|Year : 2020 | Volume
| Issue : 1 | Page : 32-38
Contraceptive use and unmet need for family planning among HIV-positive women: A hospital-based study
Preeti Dugg1, Pragti Chhabra2, Arun Kumar Sharma2
1 Assistant Professor, Department of Community Medicine, DY Patil University, School of Medicine, Navi Mumbai, Maharashtra, India
2 Director Professor, Department of Community Medicine, University College of Medical Sciences, Delhi, India
|Date of Submission||13-Mar-2019|
|Date of Decision||29-Jun-2019|
|Date of Acceptance||06-Dec-2019|
|Date of Web Publication||16-Mar-2020|
Department of Community Medicine, DY Patil University, School of Medicine, Nerul, Navi Mumbai - 400 706, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: For women living with HIV who do not want to become pregnant or who wish to delay pregnancy, contraception has the added public health benefit of reducing the number of infants who might acquire HIV. The unmet need for contraception must be addressed to prevent unintended pregnancies among HIV-positive women and consequently mother-to-child transmission of HIV. Objectives: The objectives of this study were to assess the contraceptive usage and its various determinants and to find out the unmet need for family planning among HIV-positive women. Methods: This was a cross-sectional descriptive hospital-based study conducted among 235 HIV-positive women attending the ART center of a medical college. Data were collected using a questionnaire-containing sociodemographic details, obstetric history, treatment information, contraceptive usage, and their fertility desires. Data analysis was performed using MS Excel and the SPSS version 20.0 using frequencies, Chi-squared test, and multiple logistic regression. Results: The mean (standard deviation) age of the study participants was 28.8 (5.5) years. Majority (96.6%) of them were married and were illiterate (34.4%). The prevalence of unmet need for family planning was found to be 17%, and the prevalence of consistent contraceptive use was 74.5%. The most common family planning method used by women was male condom. Not having HIV-positive children, HIV-negative partner, and discussing contraceptive with partner were observed to be significant predictor of consistent contraceptive use on multiple logistic regression. Conclusion: There is a need to boost family planning counseling and address the unmet need and contraceptive use among HIV-infected women.
Keywords: Contraceptives, HIV, unmet need, women
|How to cite this article:|
Dugg P, Chhabra P, Sharma AK. Contraceptive use and unmet need for family planning among HIV-positive women: A hospital-based study. Indian J Public Health 2020;64:32-8
|How to cite this URL:|
Dugg P, Chhabra P, Sharma AK. Contraceptive use and unmet need for family planning among HIV-positive women: A hospital-based study. Indian J Public Health [serial online] 2020 [cited 2021 May 11];64:32-8. Available from: https://www.ijph.in/text.asp?2020/64/1/32/280762
| Introduction|| |
Globally, around 36.9 million people were living with HIV/AIDS and 1.8 million people became newly infected with HIV at the end of 2017. Every week, around 7000 young women aged 15–24 years become infected with HIV. India has the third-largest HIV epidemic in the world with a total number of people living with HIV estimated at 21.4 lakhs with a prevalence of 0.22% in 2017. Children (<15 years) account for 0.61 lakhs, while the female (15 + years) accounts for 8.79 lakhs people living with HIV in India.
The World Health Organization four-pronged comprehensive strategic approach to prevent the new HIV infections among children and mother-to-child transmission of HIV, deals with the prevention of unintended pregnancies (prong 2). Family planning offers several benefits for all women who want it, regardless of their HIV status. Unmet need for family planning points to the gap between women's reproductive intentions and their contraceptive behavior. Reducing this unmet need will improve the prospects of survival among HIV-infected mothers.
India was the first country in the world to launch “The National Family Welfare Program” in 1951, but even today, the contraceptive use and unmet need for family planning are still not achieved as desired. Contraception is a highly cost-effective HIV prevention strategy, and effective contraception can not only prevent vertical HIV transmission but also avoid abortion and pregnancy-related morbidity and mortality.
Published literature from India suggests that there is inconsistent use of contraceptive methods, resulting in unmet need for family planning and high rates of unintended pregnancies among HIV-positive women. This study aims to address the knowledge gap in this area with the objectives to assess the contraceptive usage and its various determinants and to find out the unmet need for family planning among HIV-positive women.
| Materials And Methods|| |
The facility-based, descriptive, cross-sectional study was conducted at ART Center of a tertiary care hospital from November 2015 to April 2017. Women aged 18–49 years, diagnosed with HIV for not Less than 6 months and attending the ART Center were included in the study. Women who were not sexually active for the past 6 months and who were not fit for the interview were excluded from the study. Based on a published urban hospital-based study in India, the prevalence of unmet need for family planning (P) was found out to be 17%. Taking this prevalence at an absolute error (d) of 4% and with 95% confidence level, minimum sample size (n) of 231 was calculated using Statcalc module of Epi-info 7 software with finite population correction which was rounded off to 235. Both newly registered and those previously registered women meeting the inclusion criteria were included in the study. On each day of data collection, the first two eligible women coming to the center were recruited per day and that fulfilled the minimum required sample size for the study.
