Introduction
Methods
Setting
Data Collection
Data Analysis
28–38 weeks pregnant | 6 weeks postpartum | 5–7 months postpartum | |
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PHQ-9 scores | 14 (moderate depression) | 6 (mild depression) | 5 (mild depression) |
Sub-themes of financial insecurity | |||
Disruption of income | She is not working as she gave up work when she started feeling sick with her pregnancy. She has limited access to preferred foods together with challenges accessing the HIV clinic. She plans to go back to work soon after delivery | She is employed in the informal sector, mostly doing laundry, and takes her baby and babysitter along. She now has better access to food and HIV care ‘P:… I have a job and I can eat what I was not able to before.’ | She continues working, now cooking and selling food. She has access to adequate food. Though, reports struggling to pay the rent and balance work and infant care |
Unplanned pregnancy | She has an unplanned pregnancy (occurred during the first month after long term contraceptive was implanted). She feels this destroyed her life by interrupting her work. She has poor sleep and is worried about giving birth | ||
Worries about PMTCT | She was recently diagnosed with HIV, and her partner left when she disclosed her status, he says he does not know his own status and blames her. Her daughter picks up her medications at times when she lacks fare. There was also a day that once of the nurses had to pay for her fare ‘P: I am having problems with my
husband because of my status which I told him and now that I got pregnant, we are having
more problems, I mean he is not supporting me because he thinks I deliberately brought
about the disease.’ She feels weak when taking her medications without food She is worried about how she will EBF when she needs to work and how this will affect the baby’s health and HIV status. She has never EBF before. She is worried about the transmission of HIV to her baby and this is her first pregnancy while living with HIV | She has better access to her HIV care having resumed work. She struggles to balance work with EBF, understanding EBF is important for preventing HIV transmission to her baby She feels she has milk insufficiency and also wants to supplement so she can work more. EBF interferes with doing things and she faces pressure from her daughter to supplement. Though she fears HIV transmission to her baby. She seeks the healthcare provider’s advice about the traditional practice of having her baby’s plastic teeth removed | Her partner later accepted her status, but he never got tested or never disclosed his status to her if he did. She experiences HIV and BF related stigma at work but her knowledge about HIV helps her to overcome P: It was hard because sometimes I would get customers who feel bad when they see you breastfeeding the baby and serving them, some would not eat because they feel that you have touched your breasts then you are serving them and there were those who would just tell you to serve them first then you breastfeed the baby.’ ‘P: It is painful, but you just have to do what the customer demands because if you do not you will not get what to eat
so that the baby gets milk.’ She started supplemental feeds from 3-months because of her feelings of insufficient milk. Her baby’s 1st test is HIV negative and she is not worried anymore. She had baby’s plastic teeth removed against the provides advice |
Inadequate support | Married, then separated during her pregnancy. She feels her partner left when he found she was HIV + . This was their first child together. Her partner’s support is minimal to, at times, none. Her mother and daughter provider better support | She and her partner are not in communication, neither is he providing support. She texted him to inform him she gave birth and he did not respond. Her daughter and landlady/ friend provide good support | She is receiving support from her mother and daughter. Her partner came back for a few months, supported her, then left with no continued support |
Results
Before pregnancy | Pregnancy | 6 weeks | 5–7 months | |
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(n = 30) | (n = 30) | (n = 28) | ||
Employment | ||||
Employed | 25 (83%) | 6 (20%) | 4 (13%) | 12 (43%) |
Unemployed | 5 (17%) | 24 (80%) | 26 (87%) | 16 (57%) |
Employment type | ||||
None/housewife | 5 (17%) | |||
Office work | 3 (10%) | |||
Trader | 13 (43%) | |||
Day laborer | 9 (30%) | |||
Ethnic group | ||||
Luo | 29 (97%) | |||
Kisii | 1 (3%) | |||
Education | ||||
None | 17 (57%) | |||
Primary | 5 (17%) | |||
Secondary | 5 (17%) | |||
College | 3 (9%) | |||
Unknown | ||||
Time engaged in HIV care | ||||
≤ 2 years | 9 (30%) | |||
> 2 years | 21 (70%) | |||
Children living at home | ||||
None | 7 (23%) | |||
1–3 | 18 (60%) | |||
> 3 | 5 (17%) | |||
Relationship status | ||||
Living with partner | 17 (57%)* | 16 (53%) | 14 (50%) | |
Not living with partner | 13 (43%) | 14 (47%) | 14 (50%) |
M | SD | |||
---|---|---|---|---|
Age (range 18–37) | 28.8 | |||
Prenatal depressive symptoms (PHQ-9) | 8.2 | 4.0 | ||
6-weeks depressive symptoms (PHQ-9) | 4.8 | 2.7 | ||
5–7 months depressive symptoms (PHQ-9) | 4.1 | 3.2 |
Central Theme Across Time: Financial Insecurity
