1 JNK JURNAL NERS DAN KEBIDANAN (JOURNAL OF NERS AND MIDWIFERY) http://jnk.phb.ac.id/index.php/jnk Midwives’ Views Regarding Tuberculosis Screening amongst HIV/AIDS Positive Pregnant Women, South Africa Violet Manonyana Chewe1, Sisinyana Hannah Khunou2 1Advanced Midwife, Limpopo Capricorn Health District, South Africa 2Department of Health, University of South Africa Pretoria, South Africa Article Information Abstract Tuberculosis (TB) infections is classified as one of the non-pregnancy related infections (NPRI) which cause maternal mortality. Therefore, it was important for the researcher to explore the challenges faced by midwives regarding TB screening as it is the most leading complication in human immunodeficiency virus (HIV) infected pregnant women. To that effect, several strategies for TB screening during pregnancy have been introduced and implemented thus far. Screening of TB during antenatal care helps to enhance early detection, exclusion and treatment of the infection in pregnant women who are HIV positive. The study used qualitative descriptive research design. The population included all midwives aged 30 to 48 years, who were working at primary health (PHC) clinics in Kganya local area, Capricorn District, Limpopo Province in South Africa. Nonprobability purposive sampling technique was employed to select ten midwives. Data were collected through in-depth individual semi -structured interviews with ten midwives. Data analysis was accomplished, using the manual thematic analysis according to Tesch’s method of data analysis. Finally the main themes were extracted. Two themes emerged from the study, namely: Challenges regarding TB screening; Measures that can enhance TB screening. It is important that the department of health should pay attention to challenges faced by midwives to ensure adequate TB screening amongst HIV positive pregnant women. Capacitating both midwives and the community with knowledge regarding TB screening during pregnancy can be beneficial to the health of the pregnant women and their unborn babies. History Article: Received, 28/07/2022 Accepted, 01/02/2023 Published, 20/03/2023 Keywords: midwives, pregnant women, tuberculosis screening © 2023 Journal of Ners and Midwifery Correspondence Address: University of South Africa - Pretoria, South Africa P-ISSN : 2355-052X Email : khunosh@unisa.ac.za E-ISSN : 2548-3811 DOI: https://doi.org/10.26699/jnk.v10i1.ART.p001-009 This is an Open Access article under the CC BY-SA license (http://creativecommons.org/licenses/by-sa/4.0/) http://jnk.phb.ac.id/index.php/jnk mailto:khunosh@unisa.ac.za https://doi.org/10.26699/jnk.v10i1.ART.p001-009 2 Journal of Ners and Midwifery, Volume 10, Issue 1, April 2023, page 1 - 9 INTRODUCTION Tuberculosis is the most popular respiratory infection ranking above HIV globally (World Health Organisation ,2019). The HIV increases the chance of TB infection in pregnancy, hence HIV infection complicated by TB is the first indirect cause of maternal mortality (South Africa, 2018). As a result, there is a high risk for progression from latent to active TB in HIV pregnant women (McKenna, Frick, Lee, Namutamba, Smit, Theunissen, Vandevelde, Madoori, Snow and Seaworth ,2017). Diagnosis of TB during pregnancy is usually a challenge in South Africa (SA) as TB screening statistics in pregnancy are usually not reported (Mnqayi, 2016). Tuberculosis screening during antenatal care can assist with early diagnosis and prompt management to reduce maternal mortality due to HIV/TB co-infection. So far, several TB screening methods have been introduced. According to Gebreegziabiher, Adane and Abebe,2017), the most common method which is used in SA is the four-part strategy symptom- based intensified case finding as recommended by World Health Organisation (WHO). In an effort to reduce TB transmission to the entire population, the WHO (2018) further introduced the sustainable development goals (SDGs) which was also adopted by SA. Furthermore, SA introduced 90-90-90 strategy in 2014 to fast-track targets called as the End-TB strategy (Malaza, Smith, Mdaka, Haynes, and Shezi, 2016.) The END- TB strategy aimed to achieve 90% TB screening in key population, 90 % of those diagnosed with TB to be started on treatment and lastly 90% of those initiated to complete their treatment. In that regard, it is imperative to investigate common structural barriers to implementation of integrated antenatal care, of which TB screening is included (Fowks, Draper, Hellard and Stoove ,2016). TB infection is ranked the third among causes of maternal death in SA, the first being obstetric haemorrhage followed by hypertension (South Africa, 2016). It is further stated that TB screening and initiation of TB preventive therapy to HIV positive pregnant women can reduce maternal mortality (South Africa, 2016). From