Nearly all women interviewed indicated that community expectations of fertility differ by HIV infection status. Generally, they felt that their communities expect and support HIV-uninfected women to have children unequivocally. In some instances, the community even pressures a woman to have children, as long as the woman is married, so as to fulfill societal expectations of fertility.
For HIV-infected women, however, our participants reported varying perceptions of community expectations of their fertility. Most women perceived the community to discourage fertility among HIV-infected women, for three major reasons. First, they felt that their communities fear that an HIV-infected woman might die soon, and, therefore, burden the community with the care of their now orphan. Second, they felt their communities are concerned that an HIV-infected woman can transmit the infection to her infant or uninfected spouse while pregnant or attempting conception. Finally, they perceived their community members feared that childbearing might worsen the woman’s health status. Nearly all the women indicated that these community concerns were only communicated to them indirectly.
“The community would not really desire for HIV-infected women to have children as they get worried about you dying and leaving the children under their care. They also see it as a way of spreading the infection because whenever one needs to conceive they do not have protected sex. This makes people to talk a lot behind your back as they cannot face you with whatever they have to say.” 25 year-old, two living children, married from urban area.
“A woman with a positive status is not expected to have more children because it will be considered that the born child would be positive and the woman will die faster, while an HIV-negative woman will be viewed normally because she has nothing to be talked about.” 43 year-old, five living children, married from rural area.
A few women, however, felt that community expectations of their fertility did not differ from uninfected women, largely because their community members were not aware of their positive HIV status. One participant indicated that she perceived minimal community stigma against HIV-infected women, as she considers HIV infection equivalent to other illnesses, such as malaria.
“Stigma around HIV used to happen earlier when we were still girls, but these days I don’t see it happening. These days we see it (HIV) as just malaria, which needs to be treated.” 28 year-old, three living children, married from urban area.
Health provider attitudes towards fertility differ by HIV status
Nearly all women indicated that they perceived health provider attitudes towards fertility also differing by HIV status. They reported that HIV-infected women are routinely discouraged from conceiving until their immunity is “acceptable”.
“Whenever the healthcare providers know that you are HIV positive they advise for a CD4 count, nutrition status, haemoglobin, and weight confirmations. A check is also done for some diseases like diabetes. After these numerous tests, one is given the go ahead to conceive.” 25 year-old, two living children, married from urban area.
“The healthcare providers must first check the CD4 level to verify if she is fit to give birth. Then once she gives birth, some protective measures are taken for the sake of the infant.” 27 year-old, two living children, married from rural area.
Consequently, these women felt that health care providers more frequently recommended contraceptives to HIV-infected women as compared to uninfected women. They perceived providers considering contraception, alongside ART, as a tool in helping to improve the infected women’s immunity to a level where they can conceive safely. Generally, the women agreed that delaying child bearing by using effective contraception, provides them an opportunity to help improve their immunity in the interim; they perceived pregnancy and childbirth as processes that would invariably lower their immunity.
“They (health care workers) will only advise her (an HIV-infected woman) to use contraceptives, such as condoms, and also how to protect the unborn child from being infected. There is a difference in how they (healthcare workers) react to HIV-infected women compared to HIV-negative women…an HIV-infected woman’s life depends much on health care providers’ advice, as compared to an HIV-negative woman who is only advised on how to protect herself from getting infected with HIV.” 26 year-old, three living children, widowed from rural area.
Women’s fertility intentions differ by HIV status
These HIV-infected women perceived their fertility intentions to differ from those of HIV-uninfected women. They indicated that HIV-infected women have several HIV-specific factors to consider before conception, which can be grouped into the following subthemes: 1) health consequences of pregnancy for HIV-infected women; 2) financial stress of pregnancy in HIV-infected women; and 3) emotional and financial burden of already having HIV-infected children.
In contrast to the above HIV-specific factors that HIV-infected women have to consider when considering conception, the participants felt strongly that because HIV-uninfected women are healthier than infected women, they have fewer health-related worries.
“HIV-positive women often have many health problems and that is why they think that when they deliver a baby, the baby will be often affected by health problems too. However, an HIV-negative woman views themselves as without any health problems.” 25 year-old, two living children, married from urban area.
“They have to consider that they are on medication which only aids to prolong their lives so having more children will make their lives difficult. HIV-positive women have a lot of considerations to make when wanting children as compared HIV-negative women who can just have a child whenever she feels like. (Pauses.) HIV-positive women have the thought that they might give birth to infected children or their CD4s might be low hence causing more complications to them.” 27 year-old, two living children, married from rural area.
Below we discuss in detail the three major subthemes of HIV-related factors infected women have to consider before conception.
Health consequences of pregnancy differ for HIV-infected women
First, most women based their fertility intentions on their perceived immune status as the leading factor to consider for any health consequences of a pregnancy. Specifically, these women indicated using their CD4 cell count as a marker of immunity, with a firm belief that conception at low immunity would lead to further deterioration of their health.
“I wanted to have four children before I knew my HIV status, but now that I know my status, even two children are just enough for me. (Laughing) Two are enough for me. I don’t know God’s plan, but I hope God will someday add me one more (child) so that they become three. Right now, my haemoglobin is low and my CD4 is low too. I feel that sometimes I can add children, but then I may die leaving them when they are still young.” 30 year-old, two living children, married from rural area.
“The things that come to mind when deciding on whether or not to have more children is one’s life. One thinks about how their life will be when they conceive. You wonder whether your immunity will be boosted or lowered. People think that once you conceive and the infections come up, you are not able to eat well and this really reduces your CD4 counts.” 25 year-old, two living children, married from rural area.
Second, many women feared that pregnancy-related complications, such as post-partum bleeding, were more likely to occur in HIV-infected as opposed to uninfected women, which would further deteriorate their health.
“I know I can get a child…However, one has to consider how your life will be. One might loose a lot of blood during delivery, and this would be a setback to one’s health.” 25 year-old, two living children, married from rural area.
Third, a few women also pointed out that being in a sero-discordant relationship is itself a deterrent to having more children due to the fear of HIV transmission to their uninfected partner during unprotected sex.
“HIV-positive women think of the status of their spouses, like in my case, I am a widow and I am HIV-positive. Sometimes the man you have is HIV-negative, so you think about whether you will transmit the infection to him or not.” 30 year-old, two living children, widowed from rural area.
“This is the difference in what HIV-negative and positive women must consider when wanting to have children, when an HIV-negative woman has sexual intercourse with her husband she can’t think of anything else. But if you know you are HIV-positive and you want to get pregnant, it’s a must that you avoid condom use. So you must look for information so that you don’t hurt the other person.” 27 year-old, no living children, married from rural area.