorder was obtained from participants.
Data analysis
The narrative data from the in-depth individual interviews were analyzed
qualitatively using Tesch’s open coding method as postulated by Creswell
(Creswell, 2014; Grove et al., 2012). The recorded interviews were trans-
lated into English by the language expert, transcribed word by word, and
the nonverbal cues (for example, silence/sigh, frowns, and lean back) were
included in the transcripts. All transcripts were read to give meaning, and
a list of similar topics clustered. Data were grouped according to catego-
ries and sub-categories and field notes were also coded and categorized. A
literature control was done to confirm and to put the findings
into context.
Trustworthiness
The criteria for ensuring trustworthiness as outlined in Polit and Beck
(Guba & Lincoln, 1985; Polit & Hungler, 2013) were adhered to.
Credibility was ensured through prolonged engagement during data col-
lection. The researcher met with the participant to establish rapport
and to make an appointment. During the interviews, the researcher
spent time with the participants listening and observing them as they
were interviewed. The participants were interviewed to the point at
which there was data saturation. A member check was also conducted
to validate the truth and to confirm the findings. The voice recorder
was used to ensure credibility. Transferability was ensured by thick
descriptions of research methodology. The recorded interviews were
transcribed verbatim and the nonverbal cues (for example, silence/sigh,
frowns, and lean back) were included in brackets of the transcripts to
ensured authenticity.
4 F. C. MALINDI ET AL.
Presentation of findings
Demographic profile
Grandmothers/mothers-in-law were recruited from Vhembe, Mopani,
and Capricorn districts. Grandmothers from Vhembe District (n¼5)
were pensioners aged between 60 and 70 years all cared for children of
their daughters and/or daughters-in-law, and 3 of the 5 participants
had some knowledge of PMTCT. Participants from Capricorn District
were either pensioners (2 of 5) or aged between 46 and 58 years. All
the participants looked after their grandchildren (i.e., children from
their daughters and/or daughters-in-law) and 4 of the 5 participants
knew PMTCT. Participants from the Mopani district were mostly pen-
sioners, ages ranged from 48 to 65 years, and they cared for their
daughters’and/or daughters-in-law’s children. Only 2 of the 5 partici-
pants knew PMTCT.
Three themes namely; knowledge related to MTCT risks when using
traditional practices, cultural and religious practices influencer to traditional
diagnoses and management and, mixed feeding practices predispose babies
to risk of MTCT emerged. These are voices of grandmothers/mothers-in-
law of influencing implementing PMTCT interventions for HIV exposed
babies within 6 weeks of delivery from the selected districts in Limpopo
Province. Participants were coded as participant number 1–5 from the spe-
cific district. The identified themes and direct quotes will be pre-
sented below.
Theme 1: knowledge related to MTCT risks when using traditional practices
Participants were practicing traditional practices without displaying know-
ledge related to the protection of babies against MTCT. Traditional, reli-
gious, and cultural knowledge was the one that was influencing decisions
made by grandmothers/mothers-in-law when caring for the baby within
6 weeks post-discharge from the hospital. Participants cited their practices
to prevent or curing childhood illnesses.
Participant 4 from Capricorn district said “The childhood illness (Themo)
can only be diagnosed and treated traditionally. The illness can be treated by
specialized old ladies who sometimes are not traditional healers and they are
experts in diagnosing and removing it or can be treated by traditional
healers. Unfortunately, the doctors and the nurses do not know how to treat
the condition.
This was supported by Participant no 2 from the same district when say-
ing ‘If the child is suffering from ‘Themo’the elderly ladies will recognize it
and usually they ask each other for confirmation. The MTCT is a new thing
JOURNAL OF HIV/AIDS & SOCIAL SERVICES 5
and this specific illness (Themo) was there even before MTCT. I think it is
difficult for us as elders.
Participants also indicated the practice they used to cure babies and
mothers, but which could medically increase the risk of MTCT. This was
used when they perceive that the baby is weak. This was confirmed by par-
ticipant 5 from Vhembe district by saying: My grandchildren are treated at
church, where the old ladies will check the baby if the baby is weak and can-
not look up to people, the baby will look like she/he is shy. Then the mother
will be examined and will be found to be having warts on the vulva. The old
ladies will then cut warts using the razor (this called Gokhonya), the piece of
cut will be put in a bucket that is full of boiled tea with salt. The baby will
be bathed with that tea and the baby will be given that tea to drink to
treat ‘Gokhonya’.