maternal and mortality meetings which the researcher attend more often at the local hospital, most maternal mortality is due to HIV/TB co-infection. Anecdotal suggests that HIV positive pregnant women are not properly screened for TB infection. The researcher observed that in most maternity case records, patients’ files and ante-natal registers there is no record of TB screening of pregnant women in Limpopo Capricorn district. Of great concern, in the year 2016 Capricorn district had 38 maternal deaths of which 10.5 (37.7%) were due to HIV complicated by TB (Limpopo Department of Health 2017). With this leading maternal killer being non-pregnancy related infections, there was a dearth of literature regarding challenges faced by midwives regarding TB screening among HIV positive pregnant women in the setting. Several studies were conducted in Limpopo Province, with limited focus on TB screening amongst HIV positive pregnant women (Tshililo, Mangena- Netshikweta, Nemathaga and Maluleke, 2019; Mulondo, Khoza and Maputle, 2015; Lekhuleni, Kgole and Mbombi, 2015). Views of the midwives regarding TB screening amongst HIV positive pregnant women, has not been adequately studied in Limpopo Province. Thus, a qualitative paradigm is employed for this research as the study intends to explore challenges regarding TB screening of HIV positive pregnant based on the views of the midwives in naturalistic and interpretive domains. METHODS A qualitative exploratory descriptive design was espoused for this study. Exploration of views is important because there are multiple subjective meanings and understandings about certain objects or things in a certain social setting of the world in which humans live. The study espoused purposive sampling technique to select the participants. The inclusion criteria entailed midwives with more than five years’ experience, working at the research setting and trained on the following: prevention of mother to child transmission (PMTCT), HIV and TB management. Anonymity and confidentiality was ensured by naming participants as P1 to P10. Ethics committee approval (Reference number: HSHDC/934/2019) was obtained from Research Ethics committee, University of South Africa, together with permissions from Limpopo Department of health ethics committee (Reference number LP-202001- 015). Permission was also sought from the clinic operational managers. Information sheets were given to the participants before the interview date and all clarity seeking questions were answered by the researcher. Participants who were willing to Fata, Safiani, Monica, Ulfa, Wibisono, Self Management of Type 2 Diabetes Mellitus Patients at … 3 take part in the study signed an informed consent form before the commencement of an interview. Semi structured individual digital interviews were conducted from December 2020 to June 2021.The participants were recruited individually through telephones. The contact details of participants were provided by the clinic managers. The location of interviews was Capricon district of Limpopo province, Kganya local area which render both PHC and maternity health services. The setting was selected because of high incidents of maternal deaths related to TB amongst HIV positive pregnant women. The researcher secured an appointment for dates, times suitable and convenient for the participants. The digital interview methods such as zoom and teams were used because the face-to-face interactions were prohibited due to Covid-19 regulations. These interviews were conducted during the working period at the most convenient periods of the midwives. Regardless of the method chosen, all participants permitted the interview to be recorded. The average time for the interview was one hour. Data was analysed using the eight steps of Tesch method of data analysis as follows: Manual analysis of data was done, and data collected was reduced to codes following the rate of occurrence of concepts utilized in the actual transcriptions. Topics with the same meaning were grouped. The topics which belonged alone were grouped separately from others. Themes, categories, and sub-categories surfaced from the coded data in which initial data analysis was carried out (Green and Thorogood, 2018). Analysis of data was done by the researcher with no predetermined theoretical coding structure. The researcher and the co-coder met thereafter to reach an agreement on the themes, categories, and sub-categories both reached. RESULTS Data saturation was realized after interviewing ten midwives, with ages ranging from 30 to 48 years. Their experience of working with HIV positive pregnant women ranged from 6 to 17 years. All midwives were trained with the following: PMTCT, HIV and TB management. Nine out of ten participants were females and one was a male. Table1 illustrate participants’ demographic