A structured interviewer-administered semi-open-ended questionnaire, comprising three tools, was used to collect data from the participants. The first tool recorded the sociodemographic details, obstetric history, a number of alive children, and details about the number of HIV-positive children. The second tool was used to record HIV diagnosis and treatment history like the duration of HIV diagnosis, posttest counseling; ART history; and information about the partner's status and disclosure of the status to partner. The third tool was used to assess the fertility intentions of the women and their sexual partners as well as their knowledge and practice of the modern method of contraceptives. The modern method of contraception includes the use of male condoms, female condoms, oral contraception pills (OCPs), implant, injectable, Intrauterine contraceptive device (IUCD), male sterilization, female sterilization, and emergency contraceptives. Women who were using condom as a contraceptive method were asked how often they used condom, and those who responded using it every time were classified as consistent condom users. Among those who were using any modern contraceptive method, all were considered as consistent contraceptive users except the inconsistent condom users. Unmet need for family planning referred to those fecund women who were not using any contraception (or using it inconsistently) but who wished to postpone the next birth for at least 2 years (unmet need for spacing) or stop childbearing altogether (unmet need for limiting).
The collected data were analyzed using IBM SPSS Statistics for Windows, Version 20.0 (Armonk, NY: IBM Corp). The Chi-squared test was used to test the statistical association of contraceptive use and its various risk factors with a Level of significance as P < 0.05. Fisher's test was applied wherever applicable. To find out the predictors of contraceptive use, binary logistic regression was applied taking contraceptive use as dependent variable. Backward stepwise likelihood ratio model was used, and the criteria for entering and removal of the independent variables from the backward stepwise model were P < 0.05 and >0.10, respectively.
Ethical approval was taken from the Institutional Ethics Committee and informed written consent was obtained from each participant before recruitment in the study. The identity of the respondents was kept anonymous and counseling regarding family planning was given at the end of the interview.
| Results|| |
A total of 235 study participants were included in the present study. Mean (±standard deviation [SD]) age of women was 28.8 (±5.5) years with the majority (160; 68%) between the age group of 26–35 years [Table 1]. Half (115; 49%) of the participants had more than one children at the time of the study and 33 (14%) study participants had one HIV-positive child. Half (122; 51.9%) of the participants were diagnosed within 1–5 years before the study and majority (205; 87.2%) of the participants were given posttest counseling after diagnosis. A CD4 count of more than 500 were found in 101 (43%) participants and among the remaining half, 70 (27.2%) and 64 (29.8%) had CD4 count of more than 350 and 350–499, respectively.
|Table 1: Socio-demographic characteristics of the study subjects (n=235)|
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Majority (228; 97%) of the participants were in a monogamous relationship. However, two participants had more than two sexual partners and only five of them had two sexual partners in the past 6 months. Almost two-third (157; 67.3%) of participants were in a seroconcordant relationship.
Twenty (8.5%) participants found pregnant and of them, six (2.5%) were diagnosed with HIV during the current pregnancy and rest fourteen (5.9%) got pregnant postHIV.
About one-third (64; 27%) of the participants expressed desire to have children in future. Among them, 33 (14.4%) participants wanted it within 2 years and 31 (13.5%) after 2 years. Among those who were pregnant at the time of the study (n = 14), six of them had planned pregnancies, five were mistimed, and three were unwanted pregnancies. Majority of participants (97.4%) discussed their future fertility plans with their sexual partners. About one-third (70; 29.8%) of women reported that their partners had desires for children in future.
Out of a sample of 235 HIV-positive women, 200 (85%) were using any one of the modern contraceptives. Among the users, consistent contraceptive use was seen in 149 (74.5%) study participants. Majority (221; 94.4%) of the study participants had discussed contraceptive use with their partner. Multiple responses were given regarding knowledge of various contraceptive methods and majority of the women were aware of male condoms (218; 92.7%) followed by female sterilization (136; 57.9%), oral contraceptive pills (129; 54.9%), and intrauterine contraceptive devices (121;51.5%). Male sterilization (85;36.1%), injectables (50;21.2%), female condom (3;1.3%), implant (1;0.4%), and emergency contraceptive (7;3%) were the less commonly known types of contraceptives. The highest percentage of the participants (164; 69.7%) heard about contraceptives from health professionals followed by friends (76; 32.3%), Television (45; 19.1%), and partner (31; 13.2%).
