Factors Associated with Pregnancy Intentions Amongst Postpartum Women Living with HIV in Rural Southwestern Uganda

The second prong of the WHO strategy to eliminate mother to child transmission of HIV (EMTCT) is to prevent unplanned pregnancies for women living with HIV (WLWH). HIV treatment and care makes it safer for WLWH to have the children they desire, while provision and appropriate use of effective contraception are important strategies to prevent unintended pregnancies. There remains an unmet need for family planning among WLWH in Uganda [1], where the modern contraceptive prevalence rate for married women overall is 35% [2]. Less than half of sexually-active WLWH accessing ART in a large Ugandan cohort used effective contraception, of which 44% relied on male condoms [3].

Pregnancy incidence of 9.40 per 100 women years has been reported within 4 years following ART initiation amongst WLWH in Uganda [4]. Almost half of these incident pregnancies (45%) were unplanned [5]. In this same cohort, unplanned pregnancy was not associated with subsequent effective contraceptive use postpartum, with only half of the women with unplanned pregnancies and 44% with planned pregnancies reporting effective contraception postpartum. Other studies report up to 85% of pregnancies occurring within 3 years following ART initiation as unwanted [6]. Although increasing desires to have children are reported amongst mutually-disclosed serodiscordant couples in Uganda [7], couples often disagree in their perceptions of each partner’s plans for pregnancy, understandings of HIV transmission, and acceptable level of HIV risk to meet their reproductive goals [8]. While supported pregnancies are an important part of life for many HIV-affected couples, unwanted and/or unplanned pregnancies can lead to poor maternal and child outcomes including perinatal HIV transmission, pregnancy complications, and increased economic burden of care for self and others among others.

Previous studies have investigated individual and partner-level predictors collected prior to pregnancy, including pregnancy desire [1], and contraception uptake [3, 5]. However, understanding individual and or partner characteristics that influence pregnancy intentions in the immediate postpartum period among WLWH may be important to informing policy, promoting contraceptive counselling and uptake postpartum. In this paper, we examine individual and partner characteristics associated with pregnancy intentions in the next 2 years amongst recently postpartum WLWH delivering at a large clinical center in rural southwestern Uganda. We also describe the history, patterns and perception of prior contraception use. These data may inform integrated programs to support WLWH by providing counselling and contraception access for postpartum women.

Among adult postpartum WLWH in southwestern Uganda, we found that 59% report personal or partner desire for another child in the next 2 years. In a rural setting where fertility rates are among the highest in the world, intent to have more children was strongly associated with perceived partner desire for more children, previous planned pregnancy, and higher household income. Previous use of modern contraception, increasing age, parity of three or more and having more than two children living in the household were independently associated with reduced odds of reporting intent to have another child in the next 2 years. This analysis highlights the importance of comprehensive family planning that addresses fertility desires and the key role played by male partners, household income, parity and previous exposure to modern contraception among WLWH.

The importance of male partners in influencing reproductive decision-making has been described. Generally, and regardless of serostatus, male partners have been shown to have great influence on having another child, but receive minimal counselling about the benefits of spacing, options for safer pre and conception practices [8, 25‐27]. Nieves and colleagues also noted that partner’s fertility desire was independently associated with women’s contraceptive use [3]. In our study, perceived male partner desire for future pregnancy was associated with a 31-fold increased odds in female plans for pregnancy. It was also noted that over 99% of the women who reported their own desire to have more children also reported their partner’s desire to have more children. However, a study by Snow and colleagues, published in 2013 based on data from rural Uganda, reported that marriage partners of WLWH were less likely to want more children than partners of HIV-negative women, with WLWH more likely to report discordant preferences for no more children even when their partners wanted more kids [1]. These findings were noted regardless of whether the women were on ART. In our study however, all women were enrolled on ART, with mean ART duration and CD4 count of 4.5 years [SD = 3.9] and 395 cells/mm³ [SD = 62] respectively. This overwhelming success of eMTCT programming and treatment in Uganda and possible reduction in stigma for PLWH who want to have children may explain the higher percentage of WLWH reporting desires to have more children (54%) in our study compared to 28% reported by Snow and colleagues. The perceived partner desires for more children were also higher (58%). Such higher fertility intentions could further be attributed to lower stigma levels (28%), improved social support (median = 2.4, IQR = 2.1–2.8) and high HIV disclosure rate (88%) observed within this population, highlighting the importance of integrating comprehensive family planning care into HIV and antenatal, postnatal and paediatric care for WLWH and their families.