information. Table 1: Socio-demographic characteristics of the participants Participant Age Gender Academic qualifications Short course Experience in years P1 37 Female Registered midwife PMTCT; TB;HIV 10 P2 35 Female Registered midwife PMTCT; TB;HIV 06 P3 43 Male Registered accoucher PMTCT; TB;HIV 12 P4 45 Female Registered midwife PMTCT; TB;HIV 09 P5 35 Female Registered midwife PMTCT; TB;HIV 10 P6 33 Female Registered midwife PMTCT; TB;HIV 07 P7 34 Female Registered midwife PMTCT; TB;HIV 07 P8 48 Female Registered midwife PMTCT; TB;HIV 17 P9 40 Female Registered midwife PMTCT; TB;HIV 11 P10 30 Female Registered midwife PMTCT, TB, HIV 06 This study yielded two themes, namely challenges to TB screening and Measures that can enhance TB screening. Themes, categories, and participants’ testimonials can be seen in Table 2. The midwives revealed several challenges regarding TB screening amongst HIV positive pregnant women. The concern was supported by four categories namely: Shortage of midwives and work overload; Inadequate knowledge amongst some midwives regarding TB screening; Midwives’ attitude towards TB screening; Late presentation of pregnant women at the facility. These challenges are briefly described. The first challenge was identified as shortage of midwives. It is apparent that shortage of midwives leads to increased workload which hinders provision of quality care to pregnant women. Consequently, midwives will have no option but to rush all activities as much as possible and omit important activities such as history taking which forms an important aspect of TB screening. In this kind of situation, the midwives would be overwhelmed to thoroughly follow all the guidelines including TB screening amongst HIV positive pregnant women. During the interviews it was evident that some midwives were not empowered with regard to TB screening and management of HIV positive pregnant women. The participants blamed lack of development opportunities 4 Journal of Ners and Midwifery, Volume 10, Issue 1, April 2023, page 1 - 9 such as workshops and trainings. Notably, lack of knowledge regarding the guidelines amounts to incompetence in TB screening amongst HIV positive pregnant women. The attitude of midwives surfaced as the third challenge that hinders screening of TB among pregnant women who are also HIV positive. Participants revealed that some midwives classified TB as a procedure for lower category nurses. It is apparent that midwives with negative attitude, end up not screening TB amongst HIV positive just because they do not like it. Early antenatal clinic attendance ensures a healthy pregnancy because it provides the pregnant woman with an opportunity for prompt screening, health education, treatment of minor disorders and referral for further management. However, it was revealed in this study that HIV positive pregnant women missed opportunities of being screened for TB due to non –clinic attendance. In this instance pregnant women would report to the clinic in the second stage of labour or when they are already having dire TB complications. From the study findings, participants suggested several measures, which can be employed to enhance TB screening during antenatal care: Capacity building for midwives; Reliable TB screening tools; Consistent health education and campaigns. Capacity building for midwives is important in equipping them with knowledge and skills especially with regard to guidelines and procedures. Furthermore, workshops can assist to empower the midwives, enhance their confidence and competency in screening pregnant women. Participants’ responses show how in-service education to all midwives can assist with TB screening of HIV positive pregnant women. Well-functioning reliable tools and equipments are required in order to ensure quality screening for TB amongst HIV positive pregnant women. Participants alluded that screening tools should be made available so that it can be easier for the midwives to screen the women for TB. Effectiveness of all health care programmes depend on health education and behavioral change. This can be achieved through increased awareness and robust social mobilization. It was suggested by the participants that campaigns should be conducted to educated members of the community communities about TB infection. Table 2: Themes, categories, and participants’ testimonials Themes Categories Participants’ testimonials 1. Challenges regarding TB screening Shortage of midwives and work overload P2: “Sometimes we have like three nurses on duty, which is two professional nurses and one ENA (enrolled nursing assistant),… So, we just…we just don’t even ask, we don’t even have time to ask them about TB symptoms or anything. We are just…we are just short… there is just a shortage of staff. I can say that.” Inadequate knowledge P1: “Most of the professional nurses are not trained for TB management. So… they attend pregnant women not having experience in all the programs like TB management, prevention of mother to child transmission (PMTCT), so it might contribute to losing some of pregnant women”. Midwives’ attitude towards TB screening P6:“Yes, another one is that most of our midwives don’t want to collect the sputum, they say collecting the sputum is for juniors…so we miss women because, when they come to the midwife in the consulting room, the midwife has that attitude of collecting the sputum ...” Late presentation of pregnant women at the facility P1 :“Yes… another thing is those women that come to the clinic with head-on perineum., when you investigated you find that they are not booked for ANC, she just comes, and deliver. So, I think …it also affects the TB screening even if one is HIV positive they come here when they are wasted, with more complications and then there is nothing that is working for them.” Fata, Safiani, Monica, Ulfa, Wibisono, Self Management of Type 2 Diabetes Mellitus Patients at … 5 2. Measures that can enhance TB screening Capacity building for midwives P10: “At PHC level we have many… many programs, like TB management they have to go for training for longer days. So… is important for department to train midwives in TB issues”. Reliable TB screening tools P7:“I think if we can have screening tools, making copies, and each pregnant woman, we give it to them, so that even if when they are at home, they will be able to screen themselves, If I am having the night sweats I must come to the clinic.” Consistent health education and campaigns. P5:“I think we should conduct more awareness through door to door campaigns and let the community know about importance of TB screening for pregnant women…, and also through health education”. DISCUSSIONS This study aimed to explore and describe TB screening amongst HIV positive pregnant women from the viewpoint of the midwives. All in all, two main themes were revealed which include: (1) Challenges regarding TB screening; (2) Measures that can enhance TB screening. This study showed that challenges such as shortage of midwives; midwives ’inadequate knowledge towards TB management; midwives’ attitude towards TB screening and late presentation of pregnant women at the facility, hindered TB screening amongst HIV positive pregnant women. The study also revealed capacity building for midwives; reliable TB screening tools and health education and campaigns as measures which could enhance TB screening amongst HIV positive pregnant women. The current study revealed dire shortage of midwives. In this kind of situation, the midwives would be overwhelmed to thoroughly follow all the guidelines including TB screening amongst HIV positive pregnant women. Few midwives resulted in inadequacies and omissions regarding history taking which forms an important aspect of TB screening. Dire shortage of midwives, resulted in delegation of midwifery duties to lower nursing categories, thus further lowering the standard of care and screening of TB amongst HIV positive pregnant women. Shortage of nurses and other human resources in the health care system seems to be a problem for most countries, including South Africa (Jiyane ,2021; Matlala and Lumadi, 2019). In support, WHO (2012) and Haskins, Phakathi, Grant and Horwood (2014) highlighted that, programme implementation is affected and restricted by an increased workload of health workers. Midwives play an important role in delivery of quality care including early detection of TB amongst pregnant women. In that regard, insufficient number of midwives will not be able to provide expected standard care to pregnant women (Olakunde, Adeyinka, Olawepo, Pharr, Ozigbu, Wakdok, Oladele and Ezeanolue,2019; Kieft, Der Bouwer and Francke,2014). This is established by the study participants who highlighted that few midwives were not coping with workload as a result they sometimes prioritized the long queues and omitted TB screening in pregnant women. Furthermore, work overload has been related to pressure and stress which might contribute to impoliteness towards patients (Abdollahzadeh, Asghari and Vahidi, 2017). It was apparent from the present study that sufficient midwives are needed for the provision of TB screening in HIV positive pregnant women. During the interviews, it was noted that some midwives lacked knowledge regarding screening of TB for HIV positive pregnant women. In this regard, the participants blamed lack of development opportunities such as workshops and trainings. The knowledge gap amount to skills inadequacy, which result in the midwives missing important aspects of screening. It is therefore crucial that midwives who provide antenatal care at primary health facilities be trained on TB infection