Central theme across time: financial insecurity | |||
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28–38 weeks pregnant | 6-weeks postpartum | 5–7 months postpartum | |
Sub-themes with description across time | |||
Disruption of income | Loss of employment related to pregnancy leads to increased food and financial insecurity for the family | Unemployment and food insecurity persist due to continued lack of income | Hopeful about resuming work despite challenges, yet food insecurity persists for most |
Unplanned pregnancy | The impact of unplanned pregnancy | ||
Worries about PMTCT | Financial and food insecurity increase worries about PMTCT | Financial and food insecurity persist, sustaining worries about PMTCT | Worries about PMTCT are reduced but still present |
Inadequate support | Abandonment and inadequate support | Support insufficient to compensate for lost income, difficult to rely on others | Continued difficulties relying on others |
Financial Insecurity in the Third Trimester
Disruption of Income: Pregnancy Related Unemployment Increases Food and Financial Insecurity
“I am fatigued, I feel stressed and I am also experiencing many challenges like accessing food… what is mainly stressing me is not having a source of income and my baby’s father abandoned me. When I came to the hospital, I was told that my hemoglobin level was low so I am worried about what I will do after giving birth or even how my children will survive”.
28–38 weeks pregnancy | 6 weeks postpartum | 5–7 months postpartum |
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Disruption of income: pregnancy related unemployment increases food and financial insecurity 19: “P: I would get fatigued and dizzy, that work is very hard and because I was always dizzy, I had to stop. I was considering getting a job when the baby is three months old so that I am able to sustain the baby.” 24: “P: Yes, that happens like for me, I used to do business, but I stopped so you have to be depressed. You get depressed because it is something that you go back to after giving birth.” 25: “P: I am praying to God so that I have a safe delivery because my plan is to start a business, I had gotten a stall that I would start my business in after my baby turns one week old, provided his/her umbilical cord had detached from his/her navel. I had said that if I had only these children and I opened a business in a stall then I would grow.” Unplanned pregnancy 25: “P: I got pregnant while on implant. I used to see myself growing fat little did I know that I had conceived already. I could not fit into my clothes and at 5 months, I started feeling something moving around in my womb. I decided to go to a chemist in carwash (name of place) to buy a pregnancy test kit and after testing, I found out that I was pregnant. From that time, I started feeling stressed and my partner had already abandoned me.” Worries about PMTCT: increased by food and financial insecurity 04: “P: You know at times, let me say you want to go and get your medication from the clinic and you do not have money, at times you have to get someone who can support you or give you the money, I mean the means of transport to get to the health center.” | Disruption of income: Unemployment and food insecurity persist 09: “P: I plan to go back, when the child is weaned and I get some money, I will go back.” 01: “P: I will try to look for a job closer to me so that the person whom I shall leave with the baby can come over but not now, for now, I want to be with her for six months until she starts eating, then it will be better.” 28: “P: Being without a job is difficult like right now it’s very difficult because of the baby. When I didn’t have the baby, I told you that I could go and look for a casual job, sometimes I could wash clothes, so you know right now it is not possible.” 09: “P: Yes, previously I would go sell and we would have some extra cash to spend; when my husband did not have I would supplement but now, he is the only one working and sometimes there is no job so it is tough and I have to worry about that.” 09: “P: I only worry when my child is out of school because of school fees and my neighbor’s children are going to school, this makes me sad and I worry a lot.” 016: “‘P: As a woman there are things that you desire to have but because you have financial challenges you are not able to buy the things that you want; for example, you may not be able to buy enough food for your children and sometimes you have seen something good in the market that you want to have but you cannot buy it because you lack money.’ 22: “‘P: I am worried because sometimes I feel hungry but there is no food to eat.’ Worries about PMTCT: food and financial insecurity persist 01: “P: It has happened, like the last time I came, you really helped me, I can remember I did not have money for transport, I had walked from the road [FO: Pointing towards a direction] until here. You helped me with means back home.” 03: “P: What is troubling me is having a source of income but if I can get a good source of income then I can be okay so when my appointment day comes, I will have money for transport to go to the hospital as scheduled, I don’t want to miss.” 28: “P: I don’t get fare easily; I try and if I don’t get money to board a motorbike then I look for 20 Kenyan shillings (KSh) for boarding a vehicle…Once I get fare for coming, I walk when going back and that’s why I tag along with his sister because it’s easier as we carry the baby in turns.” 