Participant 2 from Vhembe concurs by saying; ‘Yes we use traditional
immunization to a newborn for protection of the baby from the evil spirit
and this is called ‘uthusa’.
From this study, participants pointed out that nurses and doctors lack
the knowledge to diagnose related traditional illnesses and they are unable
to treat them. So, grandmothers were the ones who can diagnose and treat
‘Gokhonya’and through their experience, they know traditional healers
who are experts with treating the condition. Participants displayed a lack of
knowledge on basic HIV facts and prevention of transmission to the baby.
When asked about knowledge on hygiene during the performance of the
procedure, Participant 2 from Mopani district: There was no washing of
hands during cutting of the mother’s vulval warts and cutting of the baby on
the occiput. This was evident by them indicating the lack of handwashing
between the cutting of the mother (who may be HIV positive), and the
baby, mix feeding and this can put the baby at danger of contracting
the virus.
Theme 2: cultural and religious practices influencer to traditional diagnoses
and management
Grandparents are traditional, regarded to be having knowledge, experience,
and have the responsibility to mentor mothers post-childbirth. They further
play an important traditional role in the prevention and curing of child-
hood illness. There are different practices done by grandparents that expose
the babies to the risk of MTCT, such as removal of vaginal warts or pim-
ples on the mothers’vulva which is called “Gokhonya”in Tshivenda,
“Themo”in Sepedi, and “Regoni”in Tsonga. These are traditional practices
which are done when examining the mother and cutting the valvul warts,
burning the cuts mixed with traditional medicine (muti) and incising the
6 F. C. MALINDI ET AL.
baby on the occiput, and smearing the mixture on the open cuts. Lack of
knowledge about cross-infection expose the baby to the risk of MTCT as
data reported that there was no washing of hands in between cutting off
the mother and incising of the baby, there was no clear information about
sharing of the razor between the cutting of the mother and the baby, thus
exposing the baby to the risk of MTCT. The following are the direct quota-
tions that confirmed the practice when they suspect that the baby is sick.
Participant 3 from Capricorn district said “The traditional healer will
search for growth or warts like in the vagina of the mother and remove it.
Small pieces of growth or warts will then be taken and burned and mixed
with traditional medicine (muti), and the traditional healer will cut the baby
on the red sport that appears on the occiput and apply the prepared muti
with burned cuts of warts. The mother will be given some muti to squat on
the burning muti, and then from there the baby will be well”.
Participant 1 from the Vhembe district supported the statement “Maybe
the virus was killed when they burn the cuts, but there was no washing of
hands in between the procedure. The traditional healer does not put on
gloves and no handwashing is done”.
Participant 4 from Capricorn district “The pastor will use the boiled nee-
dle to prick the baby on the back of the occiput when the baby starts to
bleed the pastor will smear coffee mixed with salt (prayed for) and he will
give another tea to give to the baby to drink, that tea will also be utilized
to splash on the head of the baby, back and chest of the baby.
Participant 1 from Mopani district: confirm the use of the practice by
saying “Regoni”is the number one killer of babies if not diagnosed and
treated in time. Unfortunately, the diagnose and treatment can only be
done by elderly ladies who are experts in “Regoni”or traditional healers,
the western medicine cannot treat “Regoni”. The doctors and nurses are
unable to diagnose and treat. If the baby is not treated early the baby
may die.
Participant 3 from the Vhembe district supported by saying; If
“Gokhonya”is there and if it is not removed, the baby may die. “Gokhonya”
kills, it shows by pimples or warts in the vulva of the mother and the baby
will have red spot below occiput and the baby will be always looking down.
The baby will be shy to look at people. The traditional healer will cut warts
mixed with traditional medicine, burned them, and then incise the baby on
or below occiput and smear the medication.
Participant 5 from the Vhembe district said “After the cord fell off the
traditional healer is brought to the family to immunize the baby traditionally
(Uthusa). The traditional healer performed all the rituals and herbs with the
instructions of putting the herbs in the clay container, add water, and
mealie meal”.
