Motherhood experiences of mothers living with
HIV and the emerging patterns relating to their
mother-child attachment relationships
S Marais
orcid.org / 0000-0003-2109-1127
Dissertation accepted in fulfilment of the requirements for
the degree Master of Arts in Research Psychology at the
North-West University
Supervisor:
Dr R Spies
Graduation:
July 2020
Table of Contents
Solemn declaration ... iv
Letter of permission ... v
Acknowledgements ... vi
Abstract ... ix
Preface ... Error! Bookmark not defined.x Chapter 1: Introduction and Contextualisation ... 1
Conceptualising motherhood ... 3
HIV-positive mothers in South Africa ... 7
Maternal practices and HIV ... 10
Childhood development, attachment and HIV ... 11
Purpose of the study ... 17
Ethical procedures and considerations ... 18
References ... 20 Chapter 2: Manuscript ... 31 Author guidelines ... 31 Manuscript ... 41 Method ... 46 Research Design ... 46 Participants ... 47 Procedure ... 47 Ethical Considerations ... 48 Data Analysis ... 48
Findings ... 50
Maternal Experiences and Challenges in the Light of HIV ... 55
Motherhood Is a Maternal Driver for MLWH ... 56
Unemployment and Poverty Significantly Impede Motherhood ... 57
Anti-retroviral Treatment, Acceptance, and Multiple Types of Support Systems Are Crucial Safeguard Mechanisms for Mothers Living with HIV ... 58
Discussion ... 60
Limitations ... 63
Conclusion ... 64
Chapter 3: Conclusion and Future Recommendations ... 70
Addendum A: HREC Letters of Approval ... 1
Addendum B: North-West Department of Health Permission ... 1
Addendum C: Certificate of Technical and Language Editing ... 1
Solemn declaration
I, Samantha Marais (student), hereby declare that the work is my own and has not been submitted to any other institution for examination.
Letter of permission
Permission is hereby granted by the co-authors that this manuscript may be submitted by the first author for the purposes of a mini-dissertation. The first author (student)
conducted the literature review, interpreted the results, and drafted the manuscript with the incorporation of suggestions from the co-authors (supervisor). She took responsibility for the technical and language editing of the manuscript.
Acknowledgements
“When anxiety overwhelms me, Your consolations cheer my soul.” ~ Psalm 94:19
I would like to thank my Heavenly Father for being my solace in the tough times and always filling my soul with joy. Your goodness has never been so clear to me. I also salute the jewels You gifted me with, those who endured the endless complaining, suffering through the hangry, sleep-deprived and grumpy days and now, also share in the celebration.
To Dr Ruan Spies, my supervisor, thank you for entertaining and even more so, supporting my ambitious timeline. I value our journey together and welcome future opportunities to work together again.
To Jan Willem, thank you for your support and concern throughout this time. Without your support and storytelling, the long nights working would have felt significantly longer. Your voice (and love) is an endless comfort.
To my dear friends Johnine, Monique, Rieke and Svenja - you all deserve some serious praise! Listening to my nagging could not have been easy. Thank you for your support, daily motivation and love - I consider myself abundantly blessed.
Last, but not least, to my family: Hans and Magriet Weyers, Kotie Marais and
Mariëtte Pretorius. Thank you for always carrying my best interests at heart and being an
Abstract
The human immunodeficiency virus (HIV) remains an epidemic in Southern Africa which disproportionately affects women in their reproductive year, many of which are or will become mothers. HIV is a communicable virus that compromises the immune system of those infected. Symptoms of the virus include fatigue, headaches, fatigue, sleep disturbances, depression and anxiety which may limit the functioning of those infected. Motherhood, which is known to be demanding, may be affected by these symptoms which result in impaired maternal care. This impairment may further impact the mother-child interactions, relationships and overall experience of motherhood. In South Africa, limited research exploring the role of HIV on motherhood exists.
This study will address this gap and is an affiliated study of Spies (2015), using a portion of qualitative data previously collected. Spies (2015) investigated the role of HIV-related psychosis on motherhood and mother-child attachment relationships in South Africa.
This study aims to explore the role of HIV in the experience of motherhood and the mother-child relationship. Secondly, it will aim to determine whether mothers with simililar mother-child attachment relationships have similar experiences. Forty-one semi-structured interviews were qualitatively analysed using thematic analysis and four themes were
identified. It was found that the role of HIV in motherhood experiences and that motherhood
is a maternal driver for MLWH. It was very clear from the data that unemployment and poverty significantly impede motherhood. Finally, the role of anti-retroviral treatment, self-care, and multiple types of support systems as crucial safeguard mechanisms for mothers living with HIV was also apparent. The themes that emanated from the participants with the
same mother-child attachment relationships were compared to determine whether patterns of similarity could be identified. When comparing the experiences of mothers with the same mother-child attachment relationships, no significant patterns of similarity was found. This
lack of similarity in the experiences of motherhood may suggest that mother-child attachment relationships poorly propose how motherhood could be experienced. This study contributed to the understanding of motherhood in a South African context.
