"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

Introduction: It 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.

Methods: Using 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.

Results: Among 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.

Conclusions: We 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.