JOURNAL OF HIV/AIDS & SOCIAL SERVICES 7
Data from all 3 districts participants reported being practicing this trad-
itional practice, which is done when the baby is sick or is perceived to be
weak and unable to lookup. Participants reported that in villages there is
an old lady who specializes in diagnosing and managing the mother and
the baby. However, the aspects of MTCT prevention were not considered.
Theme 3: mixed feeding practices predispose babies to risk of MTCT
Different feeding practices are performed from birth and continued within
6 weeks and this depended upon the knowledge, beliefs, and influences of
the grandmothers in the family. Participants indicated that they feed babies
type like; watery soft porridge immediately when the baby is discharged
from the health facility, whilst others reported that they will wait until the
cord fell off. The other group of grandmothers verbalized that they started
to give food at 3 months, and some said they give solids when the baby
starts to cry due to hunger.
Quotes to support were cited by participant 2 from Vhembe district
“After the cord fell off the traditional healer is brought to the family to
immunize the baby traditionally (Uthusa). On the third day, a watery soft
porridge was prepared for the baby to prevent childhood illness, such as
abdominal discomfort, diarrhea, and colic”.
Participant 1 from Capricorn district “I usually start to give soft porridge
to my grandchildren at 3/12 or 4/12. Before that my grandchildren are
given breast, milk, and formula feeding to prevent the baby from crying
due to hunger. Participants also reported that they use herbs to prevent
diarrhea and other childhood illness. Participants who are traditionally
influenced verbalized that the babies were fed water that is prepared by
traditional herbs (ntswu), and is given to the baby replacing food or
soft porridge.
Participant 4 from Vhembe district “After the traditional immunization
(u thusa) the traditional healer will give some roots of different herbs to
assists the baby to grow well and to protect the baby from a childhood ill-
ness. The roots will be placed in a calabash and water is added which will
make the watery soft porridge to feed the baby or the traditional healer pre-
pared (ntswu) this herbal solution is used to replace soft porridge. Those
babies who are given soft porridge are also given herbs preparation for drink-
ing early in the morning”.
Participant 5 from Mopani district “I am a church member and I only
use water that was prayed over by my pastor and nothing else. I also give all
my grandchildren gripe water and if the baby is crying, I also use “dupa”to
prevent (tetanus) Nurse you know what? Things like the essence of life and
“Umuthi we nyon”i are the best remedy to calm the babies whose stomachs
8 F. C. MALINDI ET AL.
are not settled. Some participants reported that they buy over-the-counter
medicine such as “Dupa,”“Umuthi wenyoni,”and”Gripe water,”whilst
others reported to feed their babies with water, sugar, and salt.
Participant 3 from Mopani district “Ahaaa …Yes I don’t want this baby
to cry always that that is why I gave the baby gripe water and pacifier to
keep the baby busy and it will make her calm down when the mother is at
school because milk is very expensive that is why I supplement milk with a
pacifier. The participant further said: “The mother will only breastfeed the
baby after school. I don’t want her to express and keep the milk in the fridge,
that is not acceptable it is dirty”.
Participants reported that expressed breast milk is an unacceptable prac-
tice. This was noted from participants of different ethnic groups; Venda,
Tsonga, and Pedi-speaking. Participants verbalized that expressed breast
milk is nauseating and is disgusting. Participants verbalized that breast
milk is like waste products like stools, sputum, or urine. However, other
participants agree that breast milk is good for the growth of the baby, but
expressed breast milk is not acceptable. The following were quotations
from the participants: Participant 5 from the Capricorn district had to say:
“Breast milk is like waste products, i mean things like saliva, mucus, urine,
and stools. To tell the truth I cannot stand for that. Even in my family
when you have just given birth and the breast milk is too much and flow-
ing on the T-shirt, they will not allow you to touch any food. Breast milk
has a smelling that I cannot tolerate”. This was supported by participant 4
from Mopani district: “It is a taboo for a nursing mother to cook for her
husband or even to take care of the husband, this was the responsibility of
the family to cook and doing household chores”.