in pregnancy. Consistently, De Schacht, Mutaquiha and Faria (2019) revealed that TB screening in pregnancy is still neglected due to midwives’ lack knowledge. Christian, Smith and Hompashe (2018) emphasised that the midwives should be knowledgeable with regard to early diagnosis and prompt initiation of TB treatment amongst HIV positive pregnant women. The quality of antenatal care depends on the knowledge the midwives possess regarding TB in pregnancy. Accordingly, knowledge that is possessed by the midwives has a notable impact on 6 Journal of Ners and Midwifery, Volume 10, Issue 1, April 2023, page 1 - 9 the quality of nursing care they provide (Sithole and Khunou, 2016; Oyira, Ella and Usochukwu, 2016). It is notable that, if midwives are empowered, they will be in good standing to adequately follow the guidelines and educate pregnant women regarding the importance of TB screening. In addition, the findings of the present study highlighted that midwives displayed negative attitude pertaining to screening of TB in pregnant women who are positive for HIV. Participants lamented with concern that other midwives shunned away from screening of TB of pregnant women with the perception that it should be done by lower category nurses. This kind of attitude, could be related to lack of knowledge amongst other midwives. Similarly, the negative attitude among midwives were also found in other studies (Banakhar, 2018; Negussie and Oliksa, 2020). Furthermore, attitude and eagerness of midwives has bearing on performance and commitment towards ensuring quality patient care (Banakhar, 2018). In contrast, Deressa and Zeru (2019) identified high motivation and attitude among midwives in their workplace. It is imperative that midwives should display a positive attitude towards their patient. According to Mannava, Durrant, and Fisher (2015), midwives who have a positive attitude are likely to attract patients to return to the health facility. Patients need empathy, understanding, support and acknowledgment from health care providers. The findings from this study further revealed that pregnant woman reported very late at health facilities, despite the fact that they should present at the antenatal clinic before 20 weeks of gestation, (South Africa, 2016). Late presentation resulted in the midwives omitting TB screening. Literature has identified numerous factors which contribute to late presentation for antenatal care (Christian et al, 2018; Mannava, Durrant and Fisher et al, 2015). Christian, et al (2018), Sithole and Khunou (2016) cited the use of traditional healers by pregnant women instead of seeking maternity care services. The HIV status has also influenced pregnant women to report late at antenatal clinic. In this instance, stigma associated with HIV infection may be the reason for pregnant women to present late for antenatal care. According to Dramowski, Wates, Schaaf, Zenhäusern, and Bekker (2019) women present late at public health facilities due to lack of knowledge and poor and socioeconomic status. Sithole and Khunou (2016), also cited health facility related barriers as some of the factors that contributed towards late presentation to facilities by pregnant women. Notably, lack of trust in health facilities by pregnant women prevent them from seeking health care services. Therefore, robust measures such as education need to be put in place so that pregnant women understand the importance of early antenatal clinic attendance. Provision for in-service training and workshops regarding TB screening in pregnancy were also highlighted by participants. According to Mallick, Winter and Wang (2016), TB training in pregnancy is mostly disregarded among midwives. In that regard Chaghari, Saffari, Ebadi and Ameryoun (2017) emphasised that the midwives’ professional capability and expertise need to be capacitated through tutelage. Keeping the midwives updated through workshops, would assist to keep them informed with regard to new developments pertaining to TB screening of HIV positive pregnant women. Lastly health education is highlighted by participants as a corner stone to healthy pregnancy. The findings of this study revealed that campaigns and health education can be used to empower the community about significance of TB screening during ante-natal care. The study findings further revealed that early detection and diagnosis of TB in HIV positive pregnant women, can be enhanced through accurate TB screening tools. According to Vinkeles Melchers, van Elsland, Lange (2013), limited equipment and inadequate therapeutic information systems lead to inaccurate diagnostic algorithms and deficiency of TB control programmes. It is therefore, crucial from the study findings that midwives should always be provided with accurate TB screening tool to avoid missing screening TB to HIV