Factors influencing uptake of contraceptive implants in the immediate postpartum period among HIV infected and uninfected women at two Kenyan District Hospitals

In this study we demonstrated a good uptake of postpartum implants at 50.3 %, with the uptake being higher among the HIV negative (57 %) than the HIV positive clients (43 %). Although we demonstrated an uptake higher than that found by Dhont et al. in Rwanda (38 %) [6] - who looked at effect of improved access on the uptake of Long Acting Reversible Contraceptives (LARC)- both studies show that improving access to LARC improves their uptake particularly in regards to implants. The uptake in our study is much higher than the current use of contraceptive implants in Kenya where only 1.3 % of the general population is currently using it [5]. Currently, immediate postpartum contraceptive implants are not routinely offered in the postnatal wards of our health care system and are not part of the national FP guideline [7]. Despite proven safety in the use of immediate postpartum contraceptive implants, [8] the Kenya national guidelines on FP which are based on the WHO medical eligibility criteria (MEC), [9] have restricted its use in breastfeeding mothers to 4 weeks postpartum and allowed for its immediate postpartum use only in non-breastfeeding mothers [7]. In view of the high uptake we found when we offered contraceptive implants immediately postpartum, there is need to change this policy so as to improve access to this contraceptive method among both HIV positive and negative women. This will go a long way in reducing the unmet need of FP, high rate of unintended pregnancies and mother to child transmission of HIV. Hopefully the new WHO MEC expected this year will have these changes.

Prior knowledge of implants positively influenced uptake among all participants with those who knew about implants being three times more likely to accept them. This finding is consistent with that of Tanfer who found that interest in the use of implants increased with its knowledge [10]. Similarly, Jacobstein and Stanley attributed the upswing of use of contraceptive implants in Eastern and South African countries in particular Ethiopia and Rwanda to the marked rise in implants knowledge [11]. Educating the public on this method will result in a ripple effect of improving uptake, reducing unintended pregnancies and PMTCT.

On the other hand, spouse approval significantly influenced uptake among all participants and especially among HIV positive clients. Similar findings were found by Bii et al. [12] and Akelo et al. [13], who found that partner involvement and approval was crucial in FP decision making in HIV positive mothers. Mutiso et al. also found that marital status and having a regular sexual partner influenced contraceptive use [14]. This finding emphasizes the importance of individual and couple FP counseling to improve FP uptake and hence achieve PMTCT.

The findings of this study on the factors that influence uptake of contraceptive implants, concur with the argument of Johnson et al. [15] that HIV positive women exhibit fertility desires and contraceptive behavior that are different from other women, and therefore, more needs to be done to understand their specific needs and concerns in order to reduce the unacceptably high rate of unintended pregnancy and achieve the second prong of PMTCT. As demonstrated in this study, different factors influenced uptake of immediate postpartum implants differently among HIV positive and negative mothers. In addition the HIV positive women were more concerned about the potential side effects of implants; this is consistent with the findings of Credé et al. who also found that HIV positive women were concerned of the safety of hormonal FP methods given their health status [16]. Therefore, more needs to be done to understand these factors that influence FP uptake among both HIV positive and negative mothers so that appropriate strategies are put in place to reduce unmet needs of FP.

The main reason for declining to implants insertion among all clients was; wanted to think about it, need to discuss with spouse and wanted to use another method, but among HIV positive clients there was also the fear of side effects. In view of this, proper education on implants as an FP method and its effect on HIV as well as emphasis on spouse involvement needs to be given to this subgroup in order to allay any fears and improve its acceptance.

Consistent with the findings of Peltzer et al. [17] who looked at FP needs of PMTCT clients in resource poor settings in South Africa, we also found high fertility desire among HIV positive clients where more than a half of HIV infected women (67 %) regarded three or more children as ideal family. Similarly, more than a half of HIV positive clients reported higher order pregnancies of 3 and above compared to their HIV negative counterparts. This is not surprising considering they were significantly older than the HIV negative women in the study. This may also explain the ‘replacement phenomenon’ described by Magadi and Agwanda in which HIV positive women tend to get pregnant more frequently so as to replace any child loss resulting from the anticipated increased infant/child mortality [18].

Prong 2 of PMTCT is elimination of unintended pregnancy. This study found an overall rate of unintended pregnancy of 44 %, and 60 % among the HIV positive clients in comparison to Kenya Demographic and Health Survey (KDHS) 2009 that reported an unintended pregnancy rate of 26 %. This finding is consistent with other studies which have shown that HIV positive women are more likely to report higher rates of unintended pregnancies [17‐19]. This can be explained by the fact that HIV positive women regarded 1–2 children as ideal family size yet majority reported their index pregnancy to be of higher order (gravida 3 and above). This study finding has reaffirmed the need for stakeholders to strengthen the 2nd prong of PMTCT.