25: “P: I am still feeling stressed because I am supposed to be breastfeeding him for six months and for him its exclusive and right now, he is 6 weeks and sometimes we sleep hungry. This bothers me that if I can get something [referring to a job] then I can just start working with him.” | Disruption of income: hope about resuming work despite challenges 012: “P: Right now, I can go and look for something because the baby is big and he can take porridge so after I make something for him, I just leave him with someone and then I go look for work, which I could not do when I was pregnant but now I can.” 017: “P: Right now, I have the thought of even starting a business just that my baby is still young 06: “P: Let me say like right now I am just begging for help, begging is not good, if I can get some little capital, I can start a business and I can carry my baby with me and go with him to my work place, and I can do my work without giving people a burden. I feel bad that I should not be begging.” 029: P: I would like to get more support but you cannot ask for it every day because you will be given maize or food and it will get finished, I would like them to give me capital so that I can start something for my own so that I do not have to depend on them, but right now I know it is not possible because they [referring to her husband’s second family] have three people in the university 025: “P: Yes, right now it is not as before, I may not be able to pay the rent but we can get food, not as before when we would go hungry, right now we can get porridge and drink at times we would take black tea and maize and sometimes when the maize dries, we can take it to the flour mill then make ugali.” 029: “P: We don’t have a problem with food, I farm and when I have maize I am not worried, because when there is flour in the house then you can take one chicken that you have and sell, sometimes you can sell the vegetables and you will have some ease so when you farm you can sell some of the produce you have and be able to buy 'blueband'[Margarine] and whatever else that you need.” 030: “P: I have been worried about that because I do not know where I am going to get the food for the baby because I am not even able to get food that I can eat so where would I get the one for the baby, I even joked with the doctor that should I cut my thigh so that I can give the baby. I really do not know where I am going to get the food, if I had money then I would have gone and bought flour for the baby. Where am I going to get flour and milk? 011: “P: Yes, I am having a challenge because you have to eat well in order to have enough breastmilk and the baby breastfeeds a lot, after a few minutes, he pisses and then it is fully utilized in his body then he has to breastfeed again so this is a big challenge for me to exclusively breastfeed because the baby may want to breastfeed and I don’t have milk Worries about PMTCT: reduced, but present 020: “P: Sometime I am supposed to come to the clinic and I do not have money for fare so I do talk to a ‘boda boda’[motorcycle taxi] man, he is my customer, so I talked to him so he brings me up to here.” |
Inadequate support: difficult to rely on others | ||
26: “P: I have had so many challenges, my husband left me and sometimes he can only send me 400 KSh in a week and sometimes he does not send; I decided not to be sad about it and not to depend on him I have to look for a way to be independent.” | ||
26: “P: Sometimes I don’t have money for fare that’s why I send my daughter to come and collect my medicines for me because for me to walk to ‘Riat’ [Name of place] it will take time or I will be late. If I don’t have fare, I tell myself that I will come the following week but I do receive a phone call asking why I did not go to the go to the clinic for my medication. They will tell you that you are given one month to plan on how to get fare but sometimes you were expecting some money but you don’t get it and that is why I send my daughter because I know she can walk from the stage to this place then come back | 19: “‘P: When my sister has no money, the food will be less in the house.’ I: Have you ever experienced hunger on a daily basis?” P: It can be twice in a week.” | 17: “P: There was a day I lacked fare and missed to come but I came the following day.” Inadequate support: continued difficulties relying on others |
25: “P: What can make it hard is if I get a job because I will have to carry the baby to work so that he/she does not have a hard time because the baby will be breastfeeding. Another thing is that I must have breastmilk constantly though sometimes I may not have food to eat and I need food to have enough breastmilk because the baby will be breastfeeding exclusively without giving even water for 6 months.” | 16: “P: I need support with how to feed the baby and basic needs in the house because her father goes to work but sometimes, he does not get enough.” | 019: “P: Like support with the baby. If I ask her for money to buy something, she doesn’t give me….sometimes she says she doesn’t have.” |
