Overall, 197 individuals were screened and 196 joined one of the 24 FGDs conducted (Table I). This included 68 grandmothers, 65 pregnant or breastfeeding women and 63 male partners of pregnant or breastfeeding women (referred to as male partners hereafter).
Demographic data are presented in Table II by participant group and country. The mean age of grandmothers in the study was 50 years (min 36, max 69), 21% (N = 14) were single, 43% (N = 29) were married or living with their partners and 38% (N = 26) were divorced, separated or widowed. Most grandmothers lived with their children (81%, N = 55). The mean age of pregnant and breastfeeding women was 27 years (min 19, max 40) and 77% were married or living with their partners (N = 50). The mean age of male partners was 31 years (min 19, max 54) and 81% were married or living with their partners (N = 51). The South African pregnant and breastfeeding women and male partners differed from those in the other settings with regards to marital status and living arrangements. Most were single (93% of pregnant or breastfeeding women and 92% of male partners) and majority (67% of pregnant or breastfeeding women [N = 10] and 58% of male partners [N = 7]) were living with adult family members including parents and siblings. In contrast, most pregnant and breastfeeding women and male partners in the remaining settings were married (83–94%) and living with their spouse or primary partner (79–94%). Additionally, lower numbers of South African participants reported earning an income and 60% of South African grandmothers (N = 12) were single (Table II).
Views on influential decision-makers during pregnancy and breastfeeding
Pregnant and breastfeeding women were assessed about their views on who, besides themselves, has the most influence on health-related decisions during these periods (Table III). The majority in all settings besides South Africa indicated that the father of the baby had the most influence during pregnancy (60–88%) and breastfeeding (53%-92%). However, among South African women, their mothers (40%) had more influence than the baby’s father (20–27%).
FGDs revealed similar findings to the behavioural assessment, with household composition and living arrangements appearing to impact who the key decision-making influencers were. South African grandmothers, pregnant and breastfeeding women, and male partners emphasized that it is the elders (grandmothers) who make decisions, especially in cases where the pregnant or breastfeeding women live with their mothers or returned home to their mothers to give birth (even if married). Grandmothers help look after the baby and therefore have authority:
The decision we take or follow as the family are more important that those from the clinic because as a nursing mother you live, and sleep with your granny and mother in the house, and they help look after the baby, so you must listen to them anything you do. [Dineo, Grandmother, 58, South Africa]
Decision making may also be impacted by lobola (payment a male partner or head of his family gives to the woman’s family in gratitude for allowing the marriage) or damages (payment made if a woman is impregnated before marriage to show that the male partner’s family accepts the baby as their own) as expressed by male partners and pregnant or breastfeeding women:
We grew up knowing that if a man is not married and has not paid the damages the baby belongs to the mother’s family. He has no choice if he has not paid for damages; he has to understand that my family said this because it is their baby. You must sit down with him and explain to him as the father of the baby that your family says that this or that must be done to the baby. [Nonhlanhla, Breastfeeding woman, 34, South Africa]
In the settings outside South Africa, grandmothers were generally not considered decision makers, with a few exceptions related to non-payment of lobola, living in close proximity and because the women may behave irrationally (e.g., having variable moods, getting upset) during pregnancy and need someone to decide on their behalf:
I would think it is that person who is near you, it can be your husband, your mother and the health worker because pregnant women sometimes behave funny. [Esther, Pregnant woman, 22, Uganda]
Grandmothers tended to portray their daughters and daughters-in-law as naïve during maternal times, especially if it was a first pregnancy, seeing themselves in a privileged position to support and educate them due to their own maternal experiences and expertise and as custodians of knowledge passed down through generations:
In Zulu there is a saying that say, “Ask the way from those who have walked it before”, even if people don’t have mothers, you can see from neighbours or you can ask from your aunt or any elder. [Sindiswa, Grandmother, 36, South Africa]
This included advising on cultural practices, correct food and drink, and health seeking behaviour. Grandmothers in Malawi and South Africa said they also guided their daughters/daughters-in-law in sexual matters (see Table IV).
Overall, pregnant and breastfeeding women and male partners confirmed the value of grandmothers’ traditional knowledge and advice, ascribing them with legitimacy since they had healthy pregnancies before allopathic medicine became the standard. A reliance on maternal grandmothers was emphasized in many instances:
But if you notice our mothers grew up preferring traditional doctors than medical doctors and they went through all this process without consulting [medical] doctors, of which their pregnancy and their children were healthy. [Asanda, Pregnant woman, 26, South Africa]
Given the importance of grandmothers in providing cultural information and traditional wisdom to pregnant and breastfeeding women, we explored grandmothers’ willingness to support their pregnant or breastfeeding daughters/daughters-in-law in the use of PrEP in the future as well as their views on the ring and oral PrEP for HIV prevention, including the likelihood of cultural acceptance or resistance to these products.
