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

Globally, studies estimate that 75% of all HIV-positive people are of reproductive age. Sub-Saharan Africa is home to60% of all people living with HIV/AIDS, and more than half of these are females [1]. In Ethiopia, for example, the prevalence of HIV/AIDS among women of reproductive age (1.9%) is higher than men (1.0%) in the same age [2]. Thus, interventions to meet the reproductive health needs, and specifically the needs relating to a desire to have children of this population group need to be prioritized as many HIV-positive women continue to want to have babies despite knowledge of their HIV status [3]-[7].

Evidence indicates that HIV-positive women continue to desire more children in the future, though to differing degrees in different contexts. In two studies conducted in Canada and Malawi, for example, the proportions of HIV-positive women who wanted to have children in the future were 69% and 17%, respectively [4],[5]. In Ethiopia, different studies have indicated different levels of fertility desire among HIV-positive women. A study in North Wollo, Ethiopia, demonstrated that 15.7% of HIV-positive women had fertility desire [8]. By contrast, 44% of HIV-positive women in Addis Ababa wanted more children [6], as compared to 53% of women in Harari region [7], and 92% of women in Oromia region, Ethiopia [3]. Studies in a number of settings have pointed to different factors which determine the fertility desire of HIV-positive women. For example, young age of HIV-infected individuals is significantly associated with increased fertility desire [4],[9]-[13]. Decreased fertility desire is associated with divorce or separation, as well as having at least one child [4],[12]-[14]. HIV disclosure to a woman’s sexual partner has also been associated with her having increased fertility desire [11],[14]. Sero-discordance could also affect fertility desire of couples [15]. A further study indicated that educational status was not significantly associated with fertility desire among HIV-positive women [13], while good perceived health status, and CD4 count more than or equal to 200 cells/mm³ were found to be significantly associated with increased fertility desire [14],[16].

Evidence about the association between Antiretroviral Therapy (ART) use and fertility desire is mixed, however, with some studies indicating that there is no association between the two [8],[13],[14],[16],[17], and others suggesting that commencement of ART was one of the reasons for women’s increased fertility desire, due to an improved quality of life [6],[10].

In Ethiopia, a number of studies have been conducted to investigate fertility desire of people living with HIV/AIDS [3],[6]-[8],[15],[18],[19]. However, none of these studies has been conducted on a large scale, incorporating a number of health facilities covering large demographic areas with socio-cultural diversity. The present study addresses this gap in the knowledge base by incorporating a number of health facilities covering all zones of the region, and with a large sample size.

The main aim of this study is to assess the extent of, and the factors associated with fertility desire among HIV-positive women in Tigray region, Ethiopia. This is necessary in order to help stakeholders engaged in Sexual and Reproductive Health programs and policies, such as regional health bureaus and non-governmental organizations working on HIV/AIDS and family planning, to make evidence-based decisions about the interventions they are running. Specifically, it is important to ensure that the necessary resources and programs for improved reproductive health services, such as Prevention of Mother-to-Child Transmission (PMTCT) of HIV and family planning services for HIV-positive women, are in place, and that they are as integrated into AIDS care services as current Regional health policy requires them to be. It is hoped that this will lead to a better quality of life for HIV-positive women, decrease levels of vertical HIV transmission to children, and ultimately reduce maternal and child mortality.

In this study, 45% of the HIV-positive women we surveyed desired to have children in the future. This finding is lower than findings from similar studies in Swaziland, 60% [24]; Uganda, 59% [9] and 72% [30]; and Canada, 69% [4]; while it is higher than the figures derived from studies conducted in Tanzania, 36% [14]; Uganda, 10% [12], 19% [31], and 29% [11] and Malawi, 17% [5]. In Ethiopia, various studies have reported different level of fertility desire. A similar level was reported in Addis Ababa (44%) [6]; a lower level was reported in Northern Ethiopia (24%) [18] and South Wollo (15.7%) [8]. Higher rate of fertility intention (92.3%) was also reported in Oromia region [3]. A study in Harari region indicated that 52.9% of women had fertility desire [7]. The reasons for these differences are not clear, but they are likely to be the products of specific socio-cultural and/or economic factors - or the differential expressions of these - in each setting.

Our findings indicated that ART use was not significantly associated with fertility desire, and neither was CD4 count, even though both of these would have led to or indicated improved health. These findings were consistent with studies (including a meta-analysis) conducted in Tanzania, Ethiopia, Malawi [8],[13],[14],[16],[17]. The important issue, therefore, may not have been the women’s clinical status, but rather, perhaps, their socio-demographic characteristics and fertility history.