positive pregnant women. Lastly health education is highlighted by participants as a corner stone to healthy pregnancy. The findings of this study revealed that campaigns and health education can be used to empower the community about significance of TB screening during ante-natal care. Evidently, health education helps to increase the level of awareness and empower the women to be more accountable (Vinkeles Melchers et al ,2013). Furthermore, health education program should address specific cultural stigma (Burrowes, Holcombe, Jara, Carter and Smith, 2017) health education is critical in educating the community at large and when it comes to the importance of screening of TB in pregnancy. The study was limited one district of Fata, Safiani, Monica, Ulfa, Wibisono, Self Management of Type 2 Diabetes Mellitus Patients at … 7 Limpopo Province, South Africa. Therefore, the results cannot be generalised to other provinces. CONCLUSION The study concludes that midwives face numerous challenges as expressed and voiced, which impact negatively on screening of TB among pregnant who are HIV positive women in Limpopo Province. SUGGESTIONS Therefore, it is recommended that midwives should be developed regarding TB issues in pregnancy, audit maternal health records regularly to identify gaps and lastly off duties to cover busy days. Furthermore, more midwives need to be trained to curb the issue of shortage. There should be filling of vacant posts in order to ensure adequate number of midwives who will render quality midwifery care and proper TB screening of pregnant women. Given that the study was confined to one local area of Limpopo Province the study can be extended other provinces of South Africa to get a broader understanding of the phenomenon. ACKNOWLEDGMENT The researchers would like to appreciate the University of South Africa for granting permission to conduct the study. From the bottom of my heart, we should like to thank the Department of Health Limpopo Province, Capricorn District by allowing the study to take place in their health facilities. The researchers would also like to thank the midwives who amidst their busy schedules spared some time to participate in the study in order to contribute the much valuable data. FUNDING The study was not funded CONFLICT OF INTEREST Authors declare that no conflicts of interest in this research. AUTHOR CONTRIBUTION VMC was responsible for conceptualisation of the study, data collection and analysis and writing the manuscript. SHK was responsible for supervising the study, writing and revising the manuscript. REFERENCES Abdollahzadeh, F., Asghari, E., Vahidi, M. (2017). How to prevent workplace incivility? Nurses’ perspective. Iranian Journal of Nursing and Midwifery Research. 2017; 22(2):157-163. https://www.ncbi.nlm.nih.gov Banakhar, M.A. (2018). Nurses ‘motivation and factors affecting it: A scoping review. International Journal of Nursing and Clinical Practices. 2018, 5 (277): 1-11. https://www.researchgate.net/publication/3 25496003_Nurses. Bluestone, J., Johnson, P., Judith, F. J., Carr, C., Alderman, J.,& BonTempo, J. (2013). Effective in-service training design and delivery: evidence from an integrative literature review. Biomedical centra1. Human Resources for Health 2013, 11:51. https://www.semanticscholar.org. Burrowes, S., Holcombe, S. J., Jara, D., Carter, D., & Smith, K. (2017). Midwives’ and patients’ perspectives on disrespect and abuse during labor and delivery care in Ethiopia: a qualitative study. BMC pregnancy and childbirth, 17(1), 1-14. http//: doi 10.1186/s12884-017-1442-1. Chaghari, M., Saffari, M., Ebadi, A., & Ameryoun, A. (2017). Empowering Education: New Model for In-Service Training of Nursing Staff. Journal of Advances in Medical Education and Professionalism, 5, 26-32. From: https://www,cbi.nim.nih.gov. Christian, S.C., Smith, A., Hompashe, D. (2018). Measuring quality Gaps in TB screening in South Africa using standardised patient Analysis. International Journal of Environmental Research and public Health. 15,729:1-10. https://www.academia.edu. Deressa, A.T., & Zeru, G. (2019). Work motivation and its effects on organizational performance: the case of nurses in Hawassa public and private hospitals: Mixed method study approach. BioMed Central , 12:213. P1-6. https://www.semanticscholar.org/paper. De Schacht, C., Mutaquiha, C., Faria, F., Castro, G.M., Manaca, N., Manhiça, I., & Cowan, J.F. (2019).Barriers to access and adherence to tuberculosis services as perceived by patients: A qualitative study in Mozambique. PLoS ONE. 14(7):1-11. https://www.ncbi.nlm.nih.gov/ https://www.researchgate.net/publication/325496003_Nurses https://www.researchgate.net/publication/325496003_Nurses https://www.semanticscholar.org/ https://www,cbi.nim.nih.gov/ https://www.academia.edu/ https://www.semanticscholar.org/paper