Preface
This is a mini-dissertation submitted in article format as indicated in the General Academic Rules (A4.4.2 and A4.10.5) of the North-West University. This is in partial fulfilment of the requirements for the Master of Arts degree in Research Psychology. The mini-dissertation accounts for 116 of the total 180-course credits and the article adhere to the requirements set out by the journal that was selected for submission, namely the South African Journal of Psychology. The journal does not require specific English but specific formatting is prescribed. The page numbering for this mini-dissertation is consecutive.
This study is a single study affiliated with the research study by Spies (2015). The affiliated study investigated the role of HIV and HIV-induced psychosis on motherhood. Following the completion of the study, Spies (2015) had not analysed all the data, which led to the current study. Since both studies utilise the same methodology, overlaps may occur. However, each study has its own distinct focus linked to motherhood, resulting in unique, results, discussion, implications, and contribution.
The mini-dissertation consists of three chapters. Chapter 1 conceptualises the study, providing background information which highlights the problem statement and contribution of the study. Chapter 2 is the manuscript and the main report of the findings of the study. The manuscript will be adapted to be submitted to the South African Journal of Psychology. Chapter 3 highlights the conclusions of the study and the recommendations for further research.
Chapter 1: Introduction and Contextualisation
Understanding and remedying social problems remain a crucial driver for scholarly research. Social problems are social conditions with negative consequences for individuals and the broader community, which ultimately inhibit effective societal functioning (Guerrero, 2018). An analogy by sociology pioneers, compared society to a living organism that can flourish, evolve, and suffer from illnesses. When the organism [society] is ill, determining the diagnosis and suitable treatment requires an examination into several inter-connected systems in different contexts (DeFronzo, 2018).
The human immunodeficiency virus (HIV) and mothers living with HIV (MLWH) is a pressing social problem which is inadequately addressed in current research. Notable studies on HIV, poverty, parenting and childhood development have been conducted, but only a few studies were concerned with the experiences of motherhood for MLWH
(Josephine, 2019; Schaan, Taylor, Gungqisa, & Marlink, 2016). This chapter will describe the context of motherhood in South Africa and the importance of research in the
aforementioned population.
In 2015, the United Nations (UN) made a global call for action to address current social problems; initiating the 2030 Agenda for Sustainable Development Goals (SDGs). Seventeen overarching SDGs were formulated, addressing various social issues including the continued epidemic of HIV/AIDS under goal three, ‘health and well-being’. Despite
significant improvements and the advances in medical treatments, HIV prevalence continues to increase in several developing countries across Africa (United Nations Joint Nations Programme on HIV/AIDS (UNAIDS), 2018). As such, the current study intends to explore the experiences of motherhood of MLWH in South Africa, to better describe the phenomenon and the role HIV may have on their experience of motherhood.
South Africa is the country whose population has the highest prevalence of HIV/AIDS worldwide. International-, government- and non-profit organisations are
dedicated to eliminating the spread of HIV and also supporting the populations most affected (South African National AIDS Council, 2017). In South Africa, as with other developing countries (e.g. Nigeria, India and Mozambique), young women and girls (15-24 years) are disproportionately affected by HIV. Statistics South Africa (2018a) reported at least 25% of the HIV-infected population are females in their reproductive years, of which the majority are black mothers (Short, & Goldberg, 2015; UNAIDS, 2018). Apart from physiological factors, social and environmental factors are also known to contribute to the incidence of HIV among these mothers, for instance, high unemployment rate, poverty, gender-based violence and gender discrimination (SANCA, 2017). The quadruple burden: HIV, impoverishment, gender-based violence and unemployment, results in a multidimensional crippling of women living in South Africa that requires multidimensional solutions to alleviate the suffering of this population and address the multitude of burdens (UNAIDS, 2018).
In terms of alleviation through eliminating the spread of HIV, South Africa has made significant progress. Approximately 87% of people in South Africa are aware of their HIV status and 61% of those infected are receiving HIV treatment (UNAIDS, 2018). Due to the improved medical treatment options available, the successful management of HIV has become a realistic and attainable future prospect for South Africans diagnosed with HIV. Advances in antiretroviral treatment (ARVs) more effectively reduce viral loads in the bloodstream, extending the life expectancy of those infected and contributing to improved physical health (Steinert, Cluver, Melendez-Torres, & Romero, 2017). Regrettably, however, physical health is not the only domain affected by the virus as the psychological (i.e. mental health and well-being) and external environments (i.e. family functioning) are also impaired,
which complexifies effective HIV management. For mothers living with HIV, motherhood and provision of maternal care is an important domain to be considered.
MLWH experience difficulty in managing their illness (Schulte et al. , 2017).
Evidence suggests that HIV-positive motherhood can jeopardise a woman’s maternal identity and quality of maternal care due to the physical, psychosocial, and financial strain that accompanies the virus (Malatji, Makhubele& Makofane, 2014). Having an HIV-positive diagnosis in itself is overwhelming and when combined with the motherhood, even more so (Kirshenbaum et al., 2004).
Conceptualising motherhood
Motherhood is a universally significant phenomenon that is celebrated in societies worldwide. Dating as far back as the prehistoric voluptuous European Venus figurines, the conceptualisation of women as ‘mothers’ or the phenomenon of ‘motherhood’ has resulted in some controversial disputes (Dixon, & Dixson, 2011; Parker, & Rubin, 2017). Historically, motherhood was imbued in the sense of selfless nurturing and goodness which was assumed to instinctively bloom following childbirth (Akujobi, 2011). In the present context, however, this understanding is insufficient as it lacks recognising the fluid and socially constructed nature of motherhood which is chiselled by historical, political, social, economic and individual contexts (Ross, 2016). Therefore, considering the breadth of motherhood is in itself, a motivator for contextually relevant research.