The most preferred method of contraception was male condom (186; 93%). About 75% (149) of the participants mentioned using condom every time they had sexual intercourse and rest 37 (18.5%) used it sometimes. Multiple responses were given regarding reasons for the usage of male condoms and majority (157; 84.4%) of the participants were using it to prevent HIV transmission and 142 (76.3%) were using it to prevent future pregnancy. Only 29 (15.6%) participants were using male condoms to avoid sexually-transmitted infections and seven of them did not know the reason for using condom. Majority (131; 71%) of the participants were taking condoms from the pharmacy and only 45 participants (24%) were taking it from ART center itself. Contraceptive use was observed in only one fourth (59; 25%) of the participants before they got diagnosed with HIV and male condom (37; 62.7%) was the most common method used.
Among other methods, OCPs and IUCD were used by five participants each. Forty-six (23%) women were sterilized at the time of the study. None of the participants were using female condoms, injectable, implant, and none of the participant's partner had undergone sterilization. Only three participants mentioned taking emergency contraceptive.
Multiple responses were given regarding reasons for not using any contraceptive method among 35 (14.8%) HIV-positive women at the time of the study. Majority (20; 57.1%) of them said that they were not using any contraceptive because of partner opposition followed by desire for more children (12; 34.3%), lack of awareness of any method (10; 28.6%), infrequent sex (8; 22.8%), lack of awareness of any source (7; 20%), fear of side effects (2; 5.7%), and social prohibition and dissatisfaction with available options was reported by one participant each.
Of the surveyed women, 39 (17%) did not use family planning methods despite not wanting to become pregnant, of whom 13 (5.7%) had unmet need for spacing and 26 (11.3%) for limiting [Figure 1].
|Figure 1: Unmet need for family planning among the study participants* (n = 229). *Six study participants were diagnosed with HIV during current pregnancy and were excluded from the analysis of unmet need.|
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For exploring the association of the contraceptive use with various factors, the participants were divided into two groups as follows: “Consistent contraceptive user” and “Inconsistent contraceptive user.” [Table 2] shows independent variables selected for binary logistic regression by univariate method (Chi-square test) those having a value of P < 0.25.
|Table 2: Variables significantly associated with consistent contraceptive use on univariate analysis (P < 0.25)|
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In binary logistic regression model [Table 3], number of HIV-positive children (adjusted odds ratio [AOR]-2.372, 95% confidence interval [CI] = 1.061–5.302), HIV status of partner (AOR-2.025, 95% CI = 1.049–3.908), and discussion of contraceptive with partner (AOR-10.338, 95% CI = 1.157–92.407) were found to be statistically significant.
|Table 3: Binary logistic regression analyses for predictors of consistent contraceptive use among HIV-positive women (n=235)|
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| Discussion|| |
Unmet need for contraception is an important concept for designing family planning programs and has important implications for maternal and child health, especially in the case of HIV-positive women. This study gives an insight into the contraceptive use and unmet need for family planning among HIV-infected women living in a metropolitan city in India. The study was conducted at ART center functioning under a tertiary care teaching hospital in East Delhi among 235 HIV-positive women, aged 18–49 years, attending the ART center, to assess the prevalence of contraceptive use and its associated risk factors.
The mean (SD) age of the study participants was 28.8 (5.5) years and majority were married at the time of study since there is the universality of marriage in the Indian society. Eighty-one study participants were illiterate which is higher than the state figures (18.2%) for Delhi. Majority of them were homemakers. Almost half of the participants had one or two live children with the mean (SD) number of children being 1.6 (1.14), which is in agreement with the total fertility rate of 1.7 in Delhi.
Unlike the general population, women who know that they are HIV infected, have further issues other than the desire to have children in future to be considered, including possible health risks for reinfections, vertical transmission of HIV and potential orphaning of existing and future children. In our study, about one-third (74; 31%) of the participants expressed desire for future children which is similar in the studies done in India (33.5%), Tanzania (35.6%), and Lesotho (38.7%). Furthermore, similar fertility desires were reported among HIV-positive men and women by Kakaire et al. in Uganda (28.6%); by Wekesa and Coast in Nairobi (26%) and among the