https://www.researchgate.net/profile/Ivan-Manhica-2 8 Journal of Ners and Midwifery, Volume 10, Issue 1, April 2023, page 1 - 9 https://doi.org/10.1371/journal.pone.02194 70. Dramowski, A., Wates, M. A., Schaaf, H. S., Zenhäusern, J., & Bekker, A. (2019). Tuberculosis transmission in a hospitalised neonate: need for optimised tuberculosis screening of pregnant and postpartum women. South African Medical Journal, 109 (5):310-313. https://doi:10.7196/SAMJ.2019.v109i5.13 789. Fowks, F.J. I., Draper, B.L., Hellard, M., & Stoove, M. (2016). Achieving development goals for HIV, tuberculosis and malaria in sub- Saharan Africa through integrated antenatal care: barriers and challenges. BioMed Central Medicine, 14:202. https://bmcmedicine.biomedcentral.com/ar ticles/10.1186/s12916-016-07539. Gebreegziabiher, D., Adane, K., & Abebe, M. (2017). A survey on undiagnosed active pulmonary tuberculosis among pregnant mothers in Mekelle and surrounding District in Tigray, Ethiopia. The International Journal of Mycobacteriology.Vol 6 (1): https://pubmed.ncbi.nlm.nih.gov/28317804 . Getahun, H., Kittikraisak, W., Heilig, C. M., Corbett, E. L., Ayles, H., Cain, K. P., ... & Varma, J. K. (2011). Development of a standardized screening rule for tuberculosis in people living with HIV in resource-constrained settings: individual participant data meta-analysis of observational studies. PLoSmedicine, 8(1):1-14, https://www.ncbi.nlm.nih.gov/pmc/articles /PMC3022524/pdf/pmed.10003. Green, J., Thorogood, N. (2018). Qualitative methods for health research. 4th edition. London: SAGE. Haskins, L., Phakathi, S., Grant, M., & Horwood, C. (2014). Attitudes of nurses towards patient care at a rural district hospital in the Kwazulu Natal Province of South Africa. Africa Journal of Nursing and Midwifery. 16 (1): 31–43. https://www.researchgate.net . Jiyane, M.P. (2021). Experiences of professional nurses on the shortage of resources in a tertiary hospital in Tshwane District. MA Dissertation. Pretoria: UNISA. Kieft, R.A.M.M., Der Bouwer, B.B.J.M, Francke, A.L & Delmoij, D.M.J. (2014). How nurses and their work environment affect patient experiences of the quality of care: a qualitative study. BioMed Central Health Services Research. 14(1):249; 1-10. https://www.researchgate.net. Lekhuleni, M. E., Kgole, J. C., & Mbombi, M. O. (2015). Knowledge of student nurses in nurse initiated and management of antiretroviral therapy at the University of Limpopo, South Africa: TB, HIV/AIDS and other diseases. African Journal for Physical Health Education, Recreation and Dance, 21(sup-1), 53-61. https://hdl.handle.net/10520/EJC183575. Limpopo Department of Health. (2017). District Health Plan 2016/2017. Capricorn District. https://provincialgovernment.co.za/depart ment_annual/562/2017-limpopo-health- annual-report.pdf. Malaza, A., Smith, J., Mdaka, N., Haynes, R & Shezi, S. (2016). The 90-90-90 COPENDIUM, An introduction to 90-90- 90 in South Africa. Volume 1. https://sahivsoc.org. Mallick, L., Winter, R., Wang, W., & Yourkavitch, J. (2016). Integration of infectious disease services with antenatal care services at health facilities in Kenya, Malawi and Tanzania. DHS analytical studies 62. United States Agency for International Development. P1-88. https://www.semanticscholar.org/paper/G HI. Mannava, P.K., Durrant, K., Fisher, J., Chersich, S.,& Luchters, S.M. (2015). Attitudes and behaviours of maternal health care providers in interactions with clients: a systematic review. Globalization and Health, 11:36 http://doi10.1186/s12992- 015-0117-9. Matlala, M.S. & Lumadi, T.G. (2019). Perceptions of midwives on shortage and retention of staff at a public hospital in Tshwane District. Curationis 42(1) https://doi.org/10.4102/curationis.v42i1.19 52. McKenna, L., Frick, M., Lee, C., Namutamba, D., Smit, L., Theunissen, M., Vandevelde, W., Mandoore, S., Snow, K & Seaworth, B. (2017). A community perspective on inclusion of pregnant women in https://doi.org/10.1371/journal.pone.0219470 https://doi.org/10.1371/journal.pone.0219470 https://doi:10.7196/SAMJ.2019.v109i5.13789 https://doi:10.7196/SAMJ.2019.v109i5.13789 https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-07539 https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-07539 https://pubmed.ncbi.nlm.nih.gov/28317804 https://pubmed.ncbi.nlm.nih.gov/28317804 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3022524/pdf/pmed.10003 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3022524/pdf/pmed.10003 https://www.researchgate.net/ https://www.researchgate.net/ https://hdl.handle.net/10520/EJC183575 https://provincialgovernment.co.za/department_annual/562/2017-limpopo-health-annual-report.pdf https://provincialgovernment.co.za/department_annual/562/2017-limpopo-health-annual-report.pdf https://provincialgovernment.co.za/department_annual/562/2017-limpopo-health-annual-report.pdf https://sahivsoc.org/ https://www.semanticscholar.org/paper/GHI https://www.semanticscholar.org/paper/GHI http://doi10.1186/s12992-015-0117-9 http://doi10.1186/s12992-015-0117-9 Fata, Safiani, Monica, Ulfa, Wibisono, Self Management of Type 2 Diabetes Mellitus Patients at … 9 tuberculosis drug trials. Clinical infectious disease,65 https://www.ncbi.nlm.nih.gov/pmc/articles /PMC5849125/. Mnqayi, S. O. (2016). Tuberculosis Screening for Pregnant Women Living with HIV in UThungulu District, in 2011/2012 (Doctoral dissertation). Mulondo, S.A., Khoza, L.B. &Maputle, S.M. (2015). Risk Factors and Complications Associated with Tuberculosis in Pregnancy and Neonates in Limpopo Province, South Africa. Journal of Human Ecology. 2015;51(1-2):128–137. https://doi.org/10.1 080/09709274.2015.11906903. Negussie, B.B., & Oliksa, G.B. (2020). Factors influence nurses’ job motivation at governmental health institutions of Jimma Town, South-west Ethiopia. International Journal of Africa Nursing Sciences. 13; 100253. https://www.researchgate.net/publication/3 45969223. Olakunde, B.O., Adeyinka, D.A., Olawepo, J.O., Pharr, J.R., Ozigbu, C.E., Wakdok, S., Oladele, T & Ezeanolue, E.E. (2019). Towards the elimination of mother-to- child transmission of HIV in Nigeria: a health system perspective of the achievements and challenges. International Health. (11): 240-249. https://academic.oup.com/inthealth/article/ 11/4/240/5480911 Oyira, E.J., Ella, R.E., Usochukwu, E.C., & Akpan, I.P.(2016). Knowledge Practice and Outcome of Quality Nursing Care Among Nurses in University of Calabar Teaching Hospital. Journal of Education and Training Studies. 4 (11):179-193. https://www.researchgate.net Sithole, P.M., & Khunou, S.H. (2016). Factors contributing to missed opportunities in the prevention of mother to child transmission programme in the sub-district of Ngaka Modiri Molema, Northwest Province, South Africa. African Journal for Physical Activity and Health Sciences Volume 22(3:1):667-678. https://www.semanticscholar.org/paper/Fa ctors South Africa. National Department of Health. (2016). Guidelines for maternity care in South Africa: a manual for clinics, community health centres and district hospitals. Pretoria: Government Printers. https://www.knowledgehub.org.za/elibrary /guidelines-maternity-care-south-africa- 2016. South Africa. National Department of Health. (2018).Saving mothers report 2017 seventh reports on to the confidential inquiry into maternal deaths in South Africa. Pretoria: Government Printers. https://www.gov.za/documents/saving- mothers-report-confidential-enquiries- maternal-deaths-south-africa. Tshililo, A.R., Mangena-Netshikweta, L., Nemathaga, L.H. &Maluleke, M. (2019). Challenges of primary healthcare nurses regarding the integration of HIV and AIDS services into primary healthcare in Vhembe district of Limpopo province, South Africa. Curationis 42(1), https://doi. org/10.4102/curationis. v42i1.1849. Vinkeles Melchers, N.V., van Elsland, S.L., Lange, J. M., Borgdorff, M. W., & van den Hombergh, J. (2013). State of affairs of tuberculosis in prison facilities: a systematic review of screening practices and recommendations for best TB control. PLoS One, 8(1), | http://www.plosone.org. World Health Organization. (2012). WHO policy on collaborative TB/HIV activities: guidelines for national programmes and other stakeholders. https://pesquisa.bvsalud.org/portal/resourc e/pt/who-44789. World Health Organisation. (2018). Global Tuberculosis report. Geneva: WHO. From: http://www.who.int/tb. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5849125/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5849125/ https://doi.org/10.1%20080/09709274.2015.11906903 https://doi.org/10.1%20080/09709274.2015.11906903 https://www.researchgate.net/publication/345969223 https://www.researchgate.net/publication/345969223 https://academic.oup.com/inthealth/article/11/4/240/5480911 https://academic.oup.com/inthealth/article/11/4/240/5480911 https://www.researchgate.net/ https://www.semanticscholar.org/paper/Factors https://www.semanticscholar.org/paper/Factors https://www.knowledgehub.org.za/elibrary/guidelines-maternity-care-south-africa-2016 https://www.knowledgehub.org.za/elibrary/guidelines-maternity-care-south-africa-2016 https://www.knowledgehub.org.za/elibrary/guidelines-maternity-care-south-africa-2016 https://www.gov.za/documents/saving-mothers-report-confidential-enquiries-maternal-deaths-south-africa https://www.gov.za/documents/saving-mothers-report-confidential-enquiries-maternal-deaths-south-africa https://www.gov.za/documents/saving-mothers-report-confidential-enquiries-maternal-deaths-south-africa http://www.plosone.org/ https://pesquisa.bvsalud.org/portal/resource/pt/who-44789 https://pesquisa.bvsalud.org/portal/resource/pt/who-44789 http://www.who.int/tb