Grandmothers who are caring for the babies of teenage mothers reported
that to keep the baby quiet they must give the baby pacifiers as a child
grant is not enough to buy milk to feed the baby. Participants who are
Christians reported that they feed their babies with Holy water. The water
is reported that it will be sent to the pastor to pray over the water before
the baby is being given the water (this is mixed feeding). Infant feeding has
been identified as a major problem in African countries. Grandmothers
play a major role in influencing the feeding options of the baby in
a family.
Discussion of findings
Knowledge related to MTCT risks when using traditional practices
The strong roles of elders and their beliefs influence decisions to use trad-
itional healers and medicines in place of ARV (Gourlay et al., 2013).
Grandmothers were reported to prefer traditional healers to Western
JOURNAL OF HIV/AIDS & SOCIAL SERVICES 9
medication with the mind that health care practitioners do not know how
to treat some childhood illnesses. The findings of this study indicated that
grandmothers are regarded as being knowledgeable about matters that
involved raising the children, but they lack knowledge of the risk of MTCT
as most traditional practices expose the babies to the risk of MTCT. The
lack of knowledge about the risk of MTCT was not considered because
they were traditionally regarded to know everything about the issues of
childhood illness. Their influence of taking the baby to their traditional
healer for traditional rituals performance confirmed limited knowledge of
MTCT. Grandmothers further displayed a lack of knowledge of basic hand
hygiene and cross-infection because nothing mentioned while the touching
of blood is involved during the performance of traditional practices such as
removal of valvul warts (gokhonya). The practice was noted amongst the
three ethnic groups, though they used different names.
Grandmothers were reported to exercise extreme power in the family
regarding the care of the baby with childhood illness compromising the
baby with the risk that contributes to MTCT. This report was also con-
firmed by Sujatha (2014) who indicated that there are a strong relationship
between religion, cultural practices, and beliefs in the caring of a newborn.
Participants also mention that the babies are given holy water, herbal medi-
cation, incised to smear herbal medicine to care for the baby to prevent
and to manage childhood illness (Njai & Dixey, 2013). The risk to MTCT
is very high as any food or drink is taken before 6 weeks may affect the gut
of the baby in different ways such as diarrheoa, allergies and HIV can eas-
ily invade the gut of the baby (Muheriwa et al., 2013). In the study that
was conducted by Swigart et al. (2017), it was reported that the grand-
mothers refused to take the grandchild to the doctor verbalizing that she
was born before the doctor was born (older with wisdom that is more than
that of the doctor. Therefore, without the involvement of grandmothers,
and giving health education to the mothers together with grandmothers to
upskill their knowledge, all the efforts of implementation of PMTC inter-
ventions will be a wasted endeavor.
Cultural and religious practices influence traditional diagnoses
and management
Literature indicated that different cultural practices are being practiced on
newborn babies to protect them from diseases or prevent deaths. Njai and
Dixey (2013) indicated that grandmothers consult traditional healers to
give them traditional medicine to give to the newborn to prevent evil spi-
rits which may kill the baby, whilst Semega-Janneh (Semega-Janneh et al.,
2001) reported that after the mother has given birth she has to undergo 3
10 F. C. MALINDI ET AL.
calls of prayer which lasted 12 h each. Aborigo et al. (2012) also indicated
that in Ghana babies are given herbal concoctions to feed the baby before
initiation of breastfeeding. Boys were reportedly given herbal concoctions
for 4 days whilst girls spent 3 days before they are given breast milk to pre-
vent death (Aborigo et al., 2012).
In the study that was done by Kalembo (Kalembo et al., 2013), it was
reported that elderly women prepare herbal medicine combining green
crushed leaves that are soaked in water and given to the baby to drink in
the morning and the evening and that herbs are also used to bathe the
baby to protect the baby from evil spirits, witchcraft, and the evil eye.
Sujatha (2014) indicated that grandmothers’traditional beliefs influence
mothers to give home remedies such as using oil massage before the first
bath, applying ashes, soot, or dry cow dung. It was also indicated that inci-
sion or cutting the baby on fontanel with a razor and smear the powder of
the traditional medicine on the open area increased the risk of MTCT.