Grandmothers’ willingness and motivation to support HIV prevention product use
Across all groups, the majority views about HIV testing and prevention related decision making was that it is a decision made by pregnant or breastfeeding women alone or together with their partners with emphasis placed on openness and tolerance for health seeking behaviours during these times:
When it comes to making decisions in a family, it is good to decide together as husband and wife…the most important thing is that there should be openness in the family…there is need to make decisions together not each one by themselves. [Davie, Male partner, 24, Malawi]
Many grandmothers also thought that involving the male partner in such decisions was key, as the baby is made jointly:
You are not mistaken about the man, you are not mistaken at all, it takes two to tango, HIV is not for an individual person, and it is for 2 people. It like a baby is made by 2 people, so they must [decide on HIV prevention product use together. [Dineo, Grandmother, 58, South Africa]
Pregnant and breastfeeding women additionally indicated that grandmothers should be kept out of decisions to use HIV prevention products because of cultural taboos that forbid discussing sexual issues with your mother/in-law, and issues of confidentiality among other matters:
Sometimes you find that mothers might fail to keep the matter confidential, yet partners are able to do so. I think it should be between us; the husband and the wife. [Esther, Pregnant woman, 22, Uganda]
However, they thought grandmothers could be involved in HIV prevention product use in a supportive role if this was disclosed to them:
It depends if you want to tell them because at the end of the day it is your life at risk so if you have to inform them already that you are taking either the vaginal ring or oral PrEP that I am taking this because of this. If they are interested, they will support you if they are not they won’t. [Apple, Pregnant woman, 24, South Africa]
Grandmothers themselves explained their advisory role in a range of domains during their daughters’ pregnancy and lactation (see Table IV), and also expressed a high level of willingness to support them to use both HIV prevention methods in a bid to protect them, their grandchildren and, indirectly, their sons from HIV.
They are all your children because your daughters-in-law sleeps with your son, if she is unfaithful and gets infected, she is going to infect your son also. [Pinki, Grandmother, 43, South Africa]
They expressed that a good relationship with the daughter/daughter-in-law is important for this and that choice of product would depend on what was right for the daughter or daughter-in-law:
It will depend on the relationship that is between the mother/mother-in-law and the pregnant/breastfeeding woman. If they are open to each other…. It is important to sit down with her and talk to her with patience until she understands but not forcing her, let her make a choice. [Evelyn, Grandmother, 47, Malawi]
The main motivation to support HIV prevention product use was to prevent a disease with no cure, caused in many cases by male partner promiscuity and dislike of condoms and resulting in the loss of children to HIV. Additional reasons cited included the responsibility of having to care for an HIV infected daughter/daughter-in-law and infant and continuously high HIV rates, especially among younger women. Grandmothers indicated they could offer financial, emotional and instrumental support to ensure their daughter’s/daughter-in-law’s high adherence to PrEP. For oral PrEP it included daily reminders, ensuring that she takes her pills with her when she goes out or travels or providing the pills themselves to ensure she takes it daily.
I would like her to take those drugs every day because some people forget or at times they are negligent about their lives so if she lives in next to me I would like to give her the pills by myself. We may agree to a certain time that at such a time I will knock at your door so that you take it [pill]. [Esther, Grandmother, 44, Uganda]
Support for ring use included facilitating access to the ring and ensuring it is inserted appropriately:
I would accompany her to go and change the ring and if she can’t, she can send me to fetch it for her, when I get home with it I would say let’s go the bedroom I have your parcel and see her inserting it. [Dineo, Grandmother, 58, South Africa]
Grandmothers’ views on new biomedical prevention tools
Overall, grandmothers embraced the concept of new HIV prevention products for pregnant and breastfeeding women, beyond condoms:
The advantage with these products is that they contain medicines that can kill the virus unlike a condom which when worn incorrectly can burst then you get HIV. [Mbuya Shava, Grandmother, 43, Zimbabwe]
Grandmothers expressed relief that options to protect both their daughters and their unborn grandchildren were forthcoming, although establishing the safety of these would be crucial:
I would be happy for our daughters to use it [oral PrEP pill] at least they would be protected from their partners, and their babies would be….Now the issue of health; I mean the risk of how their bodies would tolerate the tablet. The side effects are my concerns because the tablets must be consumed. [Mamorena, Grandmother, 58, South Africa]
Indeed, grandmothers expressed several concerns which may impact future endorsement of these products (see Table V). Ring concerns included its size, whether it would enlarge the vagina and be painful to the woman using it, side effects for the foetus or infant from the medication or causing newborn injuries during delivery.