Inadequate support and abandonment | 20: “‘P: Yes, sometimes I am not given and sometimes if you are given a lot then its 100 KSh so its upon you to see how you will use the 100 shillings. Once you are given the 100 shillings, it will take a week before you are given another one.’ | 22: “P: It is not easy because we are depending on one person to bring but at times you can wait for him to bring but he does not.” |
025: “P: Sometimes it gets tough because sometimes I am hungry and ask hoping that I will get but they tell me they still do not have money and that I should wait until he/she gets. Sometimes it takes even one week before he/she sends you money so if you feel like eating something, you can take it on credit from the shop but it becomes difficult to go to the shop because you have too much debts for the shop.” | 17: “P: It was challenging because waiting for the money is not easy, waiting for him until he gets back, unsure whether he is going to come back with some money or he will not make any, it is a challenge.” | 021: “P: Okay, right now I feel bad because I feel like I’m giving my parents a burden now. I can remember going to school, you are being provided for then after that, maybe they had hope that after you finish and you would get some jobs. Then, all of the sudden, you are still there. You have added another member of the family and all these things they are seeing now, like as for me, I feel like a burden to them.” |
24: “P: I must have concerns because I was used to having my own income and I could eat whatever I felt like. For example, if you are working, you can buy anything let’s say you are feeling like eating meat or fish you will easily buy but if it’s the man providing, he may leave for you money to buy vegetables even if you didn’t feel like it.” | 04: “P: It is difficult to ask for money because when you need to do something, you will have to ask for money and maybe the person you are asking may not be having money at that time so it is really difficult but if you had your own money then you would take care of your needs on your own.” | 015: “P: You just feel like everything is good when you have your money and you are not depending on a man’s money.” |
28: “P: After the baby has grown, I will go back to work and this would boost us, you know it is a burden just depending on one source of income and sometimes it is not even enough.” | 01: “P: I don’t feel good because I used to be an independent woman, asking for money is difficult.” | 13: P: My parents support me in everything now that I am not working, my mum buys food for the baby, she buys him clothes and she feeds me |
Unplanned Pregnancy
“I got pregnant while on implant. I used to see myself growing fat little, but I didn’t know that I had conceived already… I decided to go to a chemist in carwash (name of place) to buy a pregnancy test kit and after testing, I found out that I was pregnant. From that time, I started feeling stressed and my partner had already abandoned me”.
Worries About PMTCT: Increased by Food and Financial Insecurity
“Another thing is that I must have breastmilk constantly though sometimes I may not have food to eat and I need food to have enough breastmilk because the baby will be breastfeeding exclusively without giving even water for 6 months.”
Inadequate Support and Abandonment
“I went to the hospital, got tested and I was told that I was pregnant. I felt bad since I was not ready to have a child and [when I told the father] he told me that he was not ready to be a father- that is the reason we broke up”.
Financial Insecurity at 6-Weeks Postpartum
Disruption of Income: Unemployment and Food Insecurity Persist
“I will try to look for a job closer to me so that the person whom I shall leave with the baby can come over but not now, for now, I want to be with her for six months until she starts eating, then it will be better”.
Worries About PMTCT: Financial and Food Insecurity Persist
“I don’t get fare easily; I try and if I don’t get money to board a motorbike then I look for 20 shillings [U.S 20 cents] for boarding a vehicle…Once I get fare for coming, I walk home and that’s why I tag along with his sister because we carry the baby in turns”.
“I asked and I was told that there was nothing else I could give her, but sometimes I experience a challenge because the baby breastfeeds and night comes before I have even eaten anything since morning. I sometimes have pity on the baby because there is no way she can even add weight (025)”,
“[when my] baby is breastfeeding, and the breastmilk is not sufficient, he breastfeeds and cries because he does not get enough milk (022)”.
Inadequate Support: Difficult to Rely on Others
“It was challenging because waiting for the money is not easy, waiting for him until he gets back, unsure whether he is going to come back with some money or he will not make any, it is a challenge.”
Financial Insecurity at 5–7 Months Postpartum
Disruption of Income: Hopeful About Resuming Work Despite Challenges
Worries About PMTCT: Reduced, but Present
Inadequate Support: Continued Difficulties Relying on Others
“You just feel like everything is good when you have your money and you are not depending on a man’s money”.