However, the aspect of handwashing was not mentioned. Grandmothers
were reported to further apply the mixture of different herbs on the baby’s
face to prevent bad eyes. It has also been indicated that babies are given
charm water to drink to protect the baby from evil spirits (Njai & Dixey,
2013). To further protect babies, traditional healers were reported to be
doing the incision and smear with powdered remedy from burnt herbal
medicine (Bland et al., 2004). This was also achieved by using a piece of
dried burned so that the person who touches the baby with evil thoughts
will be strike by lightning (Bland et al., 2004).
Researcher realized that there was a lot of information that is given to
the mother by grandmothers to elicit fear in the mothers so that the grand-
mothers will be able to perform their traditional rituals without disturbance
from the mother. The researcher concluded that child health care must not
only involve mothers as they don’t have a say when it comes to the man-
agement of childhood illness. Grandmothers are the one who is regarded as
being knowledgeable and experienced in taking care of the baby and the
mother. There is a need for radical knowledge impartation to the grand-
mothers and traditional healers to mitigate the risks of MTCT.
Mixed feeding practices predispose babies to risk of MTCT
According to the grandmothers’version, babies are not supposed to be
breastfed colostrum as this was regarded as dirty milk (Ergenekon-Ozelci
et al., 2006). Grandmothers believe that water gives life and they prefer to
give water to the baby than to feed the baby with colostrum. Some herbs
were prepared to be given to the newborn with the belief that they will set-
tle the baby’s stomach and prevent colic.
JOURNAL OF HIV/AIDS & SOCIAL SERVICES 11
It was also noted from findings that after the baby is discharged from
the clinic, the family traditional healer is summoned to come and immun-
ize the baby traditionally. The traditional healer would bring along herbs to
be given to the baby mixed with mealie meal and water to prepare a soft
porridge to feed the baby. It is documented that mixed feeding predisposes
the baby to the risk of MTCT. Whereas physiologically, feeding with other
substances and infectious illness can all result in intestinal damage, which
could also be a risk factor for transmission Iliff et al. (2005) hypothesized
that the intestinal permeability of the young infant may be affected by the
mode of feeding, with infants who receive only breast milk having a less
permeable and therefore healthier lining of the gut than those who also
receive other foods (Iwelunmor et al., 2014; World Health Organization
PMTCT Strategic, 2010). When the baby cries, it was regarded that the
baby is hungry, and will be given soft porridge. It was indicated that babies
are given solids as early as within 6 weeks. Grandmothers were reported to
influence the early introduction of solids (Njai & Dixey, 2013). Mixed feed-
ing exposes the baby to a high risk of MTCT. The introduction of solids
while the baby is still breastfed and is under 6 months of age irritates the
gut and corrode the inner lining of the digestive system and exposes the
baby to MTCT. Participants displayed a lack of knowledge about feeding
practices that predispose babies to the risk of MTCT.
The Mother, Child Health and Nutrition booklet (Department of Health,
2008) indicated that the baby should be exclusively breastfed for 6 months
without giving the baby anything else. Exclusive breastfeeding is when the
baby is not given any other foods or liquids such as water, animal milk,
tea, baby formula milk, or porridge, not to use baby feeding bottles or
dummies to feed the baby, except the medicines prescribed by a doctor or
Nevirapine sirup (Department of Health, 2008). Exclusive breastfeeding
reduces the risk of HIV transmission compared to mixed feeding (mixed
feeding means breastfeeding and giving other milk or foods). In the study
compared with exclusive formula feeding (EFF) or exclusive breastfeeding
(EBF), “mixed feeding,”the practice of giving breast milk and any other
liquid or food simultaneously, confers the highest risk of morbidity and
mortality (Coovadia et al., 2012). Not only are infants deprived of the bene-
fits of full breastfeeding, but mixed feeding can also increase transmission
of HIV. Mixed feeding practices corrode the gut of the baby exposing the
baby to HIV (World Health Organization PMTCT Strategic, 2010).
Grandparents displayed a lack of knowledge regarding contributory risks.
