Since the initiation of PMTCT programmes in the year 2000 in SA, professional nurses have been at the forefront of PMTCT implementation (WHO 2007) and the PMTCT document used by professional nurses has been revised twice. At each review, there has been acknowledgement that the significant governmental investments have not been equalled by the reported success in PMTCT implementation and there is no evidence that men have been involved at any stage of PMTCT implementation in SA (KZN Health DOH 2012).

Many studies are largely focussed on issues related to the effective integration of PMTCT initiatives into mainstream services (Horwood et al. 2010), patients’ satisfaction, coverage and the available drugs utilised in PMTCT (KZN Health DOH 2012) neglecting the most significant support system stakeholder being the male. Notably, HIV/AIDS in pregnancy is not a female burden; instead, it should be shared by both parents. PMTCT services in South Africa are offered in almost all health facilities (98%). The percentage of HIV positive pregnant women receiving ART to reduce HIV transmission during pregnancy has steadily increased from 83% in 2009 to 87% in 2012 and mother-to-child transmission has decreased to 2.7% since 2011, and 0% HIV transmission from the mother to a child remains a challenge for all health workers and related stakeholders. Hence, this study sought to describe and explore the female perspectives of male inclusion in the prevention of mother-to-child HIV transmission programme at selected public hospitals in KwaZulu-Natal.

A qualitative approach formed the basis of this research design. Qualitative research is person-catered and takes an ‘emic’ perspective (insider’s point of view). Thus, Creswell (2009) defines qualitative research as an enquiry process of understanding based on distinct methodological traditions of enquiry that explore a social or human problem in ways that support a researcher-built complex, holistic picture. This tradition analyses words, reports detailed views of informants and conducts the study in a natural setting. Therefore, the theoretical frameworks are not predetermined (Holloway & Wheeler 1996; Mouton & Marias 1990). A qualitative approach was used to explore and describe barriers towards male inclusiveness in PMTCT programmes.

For this study, the key qualitative aspects are related to the exploratory, descriptive and a contextually determined understanding. Each of these aspects is described below to emphasise the total study focus.

Adoption of an exploratory approach assisted the researcher to collect new data in areas where little or no research has been conducted (Mouton 1996; Mouton & Marais 1990; Woods & Cantazaro 1988). Cooper and Schindler (2001) state that an exploration typically begins with a search of published data. This was done in empirical exploration and included a description of barriers towards male inclusiveness in PMTCT programme. The researcher provided an in-depth description of experiences of HIV positive pregnant mothers regarding male inclusiveness in PMTCT programmes (Chinn & Kramer 1995; Mouton 1996). During conceptualisation of the findings, an accurate description of the relational statements formed the basis on which the recommendations were described.

Polit and Hungler (2004) state that descriptive research aims at giving insights into the characteristics of individuals, situation or groups and the frequency with which certain phenomena occur. During data collection (regarding the motivational factors and barriers towards gender inclusiveness in PMTCT), the researcher provided an in-depth description of the identified attributes towards male inclusiveness in PMTCT programme (Chinn & Kramer 1995; Mouton 1996). During the conceptualisation of findings, an accurate description of the relational statements formed the basis on which the recommendations were described.

According to Lincoln and Guba (1985), a phenomenon must be studied in its natural setting because individuals take their meaning from themselves within their context. Pregnant mothers who were directly involved with PMTCT programme in the selected hospitals were able to reveal particular information in a specific context (Babbie & Mouton 2011; Mouton 1996).

The study was undertaken in KwaZulu-Natal Department of Health which has six health districts. Within this, HIV positive pregnant women are referred to the larger hospitals for comprehensive HIV management in pregnancy. Three of these larger hospitals were selected in the KwaZulu-Natal province for the purpose of this study. The selected hospitals were as follows: one from Ethekwini Health District (192 patients attend the clinic daily), which is situated in the south of the KwaZulu-Natal; one from the central region of the province (164 patients attend the clinic daily), which falls under Mgungundlovu Health District; and one from Zululand Health District (210 patients attend the clinic daily), which is situated in the north of KwaZulu-Natal. The hospitals were selected to ensure geographical representation of the province. An additional criterion for inclusion was the large number of pregnant HIV positive patients managed by each of the mother-to-child transmission services.

The study population consisted of patients on PMTCT programmes in three selected public hospitals in KwaZulu-Natal. Pregnant HIV positive patients were the primary target population for the study as the intended service users of PMTCT programmes.

The researcher upheld the confidentiality of those involved in the interviews, keeping their anonymity and privacy secured; only the researcher had access to detailed information about the participants. The study was designed in such a way that risks of breaking confidentiality were minimised. The researcher has to ensure that the right to privacy and anonymity is upheld (Streubert & Carpenter 2011; Tolich 2008; Willig 2008). To minimise threats to internal validity, the researcher facilitated all the data collection. The researcher used the local language used by the community (Creswell 2012; Parahoo 2009; Polit & Beck 2012).