Other studies have found the factors predicting fertility desire to include, for example, the desire to have children of both sexes, the desire for a large family, pressure from family or partner to have children [32], and a child being thought of as a prerequisite for a fulfilled and happy life [33]. The most important factors predicting fertility desire in our study population, by contrast, included age, disclosing HIV status to husband/sexual partner, and having no or few living children.

After adjusting for other variables, we found that age of women was significantly associated with fertility desire. Women of younger age had higher odds fertility desire compared to older women. This finding is similar from those of a methodologically diverse series of studies from Uganda and Canada, which indicate that young, HIV-infected women experience significantly more fertility desire than HIV-infected, older women [4],[9]-[12]. In Ethiopia, some studies demonstrated the presence of an association between age and fertility desire [6],[7], while another study reported that such an association was not present [8].

In the current study, women who disclosed their HIV status to their husband/sexual partner had higher odds of having fertility desire. HIV disclosure to a woman’s sexual partner has also been associated with her having increased fertility desire [11],[14]. A study in Ethiopia has reported the same finding [8], probably because communication between partners may play an important role in pre-conception planning behaviors [34]. Additionally, it is important to understand the positive impact of communication on partner participation in PMTCT programmes [35],[36]. Thus, interventions to promote the reproductive health of HIV-positive women in Ethiopia should continue to promote positive couple communication about HIV status.

Our finding that women who had no children, or who had one or two children, were much more likely to desire babies than women who had more than two children, was also expected: similar findings have been reported in a number of different countries [4],[12]-[14],[17],[37], including in Ethiopia [6],[7],[16],[19]. This could be that in some communities, such as Ethiopia, a child is thought of as a prerequisite for a fulfilled and happy life [33].In some African communities, satisfying desired family size, desire for biological children, maintaining stability of the union, and socio-cultural pressures were important reasons for continuing fertility desire among HIV-positive women [38].

An important finding of our study was that slightly more than half of these HIV-positive women reported that they did not want to have children in the future. Several reasons were given for this, with two of the most important being insufficient financial security and a fear of further deterioration in their health [10]. In other words, these women may have wanted children had their financial and health circumstances been better, a finding which may also be reflected in the wider HIV-negative female population in the region. Counseling on safer contraceptive methods for these women will have important reproductive health implications.

The current study found that 40.2% of HIV-positive women had an unmet need for contraceptives. This represents a potentially serious public health problem. It is essential that the contraceptive needs of these women are met, so that they may avoid the anxieties and possible health risks associated with an unwanted pregnancy. The health workers providing their chronic AIDS care must be made aware of this, and a range of contraceptive options should be made available, as well as all the associated information about these options.

It is important to note some limitations of this study. First, men were not included in the study, in spite of the essential role they can play in deciding about the size of their family. Second, health service providers, whose attitudes and perceptions could have a direct or indirect influence on fertility desire in this population, were not also included. Structural components of the health system and service provision quality would also be important considerations in future studies on this topic.

This study is also limited to women who are receiving chronic, long term care for their HIV infection. Fertility desire among these women could be very different from women who are not receiving such care. In addition, small numbers of HIV-positive women who are not ART users were not specifically powered to detect differences in terms of their fertility desire. Lack of comparison to HIV-negative women may also be seen as a limitation.

This study has identified two discrete groups of HIV-positive women in Tigray region, Ethiopia, with very clear and differing requirements from the health services. One of these groups, constituting 45% of the 964 women surveyed, report that they want to have children in the future; while the other group, made up of the remaining 55% of the women, say that they do not want to have children. The factors associated with fertility desire in the former group included being young, having no children, and disclosing HIV status to their husband/sexual partner; while the primary reasons for the women in the latter group not wanting to have children were insufficient financial security, having `enough’ children already, and a fear of deteriorating health.

These findings have important implications for sexual and reproductive health policy and practice in Tigray. Tigray regional SRH policy stipulates that services should be fully integrated into existing HIV/ART care and it is important that this integration is maintained and strengthened in practice. This strengthening could include ensuring that health workers are well informed about the possible effect of the factors identified in this study that are associated with HIV-positive women’s desire either to have children or not. Full information about the possible risks of having a baby should be provided to all HIV-positive women, but in a way that protects their reproductive rights, and ensures that any decision to conceive is supported all the way through the pregnancy, birth, and post-natal period. Meanwhile, for those HIV-positive women who do not desire to have children, a range of family planning method options should be made accessible from all HIV/AIDS care units.

Further research on this topic should include qualitative studies that would provide a deeper understanding of HIV-positive women’s fertility desires. One important aspect of this would be the possible role of health care workers in ensuring that the rights of HIV-positive women are protected, and that their desires and decisions to have children, or not to have children, are supported. In addition, further studies should consider including a comparison with HIV-negative women.