They were reported to be bringing their long-time experiences which
include practicing forceful feeding and early introduction of solids mixed
with herbs (Aborigo et al., 2012; Chukwukaodinaka, 2014). In the same
study, grandmothers were reported to be giving babies gripe water (over
12 F. C. MALINDI ET AL.
the counter medicine), local herbs, and traditional meaningful food which
is water mixed with flour of guinea corn (Aborigo et al., 2012). Iwelunmor
et al. (2014) indicated that grandparents believe that herbs mixed with milk
are important for the health of the baby as they prevent childhood illness.
The influence of grandmothers was identified as a barrier for family sup-
port to sustain the implementation of PMTCT interventions within 6 weeks
after delivery. Most babies were taken care of by grandmothers as their
mothers were at work or were still attending school, expressing of breast
milk was encouraged. In Western countries expressed breast milk is accept-
able and mothers would express breast milk and put it in the refrigerator
to feed the baby when the mother is at work or school (DaCosta, 2012).
Findings of the study revealed that it is taboo for a mother to express
breast milk and feed the baby. Participants indicated that expressing breast
milk and store the milk in the refrigerator was found to be unacceptable by
society because breast milk is assumed to be like a waste product (e.g., fea-
ces or urine). When doing one-on-one counseling, mothers will tell the
truth and present accurate information which is different from what they
verbalized if the grandmother can be present during the consultation.
Grandmothers were reported to be decision-makers about the matter of
feeding the baby.
Limitation of the study
This study was limited to only selected health facilities of Capricorn,
Mopani, and Vhembe districts. The findings may not be generalized to
other settings.
Conclusion
The study aimed to determine the influence of grandmothers of different
ethnic groups on continuing with PMTCT interventions within 6 weeks
after delivery. The grandmothers are being reported to be decision-makers
about the matter of feeding the baby. Findings revealed that the similarities
in the traditional practices of the three ethnic groups were influencing
MTCT risks. Grandmothers were lacking knowledge that when mix feeding
by giving any food or liquid within 6 weeks after delivery to a breastfed
baby, this put the baby at high risk as this may cause erosion to the gut of
the baby leading to MTCT.
Recommendations
During feeding counseling, mothers were found to have a clear knowledge
of accurate infant feeding practices, this should be extended to the
JOURNAL OF HIV/AIDS & SOCIAL SERVICES 13
grandmothers. Health care workers need to involve grandmothers in infant
feeding counseling to ensure PMTCT intervention sustainability
(Chukwukaodinaka, 2014; Njai & Dixey, 2013). Counseling sessions and all
information pamphlets should be conducted in the language of the partici-
pant. Mother mentors and home base carers should be involved in health
educate the community about the risk of MTCT. Information on the
importance of adherence to the implementation of PMTCT interventions
should be strengthened.
Acknowledgments
Researchers would like to acknowledge the grandmothers from different health facilities of
the selected districts for participating in the study. The University of Venda Research and
Publication Committee for funding and Limpopo Department of Health for providing per-
mission to access the primary health care facilities.
Disclosure statement
The authors declare that they had no financial or personal relationship(s) which may have
inappropriately influenced them in writing this article.
Authors’contributions
The project leader was F.C.M as a Ph.D. student and M.S.M a promoter and L.H a co-
promoter. The student was involved in conceptualization, data collection, analysis, and
report writing. She drafted the manuscript under supervision. F.C.M, M.S.M, and L.H con-
ducted a literature search. All authors contributed to data analysis, drafting, and revising
the article. All authors participated in the finalization of the article. We wish to confirm
that there are no known conflicts of interest associated with the publication of this work.
We confirm that the manuscript has been read and approved by all named authors, and all
have satisfied the criteria for authorship. We confirm that we have given due consideration
to the protection of intellectual property associated with this work and that there are no
hindrances to publication concerning intellectual property. We understand that the corre-
sponding author is the sole contact for the editorial process, including direct communica-
tion relating to submission, the progress of the manuscript, submission of revisions, and
final approval of proofs. All named authors contributed to the conception, drafting, and
finalization of the manuscript.
Funding
The South African Medical Research Council and the University of Venda Research and
Publication Committee provided financial assistance.
Data availability statement
The raw data used to support the findings of this study are included in the article and can
be available from the corresponding author upon request.