The literature surrounding motherhood is frequently controversial, however, some common grounds in the formation, norms and expectancies exist. The commonalities in arguments suggest that motherhood is not solely determined using physiology but is also a “social and historical construction” (Akujobi, 2011; Johnston, & Swanson, 2003, pg. 21) that is created within each society. Therefore, no single conceptualisation and experience of
motherhood are sufficient in the understanding of all societies. Numerous factors such as gender, culture, own mothering experiences, living conditions and the state of health, construct how motherhood is described and experienced. Yet, despite this multifaceted and fluid nature, idealistic western experiences and conceptualisations of motherhood remain dominant throughout literature - setting a stereotype of ‘good’ mothers and the ideal experience of motherhood (Atkinson, 2019; Scobie, 2017). This limited variety in
explorations sounds for the expansion of research that surpasses the traditional understanding. According to the traditional ‘white’ ideologies of the 1960s, ‘good’ mothers were placed in a hierarchical structure that necessitated control, anticipated maternal sacrifices and considered childcare and household duties to be mandatory (Johnston, & Swanson, 2003). Ideal mothers were traditionally portrayed by a well-spoken, married, middle-class, healthy Caucasian woman that stayed at home. While she had the most fulfilling experience of motherhood, her husband, the strict father figure, protected his family from harm and provided for them financially. Based on an authoritarian parenting style, children were expected to develop a solid moral character by learning control, discipline and self-restraint. This parenting style demonstrated possessive parental control of children that was led by a father figure and the mother, subsequently following suit (Lakoff, 1996; Smith, 1983). Globally, societal modernisation has debunked this understanding; encouraging the reconceptualization of being mother overall. Family structures, economic changes, and the transformation of the workplace and educational institutions have shifted gender roles, resulting in wider varieties of family structures and practices than traditional structures.
Traditionally, motherhood practices were motivated by the notion of ‘maternal instinct’ which was assigned to women by nature as only females can bear children.
Maternal instinct suggested that all women have a natural desire to have children and gladly dedicate themselves tirelessly to child-care. Moreover, this instinct provided women with the
skills or capacities to care for infants immediately after childbirth, requiring no previous training or experience while also enduring any external stressors (Firth, & Badinter, 1982; Henderson, 2018; Ridley, 1994). Motherhood was described as, the ultimate fulfilment of a woman's’ identity and purpose in life – the pinnacle of female existence. In disagreement, feminist research diligently challenged traditional views of motherhood to break the generalisations and preconceived motherhood ideologies. As such the 1970s feminist understanding of motherhood arose.
Campaigning for equality in traditional family structures, contemporary motherhood is rooted in equality while also supporting and empowering mothers to be autonomous and not confined by prescribed social structures (de Souza, 2013; Ehrensaft, 1983). According to the feminist approach to motherhood, community involvement and support services for mothers were considered valuable to ensure the best care for children and healthy experiences of motherhood. According to this model, mothers with a sense of self-efficacy driven by the pursuit of their personal interests and a rewarding profession would be better mothers in comparison to those constrained by traditional ideologies (Barnett, & Rivers, 1998; Hanson, & Sloane, 1992; Johnston, & Swanson, 2003; Newhouse, 2018). Neglecting to consider those mothers living in less favourable conditions or those in struggling contexts, adopting a ‘feminist only approach’ would not be the most suitable option in a South African context. The feminist understanding of motherhood did, however, appreciate the uniqueness and equality of women, encouraging the exploration of motherhood experiences from
perspectives freed from traditional stereotypes and broaden the understandings of mothers worldwide.
Following increased research attention, numerous other contemporary works surrounding motherhood now exist (Ross, 2016). However, the majority of research is still within the parameters of Western contexts which naturally, is not comparable to a
contemporary African environment which in some cases differ from traditional African contexts too. Traditionally, according to the African culture, motherhood is the ultimate fulfilment of identity and sense of purpose for a woman irrespective of her skills, talents or own desires. In communities not as affected by HIV, this may be true, but in those who are affected, motherhood may be experienced differently. A lack of relevant research leaves room for exploring how motherhood is experienced when having an HIV-positive diagnosis.
In African cultures motherhood has also been described as a God-given gift, and for this reason, should be respected and considered sacred (Akujobi, 2011). It is believed that childbearing and motherhood bestowed status to women, symbolising both fertility and fruitfulness while also proving them to be ‘real’ and worthy women in the community. According to common practice, self-sacrifice is often associated with ‘good’ mothering and childlessness is considered to be the “dead end of human life, not only for genealogical level but also for herself” (Akujobi, 2011, p. 3). Constructions of motherhood, as per the findings of Moore (2013), are re-negotiated in reaction to a social reorganisation that occurs in society. According to Moore (2013), the conceptualisation of mother in Cape Town, South Africa was different amongst women from different generations. Older generations described mothers as being the provider and carer while the younger generations placed more value on their own goals and having children at an appropriate time. Differences in the understanding of motherhood can clearly be noted, even amongst African countries.
