Family planning practices and pregnancy intentions among HIV-positive and HIV-negative postpartum women in Swaziland: a cross sectional survey

Unintended pregnancy and contraception use among African women living with HIV: Baseline analysis of the multi-country US PEPFAR PROMOTE cohort

BACKGROUND

About 90% of unintended pregnancies are attributed to non-use of effective contraception-tubal ligation, or reversible effective contraception (REC) including injectables, oral pills, intra-uterine contraceptive device (IUCD), and implant. We assessed the prevalence of unintended pregnancy and factors associated with using RECs, and Long-Acting-Reversible-Contraceptives (LARCs)-implants and IUCDs, among women living with HIV (WLHIV) receiving antiretroviral therapy (ART).

METHODS

We conducted cross-sectional analyses of the US-PEPFAR PROMOTE study WLHIV on ART at enrollment. Separate outcome (REC and LARC) modified-Poisson regression models were used to estimate prevalence risk ratio (PRR) and corresponding 95% confidence interval (CI).

RESULTS

Of 1,987 enrolled WLHIV, 990 (49.8%) reported their last/current pregnancy was unintended; 1,027/1,254 (81.9%) non-pregnant women with a potential to become pregnant reported current use of effective contraception including 215/1,254 (17.1%) LARC users. Compared to Zimbabwe, REC rates were similar in South Africa, aPRR = 0.97 (95% CI: 0.90-1.04), p = 0.355, lower in Malawi, aPRR = 0.84 (95% CI: 0.78-0.91), p<0.001, and Uganda, 0.82 (95% CI: 0.73-0.91), p<0.001. Additionally, REC use was independently associated with education attained, primary versus higher education, aPRR = 1.10 (95% CI: 1.02-1.18), p = 0.013; marriage/stable union, aPRR = 1.10 (95% CI: 1.01-1.21), p = 0.039; no desire for another child, PRR = 1.10 (95% CI: 1.02-1.16), p = 0.016; infrequent sex (none in the last 3 months), aPRR = 1.24 (95% CI: 1.15-1.33), p<0001; and controlled HIV load (≤ 1000 copies/ml), PRR = 1.10 (95% CI: 1.02-1.19), p = 0.014. LARC use was independently associated with country (Zimbabwe ref: South Africa, PRR = 0.39 (95% CI: 0.26-0.57), p<0.001; Uganda, PRR = 0.65 (95% CI: 0.42-1.01), p = 0.054; and Malawi, aPRR = 0.87 (95% CI: 0.64-1.19), p = 0.386; HIV load (≤ 1000 copies/ml copies/ml), aPRR=1.73 (95% CI: 1.26-2.37), p<0.001; and formal/self-employment, aPRR = 1.37 (95% CI: 1.02-1.91), p = 0.027.

CONCLUSIONS

Unintended pregnancy was common while use of effective contraception methods particularly LARCs was low among these African WLHIV. HIV viral load, education, sexual-activity, fertility desires, and economic independence are pertinent individual-level factors integral to the multi-level barriers to utilization of effective contraception among African WLHIV. National programs should prioritize strategies for effective integration of HIV and reproductive health care in the respective African countries.

Dual Contraceptive Method Utilization and Associated Factors Among HIV Positive Women Attending ART Clinic in Finote-Selam Hospital: Cross-Sectional Study

Worldwide, the human immune deficiency virus is the leading cause of death for women of childbearing age. Around two-thirds of all pregnant women living with the human immune deficiency virus experience an unintended pregnancy. The correct and consistent use of dual contraceptive methods is important to prevent unintended pregnancy and transmission of sexually transmitted infections. However, little is known about the utilization of dual contraceptive methods among HIV-infected women. Thus, this study aimed to assess dual contraceptive utilization and associated factors among HIV-positive women attending antiretroviral therapy (ART) in Finote Selam Hospital, Northwest Ethiopia. Facility-based cross-sectional study design was conducted from September 1 to October 30, 2019, in Finote Selam Hospital among HIV-positive women. A systematic random sampling technique was used to select study participants and the data were gathered by an interviewer-administered structured pretested questionnaire. Factors associated with dual contraceptive use were identified through binary logistic regression. Finally, a p-value < 0.05 was taken as a cutoff point to declare a significant association, and the direction and strength of the association were determined by the adjusted odds ratio. The study showed that 21.8% of HIV-positive women attending ART care in Finote Selam Hospital utilize dual contraceptive methods. Dual contraceptive utilization was significantly associated with having a child (AOR: 3.29; CI 1.45, 7.47), having family support to use dual contraceptives (AOR: 3.02; CI 1.39, 6.54), having multiple sexual partners (AOR: 0.11; CI 0.05, 0.22), and urban residence (AOR: 3.64; 1.82, 7.3). The study revealed that low utilization of dual contraceptive methods. This will continue major public health problems in the study area unless future interventions conducted.

Comparative situational analysis of comprehensive abortion care in four Southern African countries

We report on a comparative situational analysis of comprehensive abortion care (CAC) in Botswana, Eswatini, Lesotho and Namibia. We conducted systematic literature searches and country consultations and used a reparative health justice approach (with four dimensions) for the analysis. The following findings pertain to all four countries, except where indicated. Individual material dimension: pervasive gender-based violence (GBV); unmet need for contraception (15-17%); high HIV prevalence; poor abortion access for rape survivors; fees for sexual and reproductive health (SRH) services (Eswatini). Collective material dimension: no clear national budgeting for SRH; over-reliance on donor funding (Eswatini; Lesotho); no national CAC guidelines or guidance on legal abortion access; poor data collection and management systems; shortage and inequitable distribution of staff; few facilities providing abortion care. Individual symbolic dimension: gender norms justify GBV; stigma attached to both abortion and unwed or early pregnancies. Collective symbolic dimension: policy commitments to reducing unsafe abortion and to post-abortion care, but not to increasing access to legal abortion; inadequate research; contradictions in abortion legislation (Botswana); inadequate staff training in CAC. Political will to ensure CAC within the country's legislation is required. Reparative health justice comparisons provide a powerful tool for foregrounding necessary policy and practice change.

Factors influencing utilization of modern family planning services by persons living with Human Immunodeficiency Virus at Luwero Hospital, Uganda

Introduction

The use of modern family planning methods is key for achieving the prevention of unintended pregnancies among women living with HIV, in the prevention of Mother-to-child transmission (PMTCT) package. The purpose of this study was to examine the factors influencing the utilization of modern family planning services by persons living with HIV at Luwero Hospital, Uganda.

Methods

The study was conducted among 210 persons living with HIV attending the ART clinic and was based on cross-sectional descriptive and analytical design. Sampling was by simple random techniques. Data was collected using researcher-administered questionnaires.

Results

The uptake of Modern FP services is low (36.7%) among persons living with HIV. It was attributed to client-related factors such as being married [AOR: 2.2, 95% CI [1.123-4.140], p = 0.038]) and other factors. These are; religious views discouraging use of modern FP (p= 0.034), negative side effects (AOR: 1.8, 95% CI [0.043-1.968], p = 0.044) and services being unfriendly for persons living with HIV (p=0.000]).

Conclusions

Despite the presence of modern family planning services, uptake among persons living with HIV is low. Poor utilization is a recipe for unintended pregnancy and thus jeopardizes efforts in the elimination of mother-to-child transmission of HIV.

Contraceptive trajectories postpartum: A longitudinal qualitative study of women living with HIV in Cape Town, South Africa

BACKGROUND

Supporting the ability of women living with HIV (WLWH) to avoid unintended pregnancy during the postpartum period decreases the number of new pediatric HIV infections, reduces pregnancy-related morbidity and mortality, and is a cost-effective strategy for the elimination of mother-to-child transmission. However, little is currently known about the contraceptive intentions and experiences of reinitiating family planning use among mothers living with HIV as they transition from pregnancy into postpartum.

STUDY OBJECTIVES

To (1) understand the contraceptive trajectories of women living with HIV during pregnancy and postpartum in Cape Town, South Africa, and (2) identify factors shaping differing contraceptive trajectories during the postpartum period.

METHODS

Thirty pregnant WLWH were interviewed during their eighth month of pregnancy and completed follow-up interviews at 6-8 weeks and 9-12 months postpartum (n = 81 total interviews). Interview topics included postpartum contraception intentions, contraceptive use, and experiences accessing family planning services. Trajectory analysis of contraceptive intentions was applied after initial thematic coding.

RESULTS

While nearly half of women interviewed during pregnancy expressed an intention to utilize a non-injectable contraceptive option after childbirth (e.g. implant, IUD, sterilization, oral contraceptive pills), all women interviewed at one year postpartum had received at least one injection. Three main contraceptive trajectories were identified. (1) realization of contraceptive intentions postpartum; (2) unrealized contraceptive intentions postpartum; and (3) change in contraceptive intention over time. Provider influence, coordination of services, and low contraceptive inventory were identified as potential factors shaping the contraceptive trajectories of participants enrolled in the study.

CONCLUSION

Disparities between contraceptive method intentions articulated by WLWH during pregnancy and methods attained postpartum suggest that significant barriers remain for women who are unsatisfied with injectable contraception. Failing to provide postpartum mothers living with HIV their intended family planning method undermines efforts to prevent unintended pregnancy, a key pillar of elimination of mother-to-child transmission.

Attitudes Toward Pregnancy Among Women Enrolled in Prevention of Mother-to-Child Transmission of HIV (PMTCT) Services in Moshi, Tanzania

For pregnant women living with HIV (WLWH), feelings about pregnancy may influence their emotional well-being and health seeking behaviors. This study examined attitudes toward pregnancy and associated factors among women enrolled in prevention of mother-to-child transmission of HIV (PMTCT) services in Moshi, Tanzania. 200 pregnant WLWH were enrolled during their second or third trimester of pregnancy and completed a structured survey. Univariable and multivariable regression models examined factors associated with attitudes toward pregnancy, including demographics, interpersonal factors, and emotional well-being. Attitudes toward the current pregnancy were generally positive, with 87% of participants reporting feeling happy about being pregnant. In the final multivariable model, having higher levels of partner support, being newly diagnosed with HIV, and having fewer children were significantly associated with more positive attitudes toward their pregnancy. Findings point to a need for tailored psychosocial support services in PMTCT, as well as comprehensive reproductive health care for WLWH.