14 F. C. MALINDI ET AL.
References
Aborigo, R. A., Moyer, C. A., Rominski, S., Adongo, P., Williams, J., Logonia, G., Affah,
G., Hodgson, A., & Engmann, C. (2012). Infant nutrition in the first seven days of life in
rural northern Ghana. BMC Pregnancy and Childbirth,12, 76. https://doi.org/10.1186/
1471-2393-12-76
Bland, R., Rollins, N., Van den Broeck, J., & Coovadia, H. (2004). The use of non-pre-
scribed medication in the first 3 months of life in rural South Africa. Tropical Medicine
& International Health : TM & IH,9(1), 118–124.
Brittain, K., Giddy, J., Myer, L., Cooper, D., Harries, J., & Stinson, K. (2015). Pregnant
women’s experiences of male partner involvement in the context of prevention of
mother-to-child transmission in Khayelitsha, South Africa. AIDS Care,27(8), 1020–1024.
Chukwukaodinaka, N. E. (2014). Factors influencing the utilisation of PMTCT services in the
Federal Capital Territory of Nigeria. University of South Africa. http://hdl.handle.net/
10500/19036.
Coovadia, H. M., Brown, E. R., Fowler, M. G., Chipato, T., Moodley, D., Manji, K., Musoke,
P., Stranix-Chibanda, L., Chetty, V., Fawzi, W., Nakabiito, C., Msweli, L., Kisenge, R.,
Guay, L., Mwatha, A., Lynn, D. J., Eshleman, S. H., Richardson, P., George, K., …
Maldonado, Y. (2012). Efficacy and safety of an extended nevirapine regimen in infant
children of breastfeeding mothers with HIV-1 infection for prevention of postnatal HIV-1
transmission (HPTN 046): A randomised, double-blind, placebo-controlled trial. Lancet
(London, England),379(9812), 221–228. https://doi.org/10.1016/S0140-6736(11)61653-X
Creswell, J. W. (2014). A concise introduction to mixed methods research. Sage Publications.
DaCosta, S. (2012). Ethno-cultural factors that influence infant feeding among south Asians
in the region of peel: Findings from stakeholder consultations. Region of Peel-Public
Health, Family Health Division.
Department of Health (2008). Prevention of mother transmission of HIV (PMTCT) guide-
lines. Department of Health, South Africa.
Ergenekon-Ozelci, P., Elmaci, N., Ertem, M., & Saka, G. (2006). Breastfeeding beliefs and
practices among migrant mothers in slums of Diyarbakir, Turkey, 2001. European
Journal of Public Health,16(2), 143–148. https://doi.org/10.1093/eurpub/cki170
Goga, A. E., Dinh, T.-H., Jackson, D. J., Lombard, C. J., Puren, A., Sherman, G., Ramokolo,
V., Woldesenbet, S., Doherty, T., Noveve, N., Magasana, V., Singh, Y., Ramraj, T.,
Bhardwaj, S., & Pillay, Y. (2016). Population-level effectiveness of PMTCT option A on
early mother-to-child (MTCT) transmission of HIV in South Africa: Implications for
eliminating MTCT. Journal of Global Health,6(2), 020405. https://doi.org/10.7189/jogh.
06.020405
Goosen, C., McLachlan, M. H., & Sch€
ubl, C. (2014). Infant feeding practices during the
first 6 months of life in a low-income area of the Western Cape Province. South African
Journal of Child Health,8(2), 50–54. https://doi.org/10.7196/sajch.675
Gourlay, A., Birdthistle, I., Mburu, G., Iorpenda, K., & Wringe, A. (2013). Barriers and
facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child
transmission of HIV in sub-Saharan Africa: A systematic review. Journal of the
International AIDS Society,16(1), 18588. https://doi.org/10.7448/IAS.16.1.18588
Grove, S. K., Burns, N., & Gray, J. (2012). The practice of nursing research: Appraisal, syn-
thesis, and generation of evidence. Elsevier Health Sciences.
Guba, E. M., & Lincoln, Y. S. (1985). Naturalistic enquiry. SAGE.
Iliff, P. J., Piwoz, E. G., Tavengwa, N. V., Zunguza, C. D., Marinda, E. T., Nathoo, K. J.,
Moulton, L. H., Ward, B. J., Humphrey, J. H., & Group, Z. S. (2005). Early exclusive
JOURNAL OF HIV/AIDS & SOCIAL SERVICES 15
breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free
survival. AIDS,19, 699–708.