Highlighting the difference, Omotoyinbo (2018) emphasised the value of traditional African women. He stated that they have, are, and always will be “prestigious members of the African society” (p.170) that preserve valuable cultural practices. He further describes westernised African woman to be self-centred and far from the traditional norms. He suggested that traditional women serve as the first ‘institution’ that young members of the community engage with to ideally teach them the significant cultural values, traditions and
practices. These African mothers are known to carry spiritual powers that are essential in the development and maintenance of the community. Communities, especially those sharing African roots, are easily trapped within an overarching African stereotype which disregards the uniqueness and diversity we strive towards in modern society.
To delineate such stereotypes, contemporary African-feminist works dispute the ideologies pertaining to the worth of women and mothers in traditional African cultures. African feminist ideologies emphasise the need to dissolve gender and culture roles that pre-empt the value and experiences of motherhood in contemporary-Africa (Masola, 2018). Varigated political and social works argue the distinction between motherhood and
womanhood across broader sub-Saharan Africa, celebrating the differences amongst mother groups and emphasising the need for context-specific research that accounts for relevant challenges.
Following a similar trend, recent South African works have also redirected focus to specific mother groups such as adolescent mothers, single mothers or grandmother-headed homes. Surprisingly, especially considering the epidemic of HIV/Aids, research relating to the experiences of mothers living with HIV is scarce which has left a gap in the literature. Kruger (2006) went as far as to suggest that contemporary descriptions of motherhood in South Africa are essentially non-existent. In response, this study will qualitatively explore the experience of motherhood of mothers living with HIV in order to better understand the role of HIV in their mothering and their mother-child relationship.
HIV-positive mothers in South Africa
South Africa, a wonderfully diverse and unique country, is severely confronted by hardships that threaten the livelihood and quality of life for a large portion of the population (51%) including of black HIV-positive mothers (30%). Entering into its fifth decade, the
HIV epidemic continues to be a major public health problem. As per the Human Sciences Research Council (2018), more than one-fifth of the female population is HIV-positive along with approximately 30% of pregnant women. The slow-acting virus spreads through the exchange of body fluids, most often during unprotected sex. Physiologically, due to a larger surface area that has contact with bodily fluids, females have a higher likelihood of being infected (UNAIDS, 2018). In addition, socioeconomic risk factors such as sexual violence, prostitution, the progressively popular ‘blessa” or sugar daddy trend and a lack of education also significantly contribute to the spread of HIV amongst women (UNAIDS, 2019; .
Not limited to spreading through unprotected sexual activity, HIV-positive mothers can also spread the virus to their children. In the past, mother-to-child transmission of HIV during childbirth and breastfeeding was a common occurrence, which resulted in the vast majority of HIV-infections amongst children younger than 14 years. Fortunately,
antiretroviral regimes (ARVs) have reduced the risk of transmission to below 5%, limiting new HIV infections among children and keeping their mothers alive for longer (Vrazo, Sullivan, & Phelps, 2018). Consequently, the prevalence of mothers living with HIV is increased. Liamputtong (2013) reported that within many African communities, the mothers who are known to be HIV-positive are labelled as ‘unfit mothers’ and their children are also stigmatised. Hence, MLWH may decide not to disclose their status to anyone but rather isolate themselves to avoid being victimised. This isolation exaggerates the manifestation of HIV and often, due to the fear of scrutiny, MLWH does not seek medical treatment when contracting co-morbid illnesses or during times of psychological need.
Persons with HIV have reported a myriad of physical and psychological symptoms that vary depending on the progression of the condition. In a South African study about the prevalence of HIV-symptoms, a total of 64 different symptoms were reported with a mean of 26 symptoms per person. The research found that irrespective of the ARV advances, many
people living with HIV still experience high levels of physical and psychological
symptomology. Participants of this study also reported high levels of psychological problems such as worry, depression, and anxiety. Physically, fatigue was the most prevalent symptom amongst HIV-positive women, following body pain that ranged from headaches to muscle aches (Peltzer, & Phaswana-Mafuya, 2008). When faced with somatic symptoms,
performing daily tasks that require physical energy such as cooking, going to work, or child-rearing, is further exhausting or sometimes not at all possible. These physical symptoms of HIV limit the capacity for MLWH to function and care for their households and place strain on their psychological well-being.
It is well known that a negative relationship between HIV, psychological health and vulnerability exists. The psychological symptoms of anxiety, fear and depression often experienced by MLWH are mostly related to individual and social domains such disease disclosure to loved ones, the uncertainty of their lifespan, societal stigma and in those who have children, the well-being and protection of their children once they die (Hudson, Kirksey, & Holzemer, 2004). In the same study, the Centre for Epidemiologic Studies Depression Scale (CES-D) was administered. Eighty-one percent of women in the study (n = 118) met the criteria for depression according to the aforementioned scale. Other studies found the same psychosocial stressors amongst HIV-positive women which indicate the impoverished state of physicological well-being amongst MLWH (Murphy, Koranyi, Crim, & Whited, 1999; Richardson et al., 2001). According to these mothers, the combination of
psychological and medicinal demands required to survive HIV is their primary source of stress which decreases their motivation to participate in motherhood activey.