Men in Uganda have often been regarded as unsupportive of their partner’s use of family planning [28] and some studies show that poor communication within partnerships may make it challenging for men to be involved [8]. In our study, 78% of the women reported that their partners knew they were on family planning, the rest choosing not to disclose it, while 14% of the sexual partners reportedly disapproved their partners using contraception. Half of the women who reported previous use of family planning used injectables. Some studies have shown that providing men with supportive opportunities to access information on safer conception practices by health care providers is key in influencing their pregnancy intentions, attitude and uptake of reproductive health services [27, 29]. Their active involvement in reproductive health has been facilitated by a clear understanding and integration of the existing gender-based and socio-cultural norms into routine sexual and reproductive health programs [30]. This approach according to Onyango and colleagues makes services more male-friendly, while helping to debunk negative traditional beliefs surrounding reproductive health practices thus supporting the health of men and women and families. Training of male peer trainers and mobilisers has also been found to improve contraceptive uptake [31]. Other attempts to actively involve men in reproductive health and maternity care have shown to improve their decision making, presence during antenatal visits, postpartum visits, childbirth, and the initiation of breastfeeding within 1 h of birth, leading to better maternal and new born outcomes [32, 33]. These carefully thought out strategies to actively engage male partners in sexual and reproductive programs, coupled with improved access to appropriate information and effective contraception could therefore be crucial to realising positive outcomes championing better contraceptive uptake to prevent unintended/unplanned pregnancies amongst WLWH in Uganda. The couple’s improved awareness of their health risks, contraception use benefits and the available HIV prevention and conception strategies could also guide and influence their decision on when or if to have another child in the future. Indeed in our adjusted model, previous use of modern contraception was independently associated with reduced pregnancy intentions within 2 years postpartum, alongside increasing age, parity or children living in a particular household. Additionally, the higher rate of planned pregnancies (83%), coupled with a high pregnancy desire observed in this population emphasise the vital need to counsel WLWH and their spouses not only about contraception but also opportunities for safer conception. The observed high rate of injectables on the other hand shows how much women rely on this method and the importance of understanding the reasons for its preference as well as the effects of ART on levels of hormonal therapy.

The impact of HIV on pregnancy intentions is affected by underlying fertility norms and beliefs about the importance of child bearing in a society with or without ART [34, 35]. In Uganda, the key role of boy child bearing and number of children born for example, has been well documented [35]. In this study, factors such as bearing of own children or having a considerable number of children (at least 3) < 18 years of age living in a particular household or increasing parity were indeed associated with suppressed pregnancy intentions alongside age within this study population. These findings are in line with previous studies showing decreased fertility aspirations with the economic burden of caring for children below 18 years of age in a household [1, 36]. However, a person’s ability to generate regular or more income, overcome barriers to provide basic needs like food, shelter, medicines and instrumental social support has been found to positively-impact households of persons living with HIV [37, 38]. This eased economic burden and improved quality of life may therefore explain a key role played by increasing household incomes in predicting women’s greater interest in having more children in future observed in this study.

Food security and social support received, which seemed to significantly influence pregnancy desires were edged out in a regression model probably due to their known interdependent association with adherence among people living with HIV [38]. The low CD4 count < 250 cells/mm³ and duration on ART also seemed important in diminishing pregnancy intentions within 2 years postpartum in unadjusted model but looked to be greatly dependent on other factors like food security, social support, partner desires and contraception use, which edged them out in the multivariate analysis.

This work presents baseline data for an ongoing randomized controlled trial at a publicly-funded and operated hospital in a rural low-resource setting that delivers over 12,000 women annually from various social and demographic backgrounds, making results generalizable to similar settings. The population of postpartum WLWH with a high proportion of pregnancy intentions also enabled us to document the effect of age, duration on ART, CD4 count, disclosure, parity, living with children in a homestead, perceived spousal pregnancy desires, planned pregnancy, household income, prior use of modern contraception and mode of referent delivery within a multivariate model.

There were also limitations to this work. Individual and perceived spousal desires to have more children were both reported by the study participant. There is therefore a possibility that assumptions about partners desiring more children was skewed depending on the structural or cultural underpinnings/understanding of the roles and women’s identity of child bearing with in this setting. There may also have been an under report of pregnancy intentions due to stigma of WLWH and fear of being reprimanded by health care providers especially immediately after child birth. Women may also be less interested in subsequent child bearing within a few days postpartum.

Our findings highlight the striking role male partners play in influencing pregnancy intentions postpartum alongside income, planned pregnancy, age, parity and previous contraceptive use amongst WLWH in modern Uganda. In adjusted analysis, perceived male partner desire for future pregnancy was associated with a 31-fold increased odds in female plans for pregnancy. It is therefore very important to accept gender norms in this context, actively engage male partners in sexual and reproductive health counselling about child spacing for the health of women, children, and families alongside individual-level social, economic and structural factors within which couples can ably and supportively understand the risks of unplanned pregnancies and thus access reliable contraceptive methods whenever they need or want them. The high rate of planned referent pregnancy and future plans for pregnancy noted in this population of WLWH on ART requires integration of these reproductive health services into routine HIV care, which could also improve access to contraception and minimise the burden (time and money) spent looking for such services by WLWH. Additionally, the observed high rate of injectables shows how much women rely on this method and the importance of understanding the effects of ART on levels of hormonal therapy.