Iwelunmor, J., Ezeanolue, E. E., Airhihenbuwa, C.,O., Obiefune, M. C., Ezeinoluwe, C. O.,
& Ogedegbe, G.,G. (2014). Socio-cultural factors influencing the prevention mother-to-
child transmission of HIV in Nigeria: A synthesis of the literature. BMC Public Health,
14, 771.
Kalembo, F. W., Maggie, Z., & Du, Y. K. (2013). Progress of mother-to-child transmission
of HIV programs in China: Successes challenges and way forward. Chinese Medical
Journal,126(16), 3172–3176.
Mlambo, M. G., & Peltzer, K. (2020). Perceptions of grandmothers and HIV-infected moth-
ers on infant feeding practices in a rural South African district. Health SA ¼SA
Gesondheid,25(0), 1372. https://doi.org/10.4102/hsag.v25i0.1372
Mnyani, C. N., Tait, C. L., Peters, R. P. H., Struthers, H., Violari, A., Gray, G., Buchmann,
E. J., Chersich, M. F., & McIntyre, J. A. (2020). Implementation of a PMTCT pro-
gramme in a high HIV prevalence setting in Johannesburg, South Africa: 2002–2015.
Southern African Journal of HIV Medicine,21(1), a1024. https://doi.org/10.4102/saj-
hivmed.v21i1.1024
Muheriwa, S. R., Chimwaza, A., Maluwa, A. O., Nyasulu, B. M., & Pindani, M. (2013).
Beliefs and practices of young women on utilization of prevention of Mother-to-Child
transmission of HIV services in Malawi. Health,05(07), 1172–1179. https://doi.org/10.
4236/health.2013.57158
Njai, M., & Dixey, R. (2013). A study investigating infant and young child feeding practices
in Foni Kansala district, western region, Gambia. Journal of Clinical Medicine and
Research,5(6), 71–79. https://doi.org/10.5897/JCMR11.039
Polit, D. F., & Hungler, B. P. (2013). Essentials of nursing research: Methods, appraisal, and
utilization (8th ed.). Wolters Kluwer/Lippincott Williams and Wilkins.
Semega-Janneh, I. J., Bohler, E., Holm, H., Matheson, I., & Holmboe-Ottesen, G. (2001).
Promoting breastfeeding in rural Gambia: Combining traditional and modern know-
ledge. Health Policy Plan,16(2), 199–205.
Sujatha, R. (2014). Cultural practices and beliefs on newborn care among mothers in a
selected hospital of Mangalore taluk. Nitte University Journal of Health Science,4(2), 21.
Swigart, T. M., Bonvecchio, A., Th
eodore, F. L., Zamudio-Haas, S., Villanueva-Borbolla,
M. A., & Thrasher, J. F. (2017). Breastfeeding practices, beliefs, and social norms in low-
resource communities in Mexico: Insights for how to improve future promotion strat-
egies. PLoS One,12(7), e0180185. https://doi.org/10.1371/journal.pone.0180185
United Nations Children’s Fund (2017). Evaluation of the UNICEF PMTCT/Paediatric HIV
care and treatment programme. Retrieved November 15, 2020, from https://www.unicef.
org/evaldatabase/files/PMTCT_Evaluation_FullReport_WEB.pdf
van den Berg, W., Brittain, K., Mercer, G., Peacock, D., Stinson, K., Janson, H., & Dubula,
V. (2015). Improving men’s participation in preventing mother-to-child transmission of
HIV as a maternal, neonatal, and child health priority in South Africa. PLoS Medicine,
12(4), e1001811. https://doi.org/10.1371/journal.pmed.1001811
World Health Organization (2020). Mother-to-child transmission of HIV. Retrieved
November 15, 2020, from http://www.who.int/hiv/topics/mtct/en/
World Health Organization PMTCT Strategic (2010). Vision 2010-2015: Preventing mother-
to-child transmission of HIV to reach the UNGASS and millennium development goals.
World Health Organization.
16 F. C. MALINDI ET AL.