Across the board, transitioning into motherhood is described as a bitter-sweet experience. On the one hand, it is an overwhelming state of joy while on the other, immensely stressful with wavering emotions (Akujobi, 2011; Coutinho et al., 2014;
Liamputtitong, 2013). Naturally, as mothers adjust to managing the demands of motherhood, it becomes somewhat ‘easier’ to maintain a balance between mothering, self-care and life-related demands. For HIV-positive mothers, however, managing maternal and life demands are far more challenging. Juggling everyday life and child-care challenges in addition to managing HIV, is strenuous on both their own and family’s physical and mental health (UNAIDS, 2018; Stats SA, 2015; Stats SA, 2018a). Critical aspects of maternal health easily influenced by HIV is i) consistency and quality of maternal care, ii) the perceptions of
parenting self-efficacy and, iii) the mother-child attachment relationships (Murphy, Koranyi, Crim, & Whited, 1999).
Maternal practices and HIV
According to recent estimates, approximately one-third of children in Southern Africa are raised by an HIV-positive parent, of which the majority are single black mothers (Short, & Goldberg, 2015). Since the onset of the epidemic, cardinal research unpacking the
intersection of maternal HIV, parenting and child development have been studied. Amongst the sea of scholarly works, limited research explores the experiences of black South African mothers (Josephine, 2019; Moore, 2013). But, other research about maternal HIV found that it disrupts family structures and limits the performance of maternal tasks such as physical care, emotional responsiveness and physical touch. Other studies found that impaired parenting leads to poor child outcomes such as significantly more internalising and externalising problems. In the study by Murphy, Roberts and Herbeck (2010), MLWH disclosed that their HIV status had negatively affected their relationship with their children and they felt like ‘bad mothers’ because they often ‘missed out’ on things in their children’s lives and could not do everything they would have wanted to.
Parenting self-efficacy, a parent’s ability to execute a range of valuable behaviours that foster healthy childhood development, is crucial to bolster the well-being of both mother
and child (Rochat, Netsi, Redinger, & Stein, 2017). Well-being and parenting self-efficacy have a reciprocal relationship, hence, a healthy state of well-being fosters higher levels of parenting self-efficacy, and visa-versa. Likewise, parenting self-efficacy and parenting practices are also directly proportionate (Albanese, Russo, & Geller, 2019). Parents with high levels of perceived parental self-efficacy exhibit higher competencies in their parenting behaviours and have better responsiveness to their children. In the case of MLWH, parenting self-efficacy is relatively low and due to the high prevalence of single mothers, children rely solely on their mothers to meet their biological, emotional and social needs (Dorsey, Klein, Forehand, & Group, 1999). Due to poor parenting practices, low parenting self-efficacy and inadequately met needs, children born into HIV-positive families more frequently present with physical and psychological problems when compared to similar unaffected families. These children frequently reported fear, isolation, anxiety, low self-esteem, and trauma (Murphy, Armistead, Marelich, & Herbeck, 2015). Additionally, later research found that social adversity, decreased cognitive development and exposure to risky sexual behaviour, to be common outcomes for children in HIV families (Islam, Minichielle, & Scott, 2014). Fostering positive motherhood experiences may lead to higher levels of maternal self-efficacy and improved mother-child relationships (Rochat, et al.,2017). In a ripple down effect, positive motherhood experiences promote healthy mother-child relationships required for healthy childhood development.
Childhood development, attachment and HIV
The mental health of infants and young children are crucial in the development of social and emotional regulatory skills and is defined as:
The developing capacity of the child from birth to five years of age to form close and secure adult and peer relationships, experience, manage and express a full range of
emotions, and explore the environment and learn - all in the context of family, community and culture. (Cohen, Oser, & Quigley, 2012, pg. 1)
Healthy child development is a global priority and also forms part of goal three Good
Health and Well-being of the Sustainable Developmental Goals (UN, 2015). Approximately
one million babies are born in South Africa annually, and one in every four is likely to be growth stunted by the age of 5 years old (United Nations Children’s Fund, 2017). Child development is a maturational process beginning as early as conception which results in progressive cognitive, perceptual, motor, language, socio-emotional, and self-regulation skills. Therefore, ensuring a healthy environment for childhood development is a top-ranking priority for several countries including South Africa (StatsSA, 2018c).
Early childhood, a period that is known for its heightened sensitivity to risk factors, plays a critical role in the ability of children to function well. According to scientific studies, a new-born baby has almost all of the neurons present in adulthood (World Health
Organisation, & United Nations Children’s Fund, 2018). At the very young age of two-years-old, a colossal amount of neuronal connections are formed based on the interactions with the environment and caregiver. Although risks do not guarantee harm, a poor start to life can threaten the health of children. In the short term, it is suggested that trauma during childhood is associated with an increase in behavioural problems, inadequate learning and restricted development. In future, the aforementioned limitations may have possible long term implications which results in low adult earnings, an unskilled workforce and a population that does not meet their developmental potential (Sherr et al., 2014).