In qualitative research, ethical conduct involves accountability to all different stakeholders and the unanticipated ethical concerns related to the ever-changing expectations of the study (Streubert & Carpenter 2011). In this study, the participants’ rights were observed in accordance with the international ethical principles as stipulated in the Belmont Report 1979 (Streubert & Carpenter 2011; Tolich 2008), the Medical Research Council Guidelines on Ethics for Medical Research and Guidelines for Good Practice in the Conduct of Clinical Trials in Human Participants in South Africa. Focus was on ensuring absolute protection and confidentiality of prospective participants, particularly as the subject matter related to HIV/AIDS is sensitive and can be a source of stigma for affected individuals. To minimise the risk of exposure, eventual participants had the option of selecting a venue of their choice at any of the available service delivery centres, and most participants opted for comfortable beds familiar to them.

The biographical information is as follows: 15 interviews were conducted with the participants (n = 15), ages of the participants varied between 18 and 35 years of old, and the majority (87%) of participants were unemployed (n = 13).

The pregnant mothers (n = 15) took part in unstructured interviews. With each participant, a question was asked:

From this enquiry, participant responses related to the ‘structure’ of PMTCT services they had been involved with and from this a range of themes emerged. Participants felt that service policies dictated much of their experience and, in some instances, participants appeared unaware that males were allowed to be part of their antenatal care. In supporting the latter viewpoint, a quote from one of the participants is presented:

From the above response, the suggestion was that the lack of awareness about an inclusive service structure was partially responsible for the non-engagement of male partners. The feeling that no other person would be allowed to support an expectant mother was expressed by others and included views such as:

One of the participants noted that the exclusion of a partner from her PMTCT sessions was not self-initiated but rather had been influenced by professionals, one of whom was quoted as saying:

In addition to the participants identifying ‘service-structure’ as an important factor in the usage of PMTCT, the role ‘resources’ played in the experience of PMTCT services was specifically identified. Some of the expectant mothers noted that they were acutely aware that the issue of resources defined their own personal experiences of PMTCT services. The views were captured in some of the responses they offered, which included the following opinion:

One of the participants spoke specifically about the possibility of engaging their male partners within their PMTCT and, within this, identified concerns about a general lack of resources as an important barrier. She indicated:

The participant feedback about the impact that resources had on service delivery also highlighted the role ‘lack of space’ in clinics played as a likely barrier to the inclusion of men. Some participants felt that the limited space, the long waiting periods and concerns about privacy in the clinics made it difficult to allow males to participate and, for that reason, discussions about the involvement of males in PMTCT could only be contemplated if issues acknowledging the lack of space and long waiting periods in clinics could be satisfactorily addressed. Below are some of the expressed viewpoints that spoke to this observation:

In addition to identifying limitations related to ‘lack of space’, and ‘privacy requirements’, factors related to personal circumstances were identified as having noteworthy influence on participants’ experiences of PMTCT. Lack of funds and the general unavailability of male partners because of work-related commitments were specified as potential barriers to the involvement of men. To support this, one of the participants indicated that:

There was widespread suggestion that the lack of financial resources had some negative impact on the possibility of widening PMTCT services to include males. Beyond that, participants also pointed to attitudinal factors that they felt were important considerations. For example, two of the participants expressed the following:

As part of the exploration, participants’ knowledge about key issues including their pre-existing knowledge about the PMTCT programme was elicited. The exploration focussed on participants’ knowledge of the drugs used in the PMTCT programme and to this a number of responses emerged in the discussion. These included:

The study was conducted in three selected hospitals, and as such the sample was not wholly representative of their wider province of KwaZulu-Natal. Within that consideration, it is noted that the findings cannot be generalised to other areas in KwaZulu-Natal or South Africa. Although reassurances of confidentiality and anonymity were addressed in the information and consent sheet, it is possible that some participants offered responses that they thought would not impact future treatment – to this end, there was a specific acknowledged need for the research to evaluate whether participants’ answers reflected noteworthy levels of social desirability bias.

The study offered a range of insights into participants’ perceptions as they related to the inclusion of males within their treatment programmes. To ensure application to wider practice contexts, participants’ views and the determinations from the background literature review were summarised into corrective service and practice recommendations as noted below.

Service structure: the design of service provision should be gender sensitive and make accommodations for males to be part of the serviced population. This may require additional monetary investment by health providers.

Primary resource capacitation: the current resources appear adequate to offer support to the women who attend MTCT services and, if any expansion in groups to be served occurs, then there will be a prerequisite need for a total review of resources to ensure that the inclusion of males does not further deprive expectant mothers from the scarce resources they currently have to share amongst themselves.

De-stigmatisation interventions: PMTCT services have inherent stigma-based challenges by virtue of their association with HIV/AIDS and this requires a concerted effort by service developers to work with local communities in educating them about HIV/AIDS to reduce the stigma associated with this area of health care.