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When women do not enjoy full maternity benefits, their health – and that of their children – may be affected.

Pregnant women have spoken out about nurses forcing them to undergo testing without their informed consent.

Many pregnant women fear going to state antenatal clinics because they believe they will be forced to test for HIV, and their status will not be kept private, according to a new report by Amnesty International.  

But delays in seeking antenatal care are responsible for a quarter of avoidable maternal deaths in South Africa, the report said.
“These fears are not unfounded. Amnesty International found that practices at clinics and the behaviour of healthcare workers, combined with problems such as staff shortages and inadequate infrastructure, regularly compromise women and girls’ right to privacy and confidentiality at clinics, as well as their right to informed consent when asked to test for HIV,” the report found.   

The organisation interviewed 200 women in Mpumalanga and KwaZulu-Natal between March 2013 and September 2014. Researchers also spoke to traditional leaders, nurses, home-based carers and sex workers in the two provinces. 
Although health department guidelines recommend women seek antenatal care before 14 weeks of pregnancy, less than half of pregnant women attend a clinic before 20 weeks, according to the Human Sciences Research Council.  

South Africa’s high maternal death rate – at 269 deaths in 100 000 live births, according to health department figures – is far behind the country’s United Nations millennium development goals target for next year of 38 deaths in 100 000 live births. 

This goal, which has a target date of 2015, “looks impossible to achieve”, the Amnesty report stated.   

Stigma is still rife

Amnesty International researchers found that HIV-related stigma is still rife in many areas and that women and girls fear they will be abandoned, discriminated against, shunned or hurt by their partners and communities if they reveal they are HIV positive.

“This fear [of the social consequences] is exacerbated when HIV testing is perceived to be mandatory. In addition, pregnant women and girls fear that if they refuse an HIV test, they will be denied other antenatal services,” said the report. 

Amnesty International found that even though South Africans, including pregnant women, have the right to refuse an HIV test and cannot be denied other health services for doing so, many are unaware of this right and health workers entrench this perception. 

Mavis Mulaudzi, head of the University of Pretoria’s nursing sciences department, explained that nurses experience ethical dilemmas if pregnant women refuse to be tested, which is why they may tell patients testing is mandatory. 

“In the case of pregnant women, nurses may feel obliged to advocate for the unborn foetus by encouraging women to know their status to protect their own babies,” she said.  

According to the health department, HIV testing rates for pregnant women have increased drastically from 70% in 2007 to almost every pregnant women being tested in 2012.

The Amnesty report suggests, however, that this high rate has been achieved outside of the parameters of informed consent, with nurses forcing women to be tested.

“If you say no to testing, they tell you that you will never get help,” said a KwaZulu-Natal woman interviewed by Amnesty International.  “You must go to testing first. If you don’t go there, they will not help you.”   

Factors affecting confidentiality

Factors that affect confidentiality in clinics are separate queues or dispensaries for people with HIV or different coloured files that other patients can easily recognise as “HIV files”, the authors noted. 

Some women, who are often poor and live in rural areas, save up money for months to afford transport to “faraway” clinics to protect their privacy, noted the researchers.

Amnesty International recommended that these identifying practices be abolished.  

But, according to health department spokesperson Joe Maila, this has already been done.
“The department is moving towards an integrated approach to the treatment of patients. This means that [HIV] patients will no longer be treated in silos, but in an integrated manner. We no longer colour code files, separating patients according to their diagnosis,” Maila said.

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Amy Green was a health reporter at Bhekisisa from 2013 until 2016.