In order to protect the right for every child to survive and thrive, dedicating resources to the furthering of childhood development is not wasted (President Ramaphosa, 2018). Thanks to such research, it is known that the most formative human years stem from
experiences that are rooted in the nurturing care received from our parents – especially one’s mother (Stats SA, 2016). Nurturing care grows through loving and affectionate interactions or relationships with a primary caregiver; laying down the foundation of health and well-being of the child and potentially, the generations who follow (Cohen et al., 2012).
Nurturing care traces back to the prenatal stage of development when a mother, for instance, sings to her unborn foetus. Once born, bonding between mother and child continues and is facilitated by and not limited to skin-to-skin contact, breastfeeding, and maternal sensitivity and attunement (Richter, 2018). Infants and very young children are dependent on their caregivers to respond to their cues in order to meet their needs. Infancy, which is the peak period whereby neuropathways are formed, depends significantly more on the external environment for development and growth (Clinton, Feller, & Williams, 2016). The
environmental conditions and the physical and emotional interactions with infants, can both assist as well as inhibit the development of neuropathways in infancy (WHO, & UNICEF, 2018). Therefore, a parent’s capacity to be responsive to his/her child’s biological and emotional needs are vital for healthy development. According to developmental psychology, these interactions between mother and child are critical to developing psychosocial models that will act as buffers for stressors throughout an individuals lifetime (Clinton et al., 2016). One such model is the attachment relationship between a mother (or caregiver) and a child.
Attachment theory. Originally formulated in the 1950s by John Bowlby, attachment
theory research has significantly expanded and continues to evolve (Brisch, 2002; Goldberg, 2000). Sparked by his interest in an ethological approach, Bowlby investigated precisely what it was that went on between a mother and her infant and why it was neccessary (Hinde, 2005). Since the inception of attachment theory, it has contributed substantively to the understanding of the mother-child attachment relationship, and how the quality thereof influences numerous factors throughout the human lifecycle, especially during childhood
developmental stages. Several aspects of mother-child interactions and the ‘irrational fears of children’ such as being apart from their mother or unfamiliar situations, had a functional purpose and repeatedly showed an infant’s need for maternal protection in order to survive (Bowlby, 1969).
In response to threatening, uncertain or needy situations, infants engage in attention-seeking behaviours such as crying to gain proximity and protection from their caregiver (Boris et al., 2005). According to Bowlby's attachment theory, infants at the age of one-year-old display a pattern of such proximity-seeking or -maintaining behaviours that are referred to as attachment behaviours (Bowlby, 1969). Attachment behaviours can also be seen as survival systems that restore infants to a state of homeostasis and is a protective buffer when exposed to stressors (de Schipper, Stolk, & Schuengel, 2006).
Attachment relationships are essentially either secure or insecure. Children with a secure attachment relationship could use their caregiver as a secure foundation to explore the world in a safe context, or as a safe haven to seek refuge when the context is perceived as being dangerous (Ainsworth, Blehar, Waters, & Wall, 1978). According to Bowlby (1969), a secure attachment relationship is the ideal under normal circumstances and would be fostered through a warm, responsive and lasting mother-child relationship. Children with insecure mother-child attachment relationships overemphasise patterns that result in excessive exploration and independence (avoidant type) or dependency and clinginess
(anxious-ambivalent type). Challenging the aetiology of attachment relationships initially proposed by Bowlby (1969) and Ainsworth (1990), which suggested environmental factors and maternal-behaviour, -emotional responsiveness and -availability to be the determinants of attachment relationships, recent literature indicates a genetic determinant that may contribute to the formation of attachment relationships (Oliveria, & Fearon, 2019).
In South Africa, a study involving an isiXhosa population in Khayelitsha was conducted. The study involved a sample of 449 mother-infant dyads that were randomly assigned to two groups, one receiving an intervention intending to enhance mother-child attachment (n = 162) and the other did not (n = 172). Based on the findings, the intervention appeared to be successful in fostering secure attachment relationships. In the subsequent years after establishing their attachment relationships, researchers collected genetic data from 279 participants. This genetic data from the intervention (n = 110) and control group (n = 110) was compared based on the presence of a serotonin genotype. A 26% higher attachment security in those who have the genotype was reported.
From an environmental perspective, some cases of an avoidant attachment relationship are suggested to be a result of infants being persistently neglected by their primary caregiver which when accustomed to, leads to a disconnection from their caregiver (Ainsworth et al., 1978). In contrast to infant independence, anxious-ambivalent types of attachment relationships tend to become overly attached to their caregivers while
simultaneously feeling hesitant to seek attention due to experiencing repeated rejection and inconsistent care (Ainsworth, 1990).
While conducting research, some difficulties arose when classifying infants according to the aforementioned attachment classifications of Bowlby (1969) and Ainsworth et al. (1978). Main and Solomon (1990) recognised that a vast number of infants did not match any of the existing relationships. Following the review of several of the unclassified cases, they found that infants displayed irregular behaviours that were best described as being disorganised. Hence, the third group of attachment relationships - the disorganised type of attachment relationship. This classification lacked the classic patterns usually observed in the Strange Situation Procedure (Flowers, McGillivray, Galbally, & Lewis, 2018; Main, &
Solomon (1990). Infants exhibited absent-minded behaviours, abrupt emotional changes and in some cases appeared to be afraid of their parents.
When considering the desired outcomes of attachment behaviours, it is clear that there is a set-out goal to gain proximity to the caregiver. Goal-directed behaviour requires the involvement of ‘cognitive processes’ which in infancy is not yet developed but are rather in the process of developing. Bowlby (1969) proposed the concepts of internal working models and cognitive maps to describe these cognitive developmental processes. Internal working models (IWM) are flexible cognitive maps that allow successful navigation through the child’s environment. These models represent the self, the attachment figure and the environment during the interactions the child has with their primary caregiver, their own behaviour, and the reactions they receive due to their behaviour (Cassidy, 1990; Cicchetti, Cummings, Greenberg, & Marvin, 1990; Van Deventer, 2011). Howe (2005) stated that the IWM is a kind of blueprint that outlines how one fits into a social landscape. It also mitigates the self-containing cognitions about the worth and lovableness of an individual (Cassidy, 1990). Considering the use of such processes, it is reasonable to suggest that a child’s experiences with their attachment figure can influence the attachment behaviours they exhibit. Internal working models, once internalised, act as a guide to manage future relationships and outline the construction of one’s self-perception (Ainsworth, 1990). By virtue of the crucial role that a mother has during the formation of a child’s IWM, it is essential that she be available, attuned and responsive during parenting to ensure a secure mother-child attachment relationship (Schuengel, de Schipper, & Sterkenburg, 2003).
Mother-child interactions, which inherently contribute to the formation of attachment relationships, are sensitive to the physical and psychological health of the mothers themselves (Pawlby, Fernyhough, Meins, Pariante, Seneviratne, & Bentall, 2010). Mothers suffering from lifelong chronic illness, like HIV, are known to have parenting deficits (i.e. poor
parenting or lack of parental involvement) in comparison to uninfected mothers (Murphy et al., 2015).
When considering MLWH, it is important to take into account that key symptoms of HIV such as fatigue, stress and depression, that to a great extent limit the intrapersonal capacity they have to take note of their child’s behaviours. MLWH in Southern Africa are often the family breadwinners which places even more stress on their HIV-related symptoms and limited availability. The combination of these stressors in addition to those of being a mother may significantly influence the experience of motherhood and the mother-child attachment relationships. This influence, especially in a South African context, remains to a great extent unknown due to limited research of this phenomenon.
Purpose of the study
The purpose of this study is to explore the role of HIV with regards to motherhood in a South African context. The study aims to first gain insight into their experiences of
motherhood and explore the challenges and enablers present in this context. Secondly, the study also sets out to explore whether mothers with similar mother-child attachment classifications, as identified in the larger study by Spies (2015), have similar motherhood experiences. The findings of this study will contribute to the limited knowledge about MLWH in South Africa. This knowledge may be essential to inform future studies and interventions aimed at improving maternal well-being and remedying the detrimental effects of HIV.
The research questions for this study are:
What are the motherhood experiences of mothers living with HIV in South Africa?
What patterns emerge between the experiences of mothers living with HIV and their previously identified mother-child attachment relationships?
Ethical procedures and considerations
Research ethics committees (RECs), like the Health Research Ethics Committee (HREC) at the North-West University, were created to protect participants involved with research while also ensuring high-quality research that is scientific and reliable (Barrios, García, & Tapia, 2017). Research studies are first critically evaluated by an ethical board before research activities may commence. This study, as well as the affiliated study (hereafter referred to as the original study), were both ethically approved by HREC (REC-130913-037) in 2019 (NWU-00011-19-A1) and 2014 (NWU-00046-12-A1) respectively (Addendum A).
Guided by the ethical principles set out by the American Psychological Association (2017) the researchers maintained ethical research practices that were respectful of others, caused no harm to others and was grounded in integrity (APA, 2017). Permission to conduct the study was also provided from the relevant stakeholders involved in the study (North-West Department of Health) see Addendum B. The participants involved in the research study by Spies (2015) gave both verbal and written informed consent to participate in the original research study. Since the ethical clearance of the original study, the formatting and
prerequisites of the informed consent form have changed and therefore, ethical consultation was required to ensure the appropriate use of the primary data that remained. Following ethical consultation, the owner of the data permitted to use the raw data (see Addendum C). Subsequently, the researchers anonymised the raw data, which allowed for the waiver of re-informed consent. All identifiable information was removed from the data and replaced with codenames that ensured the richness and depth of the data remained intact. Since the
completion of the original study, the data has been securely archived to prevent any data tampering.
The target population during the original period of data collection is now, still, a population considered to be vulnerable, understudied, and at high-risk. The findings and contribution of this study will, therefore, be valued without inconveniencing this group for second time. The findings of this study may contribute towards the understanding of this understudied population in South Africa through describing their experiences of motherhood.
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Chapter 2: Manuscript Author guidelines
Manuscript Submission Guidelines: South African Journal of Psychology This Journal is a member of the Committee on Publication Ethics
Please read the guidelines below then visit the Journal’s submission site
http://mc.manuscriptcentral.com/sap to upload your manuscript. Please note that manuscripts not conforming to these guidelines may be returned.
Only manuscripts of sufficient quality that meet the aims and scope of the South African Journal of Psychology will be reviewed.
There are no fees payable to submit or publish in this journal.
As part of the submission process, you will be required to warrant that you are submitting your original work, that you have the rights in the work, that you are submitting the work for first publication in the Journal and that it is not being considered for publication elsewhere and has not already been published elsewhere, and that you have obtained and can supply all necessary permissions for the reproduction of any copyright works not owned by you. 1. What do we publish?
1.1 Aims, & Scope
Before submitting your manuscript to the South African Journal of Psychology, please ensure you have read the Aims, & Scope.
1.2 Article Types
The South African Journal of Psychology considers submissions addressing South African, African or international issues, including:
Manuscripts reporting on research investigations.
Review articles focusing on significant issues in Psychology.
New submissions should not exceed 5500 words, including references, tables, figures, etc. Authors of manuscripts returned for revision and extension should consult the Editorial Office regarding amended length considerations.
All manuscripts should be written in English and include an abstract of not more than 250 words. The writing must be of a high grammatical standard, and follow the technical guidelines stipulated below. The publication guidelines of the American Psychological Association 6th edition (APA 6th) must be followed in the preparation of the manuscript. Manuscripts of poor technical or language quality will be returned without review. 1.3 Writing your paper
The SAGE Author Gateway has some general advice and on how to get published, plus links to further resources.
1.3.1 Make your article discoverable
When writing up your paper, think about how you can make it discoverable. The title, keywords and abstract are key to ensuring readers find your article through search engines such as Google. For information and guidance on how best to title your article, write your abstract and select your keywords, have a look at this page on the Gateway: How to Help Readers Find Your Article Online.
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2. Editorial policies 2.1 Peer review policy
The South African Journal of Psychology operates a blind peer review process with each manuscript reviewed by at least two referees. All manuscripts are reviewed as rapidly as possible and the editorial team strives for a decision within 8-10 weeks of submission, although this is dependent on reviewer availability.
Where authors are invited to revise manuscripts for re-submission, the editor must be notified (by e-mail to sajp@psyssa.co.za) of their intention to resubmit and the revised manuscript should be re-submitted within four weeks.
2.2 Authorship
All parties who have made a substantive contribution to the article should be listed as authors. Principal authorship, authorship order, and other publication credits should be based on the relative scientific or professional contributions of the individuals involved, regardless of their status. A student is usually listed as principal author on any multiple-authored publication that substantially derives from the student’s dissertation or thesis.
2.3 Acknowledgements
All contributors who do not meet the criteria for authorship should be listed in an
Acknowledgements section. Examples of those who might be acknowledged include a person who provided purely technical help, or a department chair who provided only general
support.
Any acknowledgements should appear first at the end of your article prior to your Declaration of Conflicting Interests (if applicable), any notes and your References.
2.4 Funding
The South African Journal of Psychology requires all authors to acknowledge their funding in a consistent fashion under a separate heading. Please visit the Funding Acknowledgements
page on the SAGE Journal Author Gateway to confirm the format of the acknowledgment text in the event of funding, or state that: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
2.5 Declaration of conflicting interests
The South African Journal of Psychology encourages authors to include a declaration of any conflicting interests and recommends you review the good practice guidelines on the SAGE Journal Author Gateway.
3. Publishing Policies 3.1 Publication ethics
SAGE is committed to upholding the integrity of the academic record. We encourage authors to refer to the Committee on Publication Ethics’ International Standards for Authors and view the Publication Ethics page on the SAGE Author Gateway.
3.1.1 Plagiarism
The South African Journal of Psychology and SAGE take issues of copyright infringement, plagiarism or other breaches of best practice in publication very seriously. We seek to protect the rights of our authors and we always investigate claims of plagiarism or misuse of
published articles. Equally, we seek to protect the reputation of the journal against
malpractice. Submitted articles may be checked with duplication-checking software. Where an article, for example, is found to have plagiarised other work or included third-party copyright material without permission or with insufficient acknowledgement, or where the authorship of the article is contested, we reserve the right to take action including, but not limited to: publishing an erratum or corrigendum (correction); retracting the article; taking up
the matter with the head of department or dean of the author's institution and/or relevant academic bodies or societies; or taking appropriate legal action.
3.1.2 Prior publication
If material has been previously published it is not generally acceptable for publication in a SAGE journal. However, there are certain circumstances where previously published material can be considered for publication. Please refer to the guidance on the SAGE Author Gateway or if in doubt, contact the Editor at the address given below.
3.2 Contributor's publishing agreement
Before publication, SAGE requires the author as the rights holder to sign a Journal
Contributor’s Publishing Agreement. SAGE’s Journal Contributor’s Publishing Agreement is an exclusive licence agreement which means that the author retains copyright in the work but grants SAGE the sole and exclusive right and licence to publish for the full legal term of copyright. Exceptions may exist where an assignment of copyright is required or preferred by a proprietor other than SAGE. In this case copyright in the work will be assigned from the author to the society. For more information please visit the SAGE Author Gateway. 3.3 Open access and author archiving
South African Journal of Psychology offers optional open access publishing via the SAGE Choice programme. For more information please visit the SAGE Choice website. For information on funding body compliance, and depositing your article in repositories, please visit SAGE Publishing Policies on our Journal Author Gateway.
4. Preparing your manuscript for submission 4.1 Formatting