I was just thinking that if it remains inside it can hurt the baby during birth. Maybe the birth canal would be too narrow. [Mbuya vaPinky, Grandmother, 48, Zimbabwe]
Several partner-related concerns were raised too:
Because once he feels the ring, that is when he might want to know what’s inserted inside and start accusing the wife of prostitution. When the ring is actually being helpful. [Mbuya Zvakanaka, Grandmother, 63, Zimbabwe]
For oral PrEP, HIV risk related to forgetting to take the pills, HIV stigma, side effects to the mother and safety of the developing foetus, including potential for miscarriage in the first trimester were indicated (Table V). Miscarriage concerns were related to medication bitterness in Malawi, Uganda and Zimbabwe:
Our parents used to say that a pregnant woman should not take drugs that are bitter because some drugs can cause abortion. It all depends on how strong one’s blood is. Some women have strong blood and some have weak blood. [Evelyn, Grandmother, 47, Malawi]
When elaborating on the stigma associated with taking ARVs as for HIV treatment, some added that having HIV these days was not seen as stigmatizing as it was previously, as the disease is commonplace, impacts everyone to some degree and is accepted by many. There was a general feeling that the health of their daughters/daughters-in-law should be prioritized and should override worry related to stigma:
It’s high time that you don’t focus on checking who is saying what about your health, it is up to you whether your health stays safe no matter who says what. [Pinki, Grandmother, 43, South Africa]
Grandmothers acknowledged that if these products have been well researched and tested, the safety concerns they raised could be overcome with the correct information from healthcare providers (HCPs) who are best positioned to guide pregnant and breastfeeding women on prevention method use:
These pills have been examined and tested first, it’s not like they will just come from the blues and get imposed on us. So, teachings are important, like we are taught when we go to clinics. So, people should be taught until they come to know and accept the new products so that no one will think that they will be affected negatively by them. [Mbuya Peter, Grandmother, 45, Zimbabwe]
The ring appeared to be favoured by grandmothers over oral PrEP given its discreteness, especially without the partner knowing, its monthly duration and hence, lower use burden (less likely to forget to use). It also avoids the need to ingest, which could cause side effects for the pregnant mother and foetus:
Because once you insert the ring you spend the whole month with it without any challenges but with the daily oral PrEP people will forget. [Mbuya Tsitsi, Grandmother, 42, Zimbabwe]
There was a general view that pregnant and breastfeeding women should be able to protect themselves and both products were referred to as a “women’s defence” to shield infection brought into their relationship by male partners, particularly in situations where women do not have decision making power (e.g., cannot negotiate condom use):
There is a need to quietly protect yourself since it is culturally accepted that a man can just find someone to have sex with and they do it without using protection. At home wives do not use protection, so it will be good if I protect myself because if he gets infected, I will block the virus and he will have his own virus. [Mbuya Rutendo, Grandmother, 44, Zimbabwe]
Grandmothers’ views on cultural misalignments with ring and oral PrEP
Although a minority concern was raised in Malawi, Uganda and Zimbabwe that pregnant women should not take bitter drugs that may provoke miscarriage, most grandmothers did not feel that the bitterness of oral PrEP was culturally taboo as with other western medication used during pregnancy (e.g., Fansidar for malaria) and because traditional medicines can also be bitter. The impact of the drug was in some cases related to the weakness of the pregnant or breastfeeding women’s bodies as well as how far along the pregnancy was:
That drug depends on the body weakness that one has because during my first pregnancy I took bitter medicine but I had no side effects. The condition was the same and I was jumping around and it was mululuuza [herb taken for fever] but I had no side effects. And it was during the first three months. [Meisha, Grandmother, 45, Uganda]
Interactions between traditional vaginal products and the ring (possibly impacting efficacy of the ring) were raised among some grandmothers but they indicated they would discourage their pregnant and breastfeeding daughters/daughters-in-law from these practices when using the ring so that they may be protected from HIV.
I will tell her to use the ring and do birth preparation practices that does not require the use of herbs. She will use the ring to prevent HIV and stop using herbs. I will encourage her to use the soap only because the soap does not contain any drug that can cause some side effects. [Mbuya Rarara, Grandmother, 36, Zimbabwe]
The majority of grandmothers interviewed did not expect oral PrEP or the ring to conflict with cultural beliefs and practises around pregnancy and breastfeeding. One grandmother likened HIV negative pregnant women taking oral PrEP to HIV positive pregnant women taking ARVs, which is widely accepted:
There is no cultural belief that can prevent a pregnant woman from taking Truvada because the Government has a policy that all pregnant women who are found to be HIV positive at the ANC, when the pregnancy is term, they are given drugs to take in order to prevent the unborn baby from contracting HIV and AIDS. So I feel this drug called Truvada is like the same as that drug [for treatment]. [Tadala, Grandmother, 40, Malawi]
Overall, grandmothers thought that HIV prevention is the priority, different illnesses require different approaches and, as there are no traditional medications available to stop HIV, the ring and oral PrEP pills are the tools to achieve this key goal:
I don’t see why there should be a clash because there’s nothing that can prevent HIV except for things like these, the ring and the pills. [Yellow, Grandmother, 43, South Africa]