Integrating Sexual and Reproductive Health Services Within HIV Services: WHO Guidance

Among the 1.9 billion women of reproductive age worldwide in 2019, 1.1 billion need family planning and 270 million have an unmet need for contraception. For women and adolescent girls living with human immunodeficiency virus (HIV), using effective contraception reduces the mother-to-child transmission of HIV by preventing unintended pregnancies and enabling the planning and safer conception of desired pregnancies with optimal maternal and child health outcomes. The World Health Organization (WHO) recommends that sexual and reproductive health services, including contraception, may be integrated within HIV services. Integration is associated with increased offers and uptake of sexual and reproductive health services, including contraception, which is likely to result in improved downstream clinical outcomes. Integrating HIV and sexual and reproductive health services has been found to improve access, the quality of antenatal care and nurse productivity while reducing stigma and without compromising uptake of care. Research is encouraged to identify approaches to integration that lead to better uptake of sexual and reproductive health services, including contraception. Implementation research is encouraged to evaluate different strategies of integration in different health systems and social contexts; such research should include providing contraception, including long-acting contraception, in the context of less frequent clinical and ART refill visits.

Provision of immediate postpartum contraception to women living with HIV in the Eastern Cape, South Africa; a cross-sectional analysis

BACKGROUND

Universal access to contraception is an important strategy adopted by the South African government to reduce the high rate of unintended pregnancies, especially in women living with HIV. In this article, we describe the choices of contraception and also, examine the influencing factors of the choices of contraception in the immediate postpartum period in parturient women with HIV in the Eastern Cape, South Africa.

METHODS

In this prospective cross-sectional study, 1617 parturient women with HIV completed a survey on the choice of contraception received in the immediate postpartum period (within 72 h) across three large maternity services in the Eastern Cape between September 2015 to May 2016. Additional information was extracted from their medical records. Choices of contraception were categorised as; short-acting (injectables), long-acting reversible (intrauterine device and implants) and permanent contraception (tubal ligation). Adjusted and unadjusted logistic regression models were employed to determine the influencing factors of the choices of contraception received by the cohort.

RESULTS

Participants were predominantly single (69.1%), unemployed (75.1%), had a grade 7-12 level of education (88.4%) and were HIV positive before their index pregnancy (81.3%). The prevalence of immediate postpartum contraception was high (n = 1507; 93.2%) with Injectables being the preferred choice in the majority of the participants (n = 1218; 75.3%). After controlling for all relevant covariates, single marital status was associated with a higher likelihood of immediate postpartum contraceptive initiation (AOR; 1.82 95% CI 1.10-3.03). Overall, women were more likely to initiate a long-acting reversible and irreversible methods when older than 35 years and having had more than two children.

CONCLUSIONS

We found a high prevalence of immediate postpartum contraception with a preference for Injectables in the study setting. Long-term monitoring of this cohort will elucidate on contraceptive discontinuation and risk of unintended pregnancies in the region. Ensuring universal access to contraceptives is an important strategy to reduce the rate of unintended pregnancies at the population level. This strategy was adopted by the South African government with a vision of stemming the tide of unintended pregnancies among women living with HIV. In this study, the choices of contraception adopted by women living with HIV following the delivery of their babies were explored. In addition, the study highlights the factors that predict these choices. Participants were asked the choice of contraception they had received prior to being discharged from the maternity centres where they had delivered their babies. The various types of contraception were then categorised by their duration of action. Three distinct groups emerged; short-acting injectables, long acting reversible contraceptives and permanent methods. Of the 1617 women included in the study, 1117 were single and 1314 knew their HIV status prior to the onset of the index pregnancy. Almost all the women (1507 out of 1617) received one form of contraception before leaving the hospital. Many women (1218 out of 1617) chose injectable contraception (short-acting contraception) over the other types of contraception. Women who were older than 34 years and who had three or more children were more likely to choose a long-acting reversible contraceptive and permanent method over the short-acting contraception or nothing. In conclusion, given the short duration of action of the predominant method adopted by these women, a long-term follow up of the study participants will provide more information on the continued use of contraception and risk for unintended pregnancies.

Prevalence and predictors for unintended pregnancy among HIV-infected pregnant women in Lira, Northern Uganda: a cross-sectional study

Prevention of unintended pregnancies is a global strategy to eliminate mother-to-child transmission of HIV. Factors surrounding unintended pregnancy among women living with HIV are not well understood. We aimed to determine the prevalence and predictors for unintended pregnancy among these women in Northern Uganda. We conducted a cross-sectional survey among 518 women using a structured questionnaire. We asked questions on socio-demographic, reproductive-related and HIV-related characteristics. We conducted multivariable logistic regression and reported adjusted odds ratios. The prevalence of unintended pregnancy was 41.1%. The predictors for unintended pregnancy were: being single (not living with a partner or being in a marital union), having five or more children and taking antiretroviral drugs for long periods of time. HIV counselling services should target women living with HIV who are not in a marital union, those having a higher parity and those who have taken ART for longer periods.

Contraceptive Use and Method Preferences among HIV Positive Women in Ethiopia: A Systematic Review and Meta-analysis

BACKGROUND

Preventing unintended pregnancies among HIV positive women has a vital role to prevent mother to child transmission. Besides, increasing access to contraceptives has a number of economical importance and reducing the costs for mitigating the unintended pregnancy consequences. Therefore, this study is aimed at assessing the contraceptive use and method of preference among HIV positive women in Ethiopia.

METHODS

A systematic review and meta-analysis reporting guideline was applied. Articles searched from the Scopus, Pubmed/MEDLINE, EMBASE, AJOL, Hinari, and Google scholar were included in this review. The Stata 11 software was used to compute the analysis. Heterogeneity of the studies was detected using the Cochran Q test and I 2 test statistics. Egger's test was used to check the evidence of publication bias within the studies. Subgroup analysis and sensitivity analysis was computed with the evidence of heterogeneity.

RESULTS

Ten thousand one hundred twenty one (10121) women living with HIV/AIDS were recruited in this study. The national estimated prevalence of contraceptive use among HIV positive women in Ethiopia was 57.78% (95% CI: 48.53-67.03). Injectables and male condom were the most preferred contraceptives accounted for 36.00% (95% CI: 6.64-45.35) and 32.74% (95% CI: 21.08-44.40), respectively. Discussion with husband/partner (AOR: 4.70, 95% CI: 2.18-10.12), disclosure of HIV status to spouse/partner (AOR: 2.18, 95% CI: 1.55-3.06), ever counseled for modern contraceptives (AOR: 2.79, 95% CI: 2.01-3.88), attending secondary and above education (AOR: 3.12, 95% CI: 2.15-4.51), and having more than one live child (AOR: 2.61, 95% CI: 1.86-3.66) were increasing the likelihood of contraceptive use whereas not currently married women (AOR: 0.23, 95% CI: 0.16-0.34) was decreases the odds of contraceptive use.

CONCLUSION

In Ethiopia, more than half of the women living with HIV/AIDS were using contraceptives. Discussion with husband/partner, disclosure of HIV status to spouse/partner, ever counseled for modern contraceptives, attending secondary and above education, and having more than one live child were increasing the uptake of contraceptives among HIV positive women. Partner discussion, having adequate information towards contraceptive use, and having desired number of child could increase the utilization; as a result, obstetric complication with HIV positive women due to unintended pregnancy is significantly decreasing.

Modern contraceptive use among postpartum women living with HIV attending mother baby care points in Kabarole District, Uganda

BACKGROUND

Preventing unintended pregnancies among women living with HIV is important for improving maternal and child health outcomes. Despite multiple contacts between postpartum women and healthcare providers at health facilities, modern contraceptive use during postpartum period remains low even among women with intentions to limit or delay childbearing. We estimated postpartum modern contraceptive use, unmet need and factors associated with modern contraceptive use among HIV positive women attending mother-baby HIV care points.

METHODS

We conducted a cross-sectional study, between April and May 2016, among HIV positive women attending postpartum care at six health facilities in Kabarole district, Uganda. Health facilities were stratified by level prior to selecting participants using systematic sampling. We administered structured questionnaires to women who had delivered within the last two to 18 months. Women who reported current use of a modern method were categorized as modern contraceptive users. Women not using but wanted to stop childbearing or space childbirth by at least 2 years were considered to have unmet need for modern contraception. We estimated a modified Poisson regression model to examine variations in the use of modern methods by various characteristics of participants.

RESULTS

We interviewed 369 women. Forty percent of them were using a modern method, with injectables being the most widely used. A third (33%) of the women had unmet need for modern methods, with unmet need for spacing (24%) being higher than for limiting births (9%). Modern contraceptive use was significantly higher among women who had delivered seven or more months earlier (Adj.PR = 2.02; CI: 1.49, 2.74); women who were counseled on family planning during antenatal care (Adj.PR = 1.53; CI: 1.07, 2.18); those who obtained methods through the care points (Adj.PR =2.27; CI: 1.32, 3.90); and those who jointly made decisions regarding childbearing with their partners (Adj.PR = 1.49; CI: 1.02, 2.17).

CONCLUSION

Use of modern contraceptives was low while unmet need was high among postpartum women living with HIV. The findings suggest that there are gaps which indicate the need to strengthen contraceptive service delivery at these care-points. Providing family planning counseling early would improve uptake of contraception upon resumption of menses and sexual activity.

[Contraceptive practices of HIV-infected women followed up on an ambulatory basis at the Treichville University Hospital (Abidjan, Ivory Coast)]

Introduction

Family planning is a high impact strategy to reduce maternal mortality and to prevent mother-to-child transmission of HIV. This study aims to describe contraceptive practices of HIV-infected women followed upon an ambulatory basis at the Treichville University Hospital.

Methods

We conducted a cross-sectional descriptive multicenter survey of people living with HIV in the ambulatory care units of the Treichville University Hospital from 1 April to 30 June 2016. During this period, all HIV positive patients of childbearing age attending the Department of Obstetrics and Gynecology, the Pneumophtisiology Department, the Department of Dermatovenereology and the Department of internal medicine were invited to complete a standardized questionnaire on the sociodemographic, medical characteristics and the contraceptive practices.

Results

In total, 283 women agreed to participate in the study, their median age was 36 years with an average parity of 1.7. Patients were nulliparous in only 22.3% of cases and lived with a partner in 54.8% of cases. They had no child with the current partner in 68.2% of cases. The partner was informed about their HIV status in 51.6% of cases. They were under antiretroviral treatment in 92.9% of cases with a median mean CD4 of 382 cells/mL. The majority of patients (62.9%) declared that they were using a modern contraceptive method. They mainly used progestin injectable (45.5%) and contraceptive implant (32.6%). The practice of dual protection was reported by only 17.4% of them. Secondary and higher education (OR=2.23 [1,35-3,69], p=0.01), multiparity (OR=1.84 [1,11-3,06], p=0.002) and revelation of HIV positive status to the partner (OR=1.86 [1,14-3,03], p<0.01) were factors significantly associated with the use of contraception.

Conclusion

Based on our experience, contraceptive practices in women infected with HIV are generally discouraging. It is essential to develop strategies to improve the integration of family planning into the management of HIV-infected women.

Unintended Pregnancy in Women Living with HIV in Sub-Saharan Africa: A Systematic Review and Meta-analysis

In 2014, about 1.5 million pregnancies occurred among HIV-positive women in low and middle-income countries. To pool magnitude and factors associated with unintended pregnancy in women living with HIV in sub-Saharan Africa, a systematic search of electronic databases was undertaken in November 2016. Pooling the magnitude of unintended pregnancy reported by 14 studies yielded a crude summary prevalence of 55.9%. The magnitude of unwanted pregnancy and mistimed pregnancy in six studies ranged from 14 to 59 and 9 to 47.2%, respectively. Contraceptive failure was an important factor for many unintended pregnancies. The magnitude of unintended pregnancy was significantly higher in HIV-positive women than for HIV-negative women in three out of six studies. The available evidence suggests that there is a high magnitude of unintended pregnancy in this population. Improving effective contraceptive utilization is thus a priority to address unintended pregnancies and to prevent mother to child transmission of HIV. PROSPERO Number: CRD42016051310.

Availability of integrated family planning services in HIV care and support sites in sub-Saharan Africa: a secondary analysis of national health facility surveys

Background

Integrating family planning (FP) with HIV care and treatment programs is a strategy to expand FP service delivery and prevent unintended pregnancies among women living with HIV. However, little is known about the extent to which FP services are available in health facilities providing HIV services across sub-Saharan Africa. In this study, we assessed the availability of integrated FP services and the associated factors in HIV care and support sites across sub-Saharan Africa.

Methods

We conducted a secondary analysis of nationally representative facility-level data from Service Availability and Readiness Assessments (SARA) and Service Provision Assessments (SPA) conducted in 10 sub-Saharan African countries between 2012 and 2015. We used six indicators that reflect the structure and process of care essential for FP service delivery in HIV care and support facilities to define the outcome of interest - onsite availability of integrated FP services. Multivariate logistic regression was used to explore facility-level characteristics associated with the outcome.

Results

Among the 3161 health facilities offering HIV care and support services, most reported also offering FP services at the same location. The availability of three FP methods was higher than the availability of FP guidelines and trained staff. Onsite availability of integrated FP services ranged from 10 to 61%. Results of multivariate logistic regression indicated that the odds of having onsite integrated FP services available was higher in HIV care and support sites that were operated by the government, classified as a tertiary level care facility, and provided services for PMTCT, antenatal care and basic surgery.

Conclusions

Our findings indicate critical shortcomings in the preparedness of HIV care and support sites to deliver onsite integrated FP services. Renewed efforts are needed to address these supply-side barriers and ensure that integrated FP and HIV services meet the unique needs of HIV clients.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0713-x) contains supplementary material, which is available to authorized users.

Integration of HIV testing services into family planning services: a systematic review

BACKGROUND

Despite significant interest in integrating sexual and reproductive health (SRH) services into HIV services, less attention has been paid to linkages in the other direction. Where women and girls are at risk of HIV, offering HIV testing services (HTS) during their visits to family planning (FP) services offers important opportunities to address both HIV and unwanted pregnancy needs simultaneously.

METHODS

We conducted a systematic review of studies comparing FP services with integrated HTS to those without integrated HTS or with a lower level of integration (e.g., referral versus on-site services), on the following outcomes: uptake/counseling/offer of HTS, new cases of HIV identified, linkage to HIV care and treatment, dual method use, client satisfaction and service quality, and provider knowledge and attitudes about integrating HTS. We searched three online databases and included studies published in a peer-reviewed journal prior to the search date of June 20, 2017.

RESULTS

Of 530 citations identified, six studies ultimately met the inclusion criteria. Three studies were conducted in Kenya, and one each in Uganda, Swaziland, and the USA. Most were in FP clinics. Three were from the Integra Initiative. Overall rigor was moderate, with one cluster-randomized trial. HTS uptake was generally higher with integrated sites versus comparison or pre-integration sites, including in adjusted analyses, though outcomes varied slightly across studies. One study found that women at integrated sites were more likely to have high satisfaction with services, but experienced longer waiting times. One study found a small increase in HIV seropositivity among female patients testing after full integration, compared to a dedicated HIV tester. No studies comparatively measured linkage to HIV care and treatment, dual method use, or provider knowledge/attitudes.

CONCLUSIONS

Global progress and success for reaching SRH and HIV targets depends on progress in sub-Saharan Africa, where women bear a high burden of both unintended pregnancy and sexually transmitted infections, including HIV. While the evidence base is limited, it suggests that integration of HTS into FP services is feasible and has potential for positive joint outcomes. The success and scale-up of this approach will depend on population needs and health system factors.

Long-term effects of unintended pregnancy on antiretroviral therapy outcomes among South African women living with HIV

OBJECTIVE

Unintended pregnancies are common among women living with HIV, but there are no data on their long-term impact on treatment outcomes. In a cohort of women initiating antiretroviral therapy (ART) during pregnancy, we examined the association between the intendedness of the current pregnancy, measured antenatally, and elevated viral load up to 5 years postpartum.

DESIGN

Prospective study with enrolment at entry into antenatal care and follow-up at study visits separate from routine care.

METHODS

At enrolment women completed the London Measure of Unplanned Pregnancy. Mixed effects models examined the impact of the intendedness of the pregnancy (planned versus each of unplanned or ambivalent, respectively) on viral load 50 or more copies/ml across postpartum study visits.

RESULTS

Overall, 459 women were followed for a median of 43 months postpartum, contributing 2535 viral load measures (median per woman: 6). Ambivalent and unplanned pregnancy were commonly reported (20 and 60%, respectively), and the proportion of women with elevated viral load increased over time (16% at 6 weeks to 43% by 36-60 months postpartum). Compared with those reporting a planned pregnancy, elevated viral load was more common among women reporting an unplanned pregnancy (odds ratio: 2.87; 95% confidence interval: 1.46-5.64), with a trend towards a higher odds among those reporting ambivalence (odds ratio: 2.19; 95% confidence interval: 0.97-4.82); associations persisted after adjustment for a wide range of demographic, clinical and psychosocial factors.

CONCLUSION

These novel data suggest that unplanned pregnancy may be a prevalent and persistent predictor of poor ART outcomes among women initiating ART during pregnancy.

Fertility desire and associated factors among women on the reproductive age group of Antiretroviral treatment users in Jimma Town, South West Ethiopia

Objectives

HIV remained the major cause of death in women of reproductive age worldwide. There is limited evidence regarding the fertility desire of HIV positive women receiving HIV care in the study area. Therefore, facility based cross-sectional study was conducted from March to April 2017 to assess fertility desire of HIV positive women and associated factors among mothers in receiving HIV care Jimma town, Southwest Ethiopia. Simple random sampling technique was taken to draw the sample after stratification. Data were analyzed using SPSS version 21 and statistical significance was declared at P value less than 0.05.

Results

This finding showed that, 175 (46.8%) of the Antiretroviral therapy users had fertility desire with those significantly associated factors; women in the age 18–29 years [AOR = 4.05, 95% CI 1.24–13.33], being married [AOR = 0.32, 95% CI (0.13–0.78)], having diploma educational level [AOR = 5.34, 95% CI 1.10, 15.60], having only boys or girls children [AOR = 2.79, 95% CI (1.24–6.25)], having 18–36$ monthly income [AOR = 1.27, 95% CI (1.56–10.67)], Partner’s HIV status [AOR = 3.56, 95% CI (3.02–9.33)] and non use of contraceptives [AOR = 2.57, 95% CI (1.08–6.13)]. Fertility desire in the study area was high. Strengthening PMTCT service should consider fertility desire of mothers living with HIV.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4190-7) contains supplementary material, which is available to authorized users.

Contraception use and unplanned pregnancies in a peri-urban area of eSwatini (Swaziland)

BACKGROUND

Despite reported high levels of contraception use in eSwatini, unplanned pregnancies are common. The aims of this study were to investigate prevalence and determinants of contraception use and unplanned pregnancies in a disadvantaged area in the Kingdom of eSwatini (Swaziland), and to investigate the association between unplanned pregnancies and antenatal care attendance.

METHODS

This cross-sectional study was conducted at the non-governmental organization Siphilile Maternal and Child Health in Matsapha, a peri-urban industrial area, using data from pre-existing client records. The sample included clients (n = 1436) registered during pregnancy or up to three months postpartum between August 2014 and April 2016. Contraception use before conception and unplanned pregnancies were analysed with logistic regression to find associations with socio-demographic factors and health care utilization.

RESULTS

In this population, 59% (n = 737) stated to have used contraception before becoming pregnant. Teenagers and first-time mothers were less likely to have used contraception. Seventy percent (789/1124) of the pregnancies were unplanned. Older women (≥35 years) were less likely while teenagers and multiparas (≥3 children) were more likely to have an unplanned pregnancy. Women with unplanned pregnancies were less likely to attend the recommended number of antenatal care visits compared to women with planned pregnancies.

CONCLUSION

The rate of unplanned pregnancies is high in this population, especially among teenagers. Family planning interventions need to focus on preconception care for teenagers to enable pregnancy planning including improved antenatal care attendance.

Da Costa T, Hofer CB. Unintended Repeat Pregnancies Among HIV Positive Women in Rio De Janeiro, Brazil

Introduction:

High rates of unintended pregnancies among HIV positive women have been reported by several studies. Among repeated pregnancies, these rates may be higher. Our aim was to describe the unintended pregnancy rate in repeat gestations of the same group of HIV-positive women.

Methodology:

From a prospective cohort of HIV-infected pregnant women followed-up from 1995 to 2013 in an Antenatal Clinic (ANC) in Rio de Janeiro, we selected women who had at least two consecutive pregnancies. Patient data were prospectively obtained from standardized questionnaires. The main dependent variable was if the pregnancy was intended or unintended. Some of the other variables were: age, the interval between pregnancies, household income, CD4 cells count at admission in the ANC and at delivery, viral load<1000 copies/ml at admission and close to delivery, and attempts to illegal abortion.

Results:

From a total of 287 women included, the number of unintended pregnancies increased from 138 (63.6%) at first pregnancy to 198 (81.8%) at second pregnancy (p < 0.01). At first pregnancy, we observed 8 women who had made an attempt to illegal abortion (7 with an unintended pregnancy and 1 with a wanted pregnancy, p = 0.06), while at second pregnancy, 34 of them had made an attempt (33 with unintended pregnancy and 1 with a wanted pregnancy, p < 0.01). Regarding viral load suppression close to delivery, there was no statistic difference between first and second pregnancies (72,7% vs. 70,5%, p = 0.36) as well as between intended and unintended pregnancies (in first pregnancy: 80% vs. 86%, p = 0.4; in second pregnancy: 72% vs. 83%, p = 0,1).

Conclusion:

High rates of unintended pregnancies and illegal abortion attempts, along with their increase from one pregnancy to the subsequent, reinforce the need for continuous family planning practices in HIV-infected patients. The majority of the women were able to reach undetectable viral load at the end of the pregnancy, including those with unintended pregnancies.

Implications:

HIV infected patients presenting in antenatal care for sequential unintended pregnancies. Despite the fact that abortion is illegal in this country, a substantial number of women, still attempt it before attending antenatal care. Family planning actions should be performed during the antenatal care.

Knowledge and utilization of family planning methods among people living with HIV in Kathmandu, Nepal

Background

Addressing family planning (FP) needs of people living with HIV is an effective response to HIV prevention. Healthy timing and spacing of births help ensure the health and well-being of all women and infants, regardless of their HIV-infection. In addition, preventing unintended pregnancies is an important strategy for prevention of mother to child transmission of HIV. The main purpose of this study was to explore the knowledge of family planning methods and identify factors affecting the utilization of such methods among HIV infected men and women attending two Anti-Retroviral Therapy (ART) sites of Kathmandu, Nepal.

Methods

This was a descriptive cross-sectional study. Two ART sites of Kathmandu were purposively chosen and a sample of 265 respondents (both men and women) was selected based on proportionate probability random sampling. A structured questionnaire was administered face to face to all of the eligible participants.

Results

The mean ± SD age of the participants was 36.62 ± 7.58 years. Sixty five percent of the respondents’ spouses were HIV positive. A majority of the respondents (72%) had heard of seven modern family planning methods. Considerably high number (72%) of the respondents or their spouses were using at least one of the method of family planning. The most common method was condom (83%) and the least common was IUCD (0.50%). The use of short acting (pills, depo-provera) and long acting (implant, IUCD) family planning methods other than condom dropped from 56.6 to 2% after diagnosis. Utilization of family planning methods was significantly associated with gender, education and HIV status of spouse. Males (Adjusted Odds Ratio (AOR) = 2.48, 95% CI = 1.20–5.07, p = 0.01) educated respondents (AOR = 3.27, 95% CI = 1.41–7.54, p = < 0.01) and individuals whose spouse were not infected with HIV (AOR = 4.70, 95% CI = 1.41–15.67, p = 0.01) were more likely to use FP methods.

Conclusion

The tendency for HIV infected men and women to avoid additional child bearing in Nepal is higher compared to sub-Saharan Africa. However, the use of effective methods of family planning is low. Therefore, more effective counselling sessions by service providers regarding the availability and use of alternative family planning methods besides condom is necessary.

Contraceptive use following unintended pregnancy among Ugandan women living with HIV

BACKGROUND

Preventing unintended pregnancy is critical for women living with HIV (WLWH) to safely achieve their reproductive goals. Family planning services should support WLWH at risk of repeat unintended pregnancies. We examined the relationship between unintended pregnancy and subsequent contraception use among WLWH in Uganda.

STUDY DESIGN

This was a retrospective analysis of data from a longitudinal cohort of individuals initiating antiretroviral therapy (ART), restricted to women with pregnancy (confirmed via urine β-hcg testing) between 2011-2013. The exposure of interest was intended vs unintended pregnancy, and the outcome was self-report of modern contraceptive use (hormonal methods, intrauterine device, sterilization, and/or consistent condom use) at 12 (range 6-18) months post-partum. A log-binomial model was used to estimate relative risks of modern contraceptive use post-partum based on intent of the index pregnancy, adjusted for age, socioeconomic status, education, relationship and HIV status of pregnancy partner, contraceptive use prior to pregnancy, years since HIV diagnosis, ART regimen, and CD4 cell count.

RESULTS

Among 455 women, 110 women reported 110 incident pregnancies with report on intent. Women had a baseline median age of 29 years, baseline CD4 count 403 cells/mm3, and were living with HIV for 3.8 years. Fifty pregnancies (45%) were reported as unintended and 60 (55%) as intended. Postpartum, 64% of women with unintended and 51% with intended pregnancy reported modern contraception (p = 0.24). In adjusted models, there was no association between pregnancy intent and post-partum contraception. However, contraceptive use prior to the referent pregnancy was positively associated with post-partum contraceptive use (aRR 1.97 (95% CI 1.12-3.48, p = 0.02), while higher baseline CD4 cell count was associated with lower post-partum contraceptive use (aRR 0.95, 95% CI 0.90-0.99, p = 0.02).

CONCLUSIONS

Almost half of incident pregnancies among WLWH in this cohort were unintended. Experiencing an unintended pregnancy was not associated with post-partum contraceptive use. Creative strategies to support contraceptive uptake for birth spacing and prevention of unintended pregnancies in the post-partum period are needed.

Factors affecting long acting and permanent contraceptive methods utilization among HIV positive married women attending care at ART clinics in Northwest Ethiopia

Background

Globally, unintended pregnancy has been very high accounting for 27% of maternal deaths. Different studies noted that nearly half of HIV positive women who gave unintended birth were using contraceptive methods prior to their unintended pregnancy. This implies that contraceptive failure contributes to unintended pregnancy. Long-term and permanent contraceptive methods are safe and effective contraceptive options. In women who are using long acting and permanent methods, the unintended pregnancy rate is very low and it is almost the same both in typical and perfect users. However, there is limited information on factors that affect long acting and permanent contraceptive methods utilization among Human Immuno-deficiency Virus (HIV) positive women in Ethiopia. Therefore, the purpose of this study was to assess long acting and permanent contraceptive utilization and its associated factors.

Methods

An institution-based cross-sectional study was conducted among 505 married women attending care at Anti Retroviral Therapy (ART) clinics in Bahir Dar from March 16, 2014 to April 15, 2014. The data were collected using a structured and interviewer administered questionnaire. Both bivariate and multivariate logistic regressions were used to identify associated factors.

Results

A total of 505 married women participated in the study with a response rate of 99.6%. The utilization of long acting and permanent contraceptive methods (LAPMs) was 27.5% [95% CI, 23.8-31.5]. The multivariate analyses showed that women who were getting pre- anti retroviral therapy (Pre-ART) services [Adjusted Odds Ratio = 2.65, 95% confidence interval: 1.44, 4.86], had spousal discussion on family planning sometimes [Adjusted Odds Ratio = 6.03, 95% CI:2.42-15.01] and frequently [Adjusted Odds Ratio = 6.61, 95% confidence interval: 2.49-17.47], had previous experience on long acting contraceptive methods [Adjusted Odds Ratio = 9.06, 95% confidence interval: 5.38-15.26], no exposure to myths about LAPMs [Adjusted Odds Ratio = 2.07, 95% confidence interval: 1.24-3.45], had birth intention after 2 years [Adjusted Odds Ratio = 6.95, 95% confidence interval: 3.35-14.42], and no such intention [Adjusted Odds Ratio = 7.60, 95% confidence interval: 3.77-15.34] were factors significantly associated with utilization of long acting and permanent contraceptive methods.

Conclusion

The utilization of long acting and permanent contraceptive methods was relatively high. Discussion with partners on family planning, previous experiences of LAPMs, not hearing myths about LAPMs, women not started ART, and no birth intention were positively associated with LAPMs utilization. It is therefore recommended that health service providers need to make couples counseling on FP, undergo behavioral change communication (BCC) to avoid misconceptions/myths regarding LAPMs. Further research is also recommended to address the gaps mentioned in the limitation section and to explore the reason/s for not using LAPMs (qualitative study).

The role of counseling on modern contraceptive utilization among HIV positive women: the case of Northwest Ethiopia

Background

Over 90% of the children with Human Immunodeficiency Virus are infected through the mother to child transmission process according to literatures. Preventing unintended pregnancy by using contraceptive methods is crucial for reducing maternal and child mortality and morbidity. Here we set out to assess the prevalence and associated factors of modern contraceptive utilization among sexually active reproductive age women attending Anti-Retroviral Therapy clinics in Amhara Region referral hospitals in 2016.

Methods

An institution based cross sectional study was carried out from April to July 2016 surveying women of reproductive age attending the Anti-Retroviral Therapy clinics in the five Amhara Region referral hospitals. A pretested and semi-structured questionnaire was used to collect data. EpiInfo7 and SPSS version 20 soft wares were used for data entry and analysis, respectively. Significant associations were identified on the basis of the adjusted odds ratio, with 95% Confidence Interval, and p value ≤0.05, was taken as statistically significant.

Result

The proportion of women utilizing modern contraceptives was 47.7% with (95% CI: 43, 52.5%), the male condom being the most (64.2%) utilized method. The use of the contraceptive methods was most prevalent among women 15–24 years of age (AOR = 6.5, 95% CI: 2–10) and age of 25–34 (AOR = 3, 95% CI: 1.6–5.5), having an urban residence (AOR = 0.095, 95% CI: 0.03–0.28), having discussed contraceptives with partner (AOR = 7, 95% CI: 5.3–11.9), receiving counseling from health care providers (AOR = 4.8, 95% CI: 1.8–7), previous history of contraceptive utilization (AOR = 5.6, 95% CI: 2.6–8.3), and with CD4 count >500mm³/dl (AOR = 2.4, 95% CI: 1.3–4.3).

Conclusion

The proportion of women utilizing contraceptive has been low in Amhara Region referral hospitals. Encouraging patients to discuss about contraception with partners and repeated counseling by health care providers may strengthen contraceptive utilization.

Women's recall of maternal and newborn interventions received in the postnatal period: a validity study in Kenya and Swaziland

Background

Despite the concentration of maternal and infant deaths in the early postnatal period, information on the content and quality of postnatal care interventions is not routinely collected in most low and middle-income countries. At present, data on the coverage of postnatal care interventions mostly rely on women’s reports collected in household surveys, such as the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), which collect limited information. We assessed the validity of a set of postnatal care indicators that reflect a range of recommended interventions for both mother and newborn and have potential to be included in household surveys for monitoring of population-level coverage.

Methods

We compared women’s reports in exit interviews on the content of postnatal care received in health facilities located in Kenya and Swaziland against a gold standard of direct observation by a trained third party. We calculated sensitivity, specificity and the area under the receiver operating curve (AUC) to assess individual-level reporting accuracy and the inflation factor (IF) to assess population-level accuracy. We also examined whether women’s reporting accuracy varied significantly by her sociodemographic characteristics.

Results

18 indicators in Kenya and 19 in Swaziland had sufficient sample size for analysis. Of these, 12 indicators in Kenya and five in Swaziland met criteria for acceptable individual and population-level reporting accuracy. Two indicators met acceptability criteria in both Kenya and Swaziland: whether the provider performed a breast exam or an abdominal exam. There was no significant association between women’s characteristics and reporting accuracy, across indicators.

Conclusion

Women are able to accurately report on multiple aspects of care received during a postnatal visit. Findings inform the recommendation of indicators for tracking progress of critical postnatal care interventions for mothers and newborns. Improved measurement of the coverage of maternal and newborn postnatal care is warranted to monitor progress in maternal and newborn care globally.

Prevalence and determinants of unplanned pregnancy in HIV-positive and HIV-negative pregnant women in Cape Town, South Africa: a cross-sectional study

OBJECTIVES

Prevention of unplanned pregnancy is a crucial aspect of preventing mother-to-child HIV transmission. There are few data investigating how HIV status and use of antiretroviral therapy (ART) may influence pregnancy planning in high HIV burden settings. Our objective was to examine the prevalence and determinants of unplanned pregnancy among HIV-positive and HIV-negative women in Cape Town, South Africa.

DESIGN

Cross-sectional analysis.

SETTINGS

Single primary-level antenatal care clinic in Cape Town, South Africa.

PARTICIPANTS

HIV-positive and HIV-negative pregnant women, booking for antenatal care from March 2013 to August 2015, were included.

MAIN OUTCOME MEASURES

Unplanned pregnancy was measured at the first antenatal care visit using the London Measure of Unplanned Pregnancy (LMUP). Analyses examined LMUP scores across four groups of participants defined by their HIV status, awareness of their HIV status prior to the current pregnancy and/or whether they were using antiretroviral therapy (ART) prior to the current pregnancy.

RESULTS

Among 2105 pregnant women (1512 HIV positive; 593 HIV negative), median age was 28 years, 43% were married/cohabiting and 20% were nulliparous. Levels of unplanned pregnancy were significantly higher in HIV-positive versus HIV-negative women (50% vs 33%, p<0.001); and highest in women who were known HIV positive but not on ART (53%). After adjusting for age, parity and marital status, unplanned pregnancy was most common among women newly diagnosed and women who were known HIV positive but not on ART (compared with HIV-negative women, adjusted OR (aOR): 1.43; 95% CI 1.05 to 1.94 and aOR: 1.57; 95% CI 1.13 to 2.15, respectively). Increased parity and younger age (<24 years) were also associated with unplanned pregnancy (aOR: 1.42; 95% CI 1.25 to 1.60 and aOR: 1.83; 95% CI 1.23 to 2.74, respectively).

CONCLUSIONS

We observed high levels of unplanned pregnancy among HIV-positive women, particularly among those not on ART, suggesting ongoing missed opportunities for improved family planning and counselling services for HIV-positive women.

Differences and similarities in women living and not living with HIV: contributions by the GENIH study to sexual and reproductive healthcare

This quantitative study in the city of São Paulo, Brazil, compared contexts of social vulnerability and sexual and reproductive behavior in a sample of 975 women living with HIV/AIDS (WLHIV) and 1,003 women not living with HIV, the latter recruited among users of the primary healthcare system. WLHIV experienced situations of greater vulnerability that potentially increased their risk of HIV infection and unplanned pregnancy and abortion. Compared to women users of the primary healthcare system, WLHIV reported higher rates of drug use, sex for money, exposure to intimate partner violence, difficulties in access to services for prevention and early diagnosis, unplanned pregnancies, induced abortion, and teenage pregnancy. A considerable number of the women users of the primary healthcare system shared these same experiences, but at lower rates. The identification of contexts of vulnerability and the integration of HIV testing services with sexual and reproductive health services should constitute lines of care for these women, both in specialized and primary care services.

Dual Method Use among Postpartum HIV-Infected and HIV-Uninfected Malawian Women: A Prospective Cohort Study

Dual method use, use of condoms plus another effective contraceptive method, is important in settings with high rates of unintended pregnancy and HIV infection. We evaluated the association of HIV status with dual method use in a cohort of postpartum women. Women completed baseline surveys in the postpartum ward and telephone surveys about contraceptive use 3, 6, and 12 months later. Nonpregnant women who completed at least one follow-up survey were eligible for this secondary analysis. Prevalence ratios were calculated using generalized estimating equations. Of the 511 sexually active women who completed a follow-up survey, condom use increased from 17.6% to 27.7% and nonbarrier contraceptive use increased from 73.8% to 87.6% from 3 to 12 months after delivery. Dual method use increased from 1.0% to 18.9% at 3 to 12 months after delivery. Dual method use was negligible and comparable between HIV-infected and HIV-uninfected women at 3 months but significantly higher among HIV-infected women at 6 months (APR = 3.9, 95% CI 2.2, 7.1) and 12 months (APR = 2.7, 95% CI 1.7, 4.3). Dual method use was low but largely driven by condom use among HIV-infected women at 6 and 12 months after delivery.

Fertility intentions and contraceptive practices among clinic-users living with HIV in Kenya: a mixed methods study

BACKGROUND

Preventing unwanted pregnancies in Women Living with HIV (WLHIV) is a recognised HIV-prevention strategy. This study explores the fertility intentions and contraceptive practices of WLHIV using services in Kenya.

METHODS

Two hundred forty women self-identifying as WLHIV who attended reproductive health services in Kenya were interviewed with a structured questionnaire in 2011; 48 were also interviewed in-depth. STATA SE/13.1, Nvivo 8 and thematic analysis were used.

RESULTS

Seventy one percent participants did not want another child; this was associated with having at least two living children and being the bread-winner. FP use was high (92%) but so were unintended pregnancies (40%) while living with HIV. 56 women reported becoming pregnant "while using FP": all were using condoms or short-term methods. Only 16% participants used effective long-acting reversible contraceptives or permanent methods (LARC-PM). Being older than 25 years and separated, widowed or divorced were significant predictors of long-term method use. Qualitative data revealed strong motivation among WLHIV to plan or prevent pregnancies to avoid negative health consequences. Few participants received good information about contraceptive choices.

CONCLUSIONS

WLHIV need better access to FP advice and a wider range of contraceptives including LARC to enable informed choices that will protect their fertility intentions, ensure planned pregnancies and promote safe child-bearing.

TRIAL REGISTRATION

Integra is a non-randomised pre-post intervention trial registered with Current Controlled Trials ID: NCT01694862 .

The Current Status of Research on the Integration of Sexual and Reproductive Health and HIV Services

Integration of services for sexual and reproductive health (SRH) and HIV has been widely promoted globally in the belief that both clients and health providers benefit through improvements in quality, efficient use of resources, and lower costs, helping to maximize limited health resources and provide comprehensive client-centered care. This article builds on the growing body of research on integrated sexual SRH and HIV services. It brings together critical reviews on issues within the wider SRH and rights agenda and synthesizes recent research on integrated services, drawing on the Integra Initiative and other major research. Unintended pregnancy and HIV are intrinsically interrelated SRH issues, however broadening the constellation of services, scaling up, and mainstreaming integration continue to be challenging. Overcoming stigma, reducing gender-based violence, and meeting key populations' SRH needs are critical. Health systems research using SRH as the entry point for integrated services and interaction with communities and clients is needed to realize universal health coverage.

Development of a mother and baby unit contraception assessment tool

Unplanned pregnancies are a unique, yet significant risk factor in perinatal mental health. Our aim was to create an assessment tool to assess mother's views on contraception as part of the discharge planning process. We used a quantitative-qualitative approach. A clinician-guided questionnaire was completed by patients prior to their discharge from hospital and analysed using Microsoft Excel. Semi-structured interviews were used to explore views regarding family planning in greater depth. Interviews were recorded and transcribed verbatim onto Microsoft Word. Emerging themes were identified using a grounded theory thematic analysis approach. Eighteen inpatients were assessed at the Bethlem Mother and Baby Unit over a 4-month period (May-August 2015). Half of the women stated that the pregnancy was unplanned. The most common contraception methods used were condoms, followed by no method/natural cycle technique. Forty-four percent felt unsure of contraception options available and were keen for further advice and referral to family planning services. Interestingly, almost all the women interviewed stated that their experience of perinatal mental illness had changed their views on having more children. The contraception assessment tool is a short, simple questionnaire that can be adopted across inpatient and community settings. In cooperating family, planning into the discharge care plan could be protective in preventing future unplanned pregnancies in women at high risk of perinatal mental illness relapse. Performing the assessment also provided an added opportunity for psycho-education regarding reproductive health and medication use during the perinatal period. The tool also encouraged liaison with GPs and local family planning services.

Effects of planned, mistimed and unwanted pregnancies on the use of prenatal health services in sub-Saharan Africa: a multicountry analysis of Demographic and Health Survey data

OBJECTIVES

We analysed the extent of planned, mistimed and unwanted pregnancies and how they predict optimal use of prenatal (timing and number of antenatal) care services in 30 African countries.

METHODS

We pooled data from Demographic and Health Surveys conducted in 30 African countries between 2006 and 2015. We described the extent of mistimed and unwanted pregnancies and further used mixed effects logistic and Poisson regression estimation techniques to examine the impacts of planned, mistimed and unwanted pregnancies on the use of prenatal health services.

RESULTS

In total, 73.65% of pregnancies in all countries were planned. Mistimed pregnancy ranged from 7.43% in Burkina Faso to 41.33% in Namibia. Unwanted pregnancies were most common in Swaziland (39.54%) and least common in Niger (0.74%). Timely (first trimester) initiation of ANC was 37% overall in all countries; the multicountry average number of ANC visits was optimal [4.1; 95% CI: 4.1-4.2] but with notable disparities between countries. Overall, mistimed and unwanted pregnancies were strongly associated with late ANC attendance and fewer visits women made in the pooled analysis.

CONCLUSIONS

Unintended pregnancies are critical risks to achieving improved maternal health in respect of early and optimal ANC coverage for women in Africa. Programmes targeted at advancing coverage of ANC in Africa need to deploy contextually appropriate mechanisms to prevent unintended pregnancies.

Unintended pregnancy, contraceptive use, and childbearing desires among HIV-infected and HIV-uninfected women in Botswana: across-sectional study

Background

Little is known about the impact of knowledge of HIV serostatus on pregnancy intention and contraceptive use in high-HIV-burden southern African settings in the era of widespread antiretroviral treatment availability.

Methods

We analyzed interview data collected among 473 HIV-uninfected and 468 HIV-infected pregnant and recently postpartum women at two sites in southern Botswana. Participants were interviewed about their knowledge of their HIV status prior to pregnancy, intendedness of the pregnancy, contraceptive use, and future childbearing desires.

Results

The median age of the 941 women was 27 years, median lifetime pregnancies was 2, and 416 (44 %) of pregnancies were unintended. Among women reporting unintended pregnancy, 36 % were not using a contraceptive method prior to conception. Among contraception users, 81 % used condoms, 13 % oral contraceptives and 5 % an injectable contraceptive. In univariable analysis, women with unintended pregnancy had a higher number of previous pregnancies (P = <0.0001), were less educated (P = 0.0002), and less likely to be married or living with a partner (P < 0.0001). Thirty-percent reported knowing that they were HIV-infected, 48 % reported knowing they were HIV-uninfected, and 22 % reported not knowing their HIV status prior to conception. In multivariable analysis, women who did not know their HIV status pre-conception were more likely to report their pregnancy as unintended compared to women who knew that they were HIV-uninfected (aOR = 1.7; 95%CI: 1.2-2.5). After controlling for other factors, unintended pregnancy was not associated with knowing one’s HIV positive status prior to conception (compared with knowing one’s negative HIV status prior to conception). Among women with unintended pregnancy, there was no association between knowing their HIV status and contraceptive use prior to pregnancy in adjusted analyses. Sixty-one percent of women reported not wanting any more children after this pregnancy, with HIV-infected women significantly more likely to report not wanting any more children compared to HIV-uninfected women (aOR = 3.9; 95%CI: 2.6-5.8).

Conclusions

The high rates of reported unintended pregnancy and contraceptive failure/misuse underscore an urgent need for better access to effective contraceptive methods for HIV-uninfected and HIV -infected women in Botswana. Lower socioeconomic status and lack of pre-conception HIV testing may indicate higher risk for unintended pregnancy in this setting.

Estimating mother-to-child HIV transmission rates in Cameroon in 2011: a computer simulation approach

BACKGROUND

Despite the progress in the Prevention of the Mother-to-Child Transmission of HIV (PMTCT), the paediatric HIV epidemic remains worrying in Cameroon. HIV prevalence rate for the population of pregnant women was 7.6% in 2010 in Cameroon. The extent of the paediatric HIV epidemic is needed to inform policymakers. We developed a stochastic simulation model to estimate the number of new paediatric HIV infections through MTCT based on the observed uptake of services during the different steps of the PMTCT cascade in Cameroon in 2011. Different levels of PMTCT uptake was also assessed.

METHODS

A discrete events computer simulation-based approach with stochastic structure was proposed to generate a cohort of pregnant women followed-up until 6 weeks post-partum, and optionally until complete breastfeeding cessation in both prevalent and incident lactating HIV-infected women. The different parameters of the simulation model were fixed using data sources available from the 2011 national registry surveys, and from external cohorts in Cameroon. Different PMTCT coverages were simulated to assess their impact on MTCT. Available data show a low coverage of PMTCT services in Cameroon in 2011.

RESULTS

Based on a simulation approach on a population of 995, 533 pregnant women, the overall residual MTCT rate in 2011 was estimated to be 22.1% (95 % CI: 18.6%-25.2%), the 6-week perinatal MTCT rate among prevalent HIV-infected mothers at delivery is estimated at 12.1% (95% CI: 8.1%-15.1%), with an additional postnatal MTCT rate estimated at 13.3% (95% CI: 9.3%-17.8%). The MTCT rate among children whose mothers seroconverted during breastfeeding was estimated at 20.8% (95% CI: 14.1%-26.9%). Overall, we estimated the number of new HIV infections in children in Cameroon to be 10, 403 (95% CI: 9, 054-13, 345) in 2011. When PMTCT uptake have been fixed at 100%, 90% and 80%, global MTCT rate failed to 0.9% (9% CI: 0.5%-1.7%), 2.0% (95% CI: 0.9%-3.2%) and 4.3% (95% CI: 2.4%-6.7%) respectively.

CONCLUSIONS

This model is helpful to provide MTCT estimates to guide the national HIV policy in Cameroon. Increasing supply and uptake of PMTCT services among prevalent HIV infected pregnant women, as well as HIV-prevention interventions including the offer and acceptance of HIV testing and counselling in lactating women could reduce significantly the residual HIV MTCT in Cameroon. A public health effort should be made to encourage health care workers and pregnant women to use PMTCT services until complete breastfeeding cessation.

Scale up use of family planning services to prevent maternal transmission of HIV among discordant couples: a cross-sectional study within a resource-limited setting

BACKGROUND

Integration of family planning services (FPS) into human immunodeficiency virus (HIV) care for HIV-infected women is an important aspect of the global prevention of mother-to-child transmission (PMTCT) strategy. We assessed the integration of FPS into routine care of HIV-infected mothers by evaluating the uptake and barriers of contraception and PMTCT services.

METHODS

We conducted an interventional study using the interrupted time series approach in the health care facilities located in Yaounde, Cameroon. First, structured questionnaires related to family planning use, PMTCT services use, and infection risk of the sexual partner were administered to the first trimester pregnant women who were HIV infected and living with uninfected partners. Second, 2 weeks before the delivery date, the women were interviewed according to the prior counseling interventions received, in order to assess their behavior on FPS, antiretroviral therapy (ART) use, delivery option, and infant nourishment to be adopted. P-values below 0.05 were considered statistically significant in the statistical analyses.

RESULTS

Of 94 HIV-infected women, 69% were stable couples. Only 13% of women had attended FPS before conception. Although the vast majority were knowledgeable about modern and traditional contraception methods, only 19% had experienced effective contraceptive methods. However, 66% preferred condom use, 45% having three children still expressed a desire to conceive, while 44% reported abortions, 65% had tried to avoid the current pregnancy, and 12% of women were ART naïve. Several predictors such as education, abortion rate, unplanned pregnancies, and partners' decision were associated with the nonuse of effective contraceptive methods. Moreover, barriers including sex inequity, lack of partner support, ART shortages, and lack of HIV viral load monitoring were prevalent among the participants (P=0.001). However FPS use, ART compliance, and safe options to PMTCT significantly increased after the educational counseling interventions (P=0.001).

CONCLUSION

Scaling up the FPS by incorporating routine PMTCT services into reproductive health care should contribute to preventing both horizontal and vertical transmission of HIV.

Addressing gender inequalities to improve the sexual and reproductive health and wellbeing of women living with HIV

INTRODUCTION

Globally, women constitute 50% of all persons living with HIV. Gender inequalities are a key driver of women's vulnerabilities to HIV. This paper looks at how these structural factors shape specific behaviours and outcomes related to the sexual and reproductive health of women living with HIV.

DISCUSSION

There are several pathways by which gender inequalities shape the sexual and reproductive health and wellbeing of women living with HIV. First, gender norms that privilege men's control over women and violence against women inhibit women's ability to practice safer sex, make reproductive decisions based on their own fertility preferences and disclose their HIV status. Second, women's lack of property and inheritance rights and limited access to formal employment makes them disproportionately vulnerable to food insecurity and its consequences. This includes compromising their adherence to antiretroviral therapy and increasing their vulnerability to transactional sex. Third, with respect to stigma and discrimination, women are more likely to be blamed for bringing HIV into the family, as they are often tested before men. In several settings, healthcare providers violate the reproductive rights of women living with HIV in relation to family planning and in denying them care. Lastly, a number of countries have laws that criminalize HIV transmission, which specifically impact women living with HIV who may be reluctant to disclose because of fears of violence and other negative consequences.

CONCLUSIONS

Addressing gender inequalities is central to improving the sexual and reproductive health outcomes and more broadly the wellbeing of women living with HIV. Programmes that go beyond a narrow biomedical/clinical approach and address the social and structural context of women's lives can also maximize the benefits of HIV prevention, treatment, care and support.

Contraceptive Adoption, Discontinuation, and Switching among Postpartum Women in Nairobi's Urban Slums

Unmet need for contraception is highest within 12 months post-delivery, according to research. Using longitudinal data from the Nairobi Urban Health and Demographic Surveillance System, we assess the dynamics of contraceptive use during the postpartum period among women in Nairobi's slums. Results show that by 6 months postpartum, 83 percent of women had resumed sexual activity and 51 percent had resumed menses, yet only 49 percent had adopted a modern contraceptive method. Furthermore, almost half of women discontinued a modern method within 12 months of initiating use, with many likely to switch to another short-term method with high method-related dissatisfaction. Women who adopted a method after resumption of menses had higher discontinuation rates, though the effect was much reduced after adjusting for other variables. To reduce unmet need, effective intervention programs are essential to lower high levels of discontinuation and encourage switching to more effective methods.

Use of HIV counseling and testing and family planning services among postpartum women in Kenya: a multicentre, non-randomised trial

BACKGROUND

Addressing the postnatal needs of new mothers is a neglected area of care throughout sub-Saharan Africa. The study compares the effectiveness of integrating HIV and family planning (FP) services into postnatal care (PNC) with stand-alone services on postpartum women's use of HIV counseling and testing and FP services in public health facilities in Kenya.

METHODS

Data were derived from samples of women who had been assigned to intervention or comparison groups, had given birth within the previous 0-10 weeks and were receiving postnatal care, at baseline and 15 months later. Descriptive statistics describe the characteristics of the sample and multivariate logistic regression models assess the effect of the integrated model of care on use of provider-initiated testing and counseling (PITC) and FP services.

RESULTS

At the 15-month follow-up interviews, more women in the intervention than comparison sites used implants (15 % vs. 3 %; p < 0.001), while injectables were the most used short-term method by women in both sites. Women who wanted to wait until later to have children (OR = 1.3; p < 0.01; 95 % CI: 1.1-1.5), women with secondary education (OR = 1.2; p < 0.05; 95 % CI: 1.0-1.4), women aged 25-34 years (OR = 1.2; p < 0.01; 95 % CI: 1.1-1.4) and women from poor households (OR = 1.6; p < 0.001; 95 % CI: 1.4-1.9) were associated with FP use. Nearly half (47 %) and about one-third (30 %) of mothers in the intervention and comparison sites, respectively, were offered PITC. Significant predictors of uptake of PITC were seeking care in a health center/dispensary relative to a hospital, having a partner who has tested for HIV and being poor.

CONCLUSIONS

An integrated delivery approach of postnatal services is beneficial in increasing the uptake of PITC and long-acting FP services among postpartum women. Also, interventions aimed at increasing male partners HIV testing have a positive effect on the uptake of PITC and should be encouraged.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01694862.

Family planning use and fertility desires among women living with HIV in Kenya

Background

Enabling women living with HIV to effectively plan whether and when to become pregnant is an essential right; effective prevention of unintended pregnancies is also critical to reduce maternal morbidity and mortality as well as vertical transmission of HIV. The objective of this study is to examine the use of family planning (FP) services by HIV-positive and HIV-negative women in Kenya and their ability to achieve their fertility desires.

Methods

Data are derived from a random sample of women seeking family planning services in public health facilities in Kenya who had declared their HIV status (1887 at baseline and 1224 at endline) and who participated in a longitudinal study (the INTEGRA Initiative) that measured the benefits/costs of integrating HIV and sexual/reproductive health services in public health facilities. The dependent variables were FP use in the last 12 months and fertility desires (whether a woman wants more children or not). The key independent variable was HIV status (positive and negative). Descriptive statistics and multivariate logistic regression analysis were used to describe the women’s characteristics and to examine the relationship between FP use, fertility desires and HIV status.

Results

At baseline, 13 % of the women sampled were HIV-positive. A slightly higher proportion of HIV-positive women were significantly associated with the use of FP in the last 12 months and dual use of FP compared to HIV-negative women. Regardless of HIV status, short-acting contraceptives were the most commonly used FP methods. A higher proportion of HIV-positive women were more likely to be associated with unintended (both mistimed and unwanted) pregnancies and a desire not to have more children. After adjusting for confounding factors, the multivariate results showed that HIV-positive women were significantly more likely to be associated with dual use of FP (OR = 3.2; p < 0.05). Type of health facility, marital status and household wealth status were factors associated with FP use. Factors associated with fertility desires were age, education level and household wealth status.

Conclusions

The findings highlight important gaps related to utilization of FP among WLHIV. Despite having a greater likelihood of reported use of FP, HIV-positive women were more likely to have had an unintended pregnancy compared to HIV-negative women. This calls for need to strengthen family planning services for WLHIV to ensure they have better access to a wide range of FP methods. There is need to encourage the use of long-acting reversible contraceptive (LARC) to reduce the risk of unintended pregnancy and prevention of vertical transmission of HIV. However, such policies should be based on respect for women’s right to informed reproductive choice in the context of HIV/AIDS.

Trial registration

NCT01694862

Demand for long acting contraceptive methods among married HIV positive women attending care at public health facilities at Bahir Dar City, Northwest Ethiopia

Background

The use of long acting contraceptive methods (LACMs) is one of the strategies for preventing mother-to-child transmission (MTCT) of HIV. Studies noted that significant proportion of unintended pregnancy among HIV positive women was due to contraceptive failure mainly of short term contraceptives. This highlights the need to use most effective types of modern contraception, long acting contraceptive. However, studies conducted on demand for long acting contraceptive methods in this particular group of people are scarce in Ethiopia. This study aimed to assess demand for long acting contraceptive methods and associated factors among married reproductive age women attending care at Antiretroviral treatment (ART) clinics in public health institutions at Bahir Dar City, Northwest Ethiopia.

Methods

Institution-based cross-sectional study was conducted among 654 systematically selected women attending care in ART clinics in public health facilities at Bahir Dar city from March to April, 2014. A structured and pretested interviewer administered questionnaire was used to collect data. Data were entered using EPI info version 3.5.3 and then exported to SPSS version 16 for analysis. Descriptive statistics were used to describe the socio-demographic and economic characteristics of the study participants. Logistic regression analyses were employed to identify factors associated with demand for long acting contraceptive methods. Odds ratios with 95 % CI were used to assess the presence and strength of association.

Results

A total of 654 respondents have participated in the study (response rate 99. 09 %). The demand for long acting contraceptive methods was 36.7 % (95 % CI: 33.2 %, 40.6 %).

The odds of demand for LACMs among HIV positive women who were living in urban were three times [AOR = 3.05, 95 % CI: 1.34, 6.89] higher than those who were living in rural. The odds of demand for LACMs among the respondents who were in elementary educational level were two times [AOR = 2.31, 95 % CI: 1.34, 3.99] more likely as compared to those who had no formal education. HIV positive women who had four or more alive children were almost four times [AOR = 3.86, 95 % CI: 1.62, 9.20] more likely to have demand for LACMs than those who had one child or had no child at all. Those who had desire to give birth after 2 years were nearly six times more likely [AOR = 5.68, 95 % CI: 3.05, 11.58] to have demand for LACMs and women who had no birth intension were eight times more likely [AOR = 7.78, 95 % CI: 4.15, 14.58] to have demand for LACMs as compared to those who had intention to have birth within 2 years. Women who had past experience on LACMs had six times more likely [AOR = 6.35, 95 % CI: 4.09, 9.87] to have demand for LACMs than those who hadn’t any experience. The odds of demand for long acting contraceptive methods among HIV positive women who had heard myths about LACMs was 55 % less [AOR = 0.45, 95 % CI: 0.29, 0.68] than those women who hadn’t heard myths.

Conclusions

Demand for long acting contraceptive methods in this study was low. There was high unmet need for LACMs. Myths about LACMs were common in the community and were the major barriers for the promotion and utilization of the methods. Demand creation on LACMs and bringing attitudinal change related to myths through provision of information, education and communication are recommended. Moreover, giving greater attention for rural residents is important.

Fertility desires and unmet need for family planning among HIV infected individuals in two HIV clinics with differing models of family planning service delivery

BACKGROUND

Eliminating family planning (FP) unmet need among HIV-infected individuals (PLHIV) is critical to elimination of mother-to-child HIV transmission. We assessed FP unmet need among PLHIV attending two clinics with differing models of FP services. Nsambya Home Care provided only FP information while Mulago HIV clinic provided information and contraceptives onsite.

METHODS

In a cross-sectional study conducted between February-June 2011, we documented pregnancies, fertility desires, and contraceptive use among 797 HIV-infected men and women (408 in Mulago and 389 in Nsambya). FP unmet need was calculated among women who were married, unmarried but had sex within the past month, did not desire the last or future pregnancy at all or wished to postpone for ≥ two years and were not using contraceptives. Multivariable analyses for correlates of FP unmet need were computed for each clinic.

RESULTS

Overall, 40% (315) had been pregnant since HIV diagnosis; 58% desired the pregnancies. Of those who were not pregnant, 49% (366) did not desire more children at all; 15.7% wanted children then and 35.3% later. The unmet need for FP in Nsambya (45.1%) was significantly higher than that in Mulago at 30.9% (p = 0.008). Age 40+ compared to 18-29 years (OR = 6.05; 95% CI: 1.69, 21.62 in Mulago and OR = 0.21; 95% CI: 0.05, 0.90 in Nsambya), other Christian denominations (Pentecostal and Seventh Day Adventists) compared to Catholics (OR = 7.18; 95% CI: 2.14, 24.13 in Mulago and OR = 0.23; 95% CI: 0.06, 0.80 in Nsambya), and monthly expenditure > USD 200 compared to < USD40 in Nsambya (OR = 0.17; 95% CI: 0.03, 0.90) were associated with FP unmet need.

CONCLUSIONS

More than half of the pregnancies in this population were desired. Unmet need for FP was very high at both clinics and especially at the clinic which did not have contraceptives onsite. Lower income and younger women were most affected by the lack of contraceptives onsite. Comprehensive and aggressive FP programs are required for fertility support and elimination of FP unmet need among PLHIV, even with integration of FP information and supplies into HIV clinics.

Strategies for improving postpartum contraceptive use: evidence from non-randomized studies

BACKGROUND

Nearly two-thirds of women in their first postpartum year have an unmet need for family planning. Adolescents often have repeat pregnancies within a year of giving birth. Women may receive counseling on family planning both antepartum and postpartum. Decisions about contraceptive use made right after counseling may differ considerably from actual postpartum use. In earlier work, we found limited evidence of effectiveness from randomized trials on postpartum contraceptive counseling. For educational interventions, non-randomized studies may be conducted more often than randomized trials.

OBJECTIVES

We reviewed non-randomized studies of educational strategies to improve postpartum contraceptive use. Our intent was to examine associations between specific interventions and postpartum contraceptive use or subsequent pregnancy.

SEARCH METHODS

We searched for eligible non-randomized studies until 3 November 2014. Sources included CENTRAL, PubMed, POPLINE, and Web of Science. We also sought current trials via ClinicalTrials.gov and ICTRP. For additional citations, we examined reference lists of relevant reports and reviews.

SELECTION CRITERIA

The studies had to be comparative, i.e., have intervention and comparison groups. The educational component could be counseling or another behavioral strategy to improve contraceptive use among postpartum women. The intervention had to include contact within six weeks postpartum. The comparison condition could be another behavioral strategy to improve contraceptive use, usual care, other health education, or no intervention. Our primary outcomes were postpartum contraceptive use and subsequent pregnancy.

DATA COLLECTION AND ANALYSIS

Two authors evaluated abstracts for eligibility and extracted data from included studies. We computed the Mantel-Haenszel odds ratio (OR) for dichotomous outcomes and the mean difference (MD) for continuous measures, both with 95% Confidence Intervals (CI). Where studies used adjusted analyses for continuous outcomes, we presented the results as reported by the investigators. Due to differences in interventions and outcome measures, we did not conduct meta-analysis. To assess the evidence quality, we used the Newcastle-Ottawa Quality Assessment Scale.

MAIN RESULTS

Six studies met our inclusion criteria and included a total of 5143 women. Of three studies with self-reported pregnancy data, two showed pregnancy to be less likely in the experimental group than in the comparison group (OR 0.48, 95% CI 0.27 to 0.87) (OR 0.60, 95% CI 0.41 to 0.87). The interventions included a clinic-based counseling program and a community-based communication project.All studies showed some association of the intervention with contraceptive use. Two showed that treatment-group women were more likely to use a modern method than the control group: ORs were 1.77 (95% CI 1.08 to 2.89) and 3.08 (95% CI 2.36 to 4.02). In another study, treatment-group women were more likely than control-group women to use pills (OR 1.78, 95% CI 1.26 to 2.50) or an intrauterine device (IUD) (OR 3.72, 95% CI 1.27 to 10.86) but less likely to use and injectable method (OR 0.23, 95% CI 0.05 to 1.00). One study used a score for method effectiveness. The methods of the special-intervention group scored higher than those of the comparison group at three months (MD 13.26, 95% CI 3.16 to 23.36). A study emphasizing IUDs showed women in the intervention group were more likely to use an IUD (OR 1.79, 95% CI 1.20 to 2.69) and less likely to use no method (OR 0.48, 95% CI 0.31 to 0.75). In another study, contraceptive use was more likely among women in a health service intervention compared to women in a community awareness program at four months (OR 1.79, 95% CI 1.40 to 2.30) or women receiving standard care at 10 to 12 months (OR 2.08, 95% CI 1.58 to 2.74). That study was the only one with a specific component on the lactational amenorrhea method (LAM) that had sufficient data on LAM use. Women in the health service group were more likely than those in the community awareness group to use LAM (OR 41.36, 95% CI 10.11 to 169.20).

AUTHORS' CONCLUSIONS

We considered the quality of evidence to be very low. The studies had limitations in design, analysis, or reporting. Three did not adjust for potential confounding and only two had sufficient information on intervention fidelity. Outcomes were self reported and definitions varied for contraceptive use. All studies had adequate follow-up periods but most had high losses, as often occurs in contraception studies.

Fertility desire among HIV-positive women in Tigray region, Ethiopia: implications for the provision of reproductive health and prevention of mother-to-child HIV transmission services

Background

There is growing recognition of the difficult reproductive decisions faced by HIV-positive women. Studies in both resource-constrained and developed countries have suggested that many HIV-positive women continue to desire children in spite of their understanding of the possible risks that HIV poses. This study investigates the factors associated with fertility desire among HIV-positive women in Tigray region, Ethiopia.

Methods

A cross-sectional survey was conducted among 964 HIV-positive women receiving HIV care in 12 health centers of Tigray region. In each health center, the number of study participants was allocated proportionally to the load of HIV-positive women in the chronic care clinics. A descriptive summary of the data and a logistic regression model were used to identify factors associated with fertility desire using odds ratios with a 95% confidence interval and P-value of 0.05.

Results

Four hundred and thirty nine (45.5%) of the participants reported a desire to have children in the future. Eighty six percent of the women had given birth to at least one live baby at the time of study, with the median number of live births being 2 (Inter quartile range = 1,3). Women in the age group of 15–24 years [AOR = 2.64(95% CI: 1.44, 4.83)] and 25–34 years [AOR = 2.37 (95% CI: 1.60, 2.4 3.50)] had higher fertility desire as compared to women in the age group of 35–49 years. Having no children [AOR = 25.76 (95% CI: 13.66, 48.56)], having one to two children [AOR = 5.14 (95% CI: 3.37, 7.84)] and disclosing HIV status to husband/sexual partner [AOR = 1.74 (95% CI: 1.11, 2.72)] were all independently associated with fertility desire.

Conclusions

Age, HIV disclosure status to husband/sexual partner, and relatively few live children were all found to influence HIV-positive women’s fertility desire. Programmers and policy makers should consider the effects of these factors for HIV-positive women as they develop HIV/AIDS interventions.

Effect of HIV status on fertility desire and knowledge of long-acting reversible contraception of postpartum Malawian women

The objectives of this study were to describe the most recent pregnancy intentions and family planning preferences of HIV-infected and HIV-uninfected postpartum Malawian women, and to assess whether HIV status is associated with fertility desire and knowledge of intrauterine contraception (IUC) and the subdermal contraceptive implant. We conducted a cross-sectional analysis of the baseline characteristics of Malawian women enrolled in a prospective cohort study assessing postpartum contraceptive uptake and continuation. Women at a government hospital completed a baseline survey assessing reproductive history, family planning preferences, and knowledge of IUC and the implant. We used Pearson's chi-square tests to compare these parameters between HIV-infected and HIV-uninfected women. Modified Poisson regression was performed to assess the association between HIV status and fertility desire and knowledge about IUC and the implant. Of 634 postpartum women surveyed, HIV-infected women were more likely to report their most recent pregnancy was unintended (49% vs. 37%, p = 0.004). Nearly all women (97%) did not want a child in the next 2 years, but HIV-infected women were more likely to desire no more children (adjusted prevalence ratio [PR]: 1.59; 95% confidence interval [CI]: 1.33, 1.89). HIV-infected women were also less likely to know that IUC (adjusted PR: 0.72; 95% CI: 0.61, 0.84) and the implant (adjusted PR: 0.83; 95% CI: 0.75, 0.92) are safe during breast-feeding. Postpartum women strongly desire family spacing and many HIV-infected postpartum women desire no more children, suggesting an important role for these long-acting methods. Education about the efficacy and safety of IUC and the implant particularly during breast-feeding may facilitate postpartum use.

Contraceptive utilization and associated factors among HIV positive women on chronic follow up care in Tigray Region, Northern Ethiopia: a cross sectional study

BACKGROUND

In sub-Sahara Africa, more than 60% of all new HIV infections are occurring in women, infants and young children. Maternal to child transmission is responsible for 90% of childhood HIV infection. Preventing unwanted pregnancy among HIV positive women is imperative to reduce maternal and infant morbidity and mortality.

METHODS

A cross-sectional survey was conducted among 964 HIV positive women in selected 12 health centers of Tigray region. In this paper, analysis was restricted only for 847 women who were sexually active and non-pregnant. In each health center the number of study participants was allocated proportionally to the load of HIV positive women in chronic care clinics. The data were entered into EpiData version 3.1, and cleaned and analyzed using Stata version 11.1. Descriptive summary of data and logistic regression were used to identify possible predictors using odds ratio with 95% confidence interval and P-value of 0.05.

FINDINGS

Three hundred ninety four (46.5%) of all HIV positive women had intension to have more children. Three hundred seventy five (44.3%) were using contraceptive methods at time of survey. Injectable (70.7%) and male condom (47.6%) were most commonly used type of contraceptives. In the multivariable analysis, women who were urban dwellers (AOR = 2.55; 95% CI: 1.27, 5.02), completed primary education (AOR = 2.27; 95% CI: 1.12, 2.86) and those openly discussed about contraceptive methods with their husbands or sexual partners (AOR = 6.3; 95% CI: 3.42, 11.76) were more likely to use contraceptive. Women who have one or more living children were also more likely to use contraceptive compared with women with no child.

CONCLUSION

Less than half of women used contraceptive methods. The use of condoms could impact unintended pregnancies and reduced risks of vertical and sexual transmission. Efforts to increase contraceptive utilization focusing on the barrier methods should be strengthen in HIV/AIDS chronic care units.

Integration of family planning into HIV services: a synthesis of recent evidence

INTRODUCTION

Increasing access to contraception among women who enter the health system for HIV care is crucial to help them achieve their fertility intentions and reduce vertical transmission of HIV. Identifying intervention strategies that contribute to effective family planning/HIV service integration and synthesizing lessons for future integration programming and research is important to move the field forward.

METHODS

Using a standard review methodology, we searched for articles in the peer-reviewed literature published between January 2008 and August 2013 that addressed the integration of family planning interventions into HIV service settings. Eligible studies were assessed in terms of methodological rigor; documented outcomes; and reported process and cost data.

RESULTS

Twelve studies met our inclusion criteria. Eight studies documented significant increases in contraceptive use by HIV service clients, and three reported significant increases in completed referrals from HIV services to family planning clinics. The outcomes of the seven studies implemented in public sector facilities were more modest than the five studies embedded in clinical trials. Process evaluation measures for some of the studies indicated weak implementation of the intervention as intended. The average rigor score was low, 3.4 out of 9.

CONCLUSION

Our review reveals an expanding evidence base for integrated family planning/HIV service delivery innovations. However, the modest observed effect under typical settings and the evidence of weak intervention implementation emphasize the need for stronger programmatic efforts and implementation research to address the health system obstacles to integrating these two essential services.