Cape Town — In July, AllAfrica.com reported on a clinic in Cape Town, South Africa, that has defied the country's distressing trend over the past decade of maternal mortality rates rising sharply. While the lethal link between undiagnosed or late treatment of HIV, tuberculosis and pregnancy has contributed to the spike in the death rate of mothers in childbirth, the midwife obstetric unit in Site B, Khayelitsha, did not have a single death in the period from April 2011 to May 2012.
Nomsa* is one of the mothers living with HIV who recently gave birth at the unit. In July she told us she was waiting to find out if her baby was HIV positive or negative. AllAfrica recently returned to Site B to hear the result.
Khayelitsha - It was Women's Day in South Africa, August 9th, but Nomsa wasn't thinking about herself as she wrestled with sleep in her township shack on the outskirts of Cape Town. She was preoccupied about her baby's HIV test results that would be waiting for her at a clinic the next day.
The area is a poor, but vibrant urban mix of corrugated-iron shacks, formal housing, schools, shops, clinics, paved roads with sidewalks, police stations and a magistrate's court. The densely populated area is a far cry from the once sparse rows of matchbox houses built by the apartheid government on this vast sandy tract in the early 1980s.
Khayelitsha, which means "new home", is one of the areas where the Treatment Action Campaign (TAC) first took root in 1999. The non-profit fought and eventually won the right for access to antiretroviral treatment for all South Africans living with HIV/Aids.
"I don't know what made me join. I saw these people marching all the time. I didn't have a job. Maybe I was just curious," Nomsa says of joining TAC in 2005. "I didn't understand this HIV thing, but I love those people. I love TAC."
First-hand experience of coping with an HIV diagnosis came to Nomsa in February 2006. She had been losing weight and feared she had tuberculosis, so she visited her local clinic. But it wasn't TB.
"I was shocked, but as the time goes, I told myself, everyone has this disease, I'm not going to frustrate myself. I must accept," she says. "I saw people living with HIV in front of me, so I have to be ok with my health."
How to Feed her Baby
After five years on antiretroviral therapy and steeped in the knowledge of how to manage her illness, Nomsa decided to have another baby. She already had a healthy son, who was born some years before Nomsa contracted HIV.
"I talked to my doctor before I got pregnant," Nomsa says. "My doctor said it was fine because my viral load is undetectable and my CD4 count is ok."
Viral load determines the intensity of HIV infection in the body, while CD4 cells, or T-cells, fight infection. Antiretroviral therapy inhibits the HI virus, enabling the T-cells to rebuild and to combat any infections that attack the immune system.
On June 29, 2012, Nomsa gave birth to a baby girl, Linomtha, whose name means "sunrise".
Nomsa is one of the many women enrolled in the Prevention of Mother to Child Transmission programme in Site B, Khayelitsha - a hospital where the medical humanitarian organisation Médecins Sans Frontières (MSF), together with the provincial government, pioneered Aids treatment and prevention here more than a decade ago. South Africa has the largest number of people living with Aids of any country, and 30 percent of pregnant women tested HIV positive in 2009.
Nomsa's first decision as an HIV-positive mother was how to feed her baby. In line with World Health Organisation guidelines, South Africa's prevention of mother-to-child transmission policy on infant feeding recommends either exclusive breast-feeding or exclusive formula feeding in the first six months. According to the policy, the choice is to be based on which method maximizes child survival - not solely on the avoidance of HIV.
Nomsa was taking all the correct medication for HIV, so breastfeeding was unlikely to transmit the virus to her infant. But even a small chance of infecting her baby was one she did not want to take, so she decided she would not breastfeed.
"Even on that day when I gave birth on the 29th, I told them, 'Not breast milk'. The nurses said, 'All the mothers must breast feed', but I said to them, 'Not my baby'. I was a member of TAC, and I had information. We advise women to use formula, so I was strong."
Nomsa said the nurses accepted her right to choose, but they weren't happy. "I told them that I'm hearing their advice, I know breast milk is best for the baby, but when you are HIV positive, it's your choice, and I wanted to give formula."
In line with a South African government health policy, Nomsa has been receiving 10 tins of formula feed each month for her baby - support that will end in December when Linomtha is six months old.
An Anxious Wait
For a well-informed, HIV-positive mother, the first few weeks of her baby's life is a time of joy mixed with dread. Nomsa did not know whether Linomtha was infected with HIV, or whether the antiretroviral therapy both mother and newborn were taking had done its job - to protect the baby from her mother's virus.
Following standard practice for testing infants of HIV-positive mothers, Nomsa took her baby back to the clinic after a month, where the nurses drew blood from each of Linomtha's tiny heels. It was to be a further week's wait until the laboratory results would be available.
"I was up just after six that morning," says Nomsa, remembering events on August 10th. "It was not a normal day. I was so stressed. I was thinking about my baby and what I would do if she was HIV-positive."
Nomsa helped her 13-year old son set off for school and at half-past eight went to the clinic.
"I tell myself: I know I take my pills every day. But still I was so nervous. There was no queue. The nurses asked me what I wanted. I said, 'I'm here for the results.' They told me not to be nervous.
"They ask the baby's name. I tell them. Then they look for the file. They read the file first, then they look at you like this [she cocks her head]. 'The baby is fine,' they say.
"I screamed, then I cried. I really cried, because I had told myself, this HIV is not going to [affect] my family or my child. I wish that it is only me. I was very happy. It was tears for joy."
Nomsa went home, told her brothers, called Linomtha's father, and then told her friends.
Sharing Sound Advice
Nomsa continues to provide support to others in her community through the Treatment Action Campaign, even though she no longer receives any remuneration. Tough financial times mean that in 2012 TAC has had to cut the number of peer educators on its books.
"When someone has a problem, or has a brother or cousin who doesn't accept their status, they call me to talk with him or her. Sometimes those people thank me, but I tell them, 'Even me, too. Other people helped me too'."
She's forthright in her advice: "Some people don't go to the clinic, they say they're waiting until they're ill. It's not all right. They must go to the clinic, go for the test. Every time you have sex, use a condom."
Nomsa is equally emphatic in her advice to other mothers to be. "People must test early, even when you are two months or three months [pregnant]. Even if you are HIV positive or negative, or you don't know your status, go for early booking," she says, referring to the system of making an appointment at the Maternal and Obstetrics Unit in Site B, Khayelitsha. "It's very important."
With her baby not quite six months old, Nomsa has no quick answers to the question of her hopes and dreams for Linomtha. It's not HIV that defines her life, but the challenges that so many other South Africans face, like making a living in hard times.
"Sometimes I forget I'm HIV positive," says Nomsa. "I feel fine. My 13-year old boy reminds me, 'Mama, it's 10 o'clock; take your pills'.
"I have my boy, and I love my baby. I wish for a better future for her.
I hope she's going to school and that she'll be successful at life. Then I hope that I can find a job, so that my child's going to be fine."
*Not her real name
The series on the health of mothers and babies in South Africa is part of AllAfrica's development reporting project, which receives support from the Bill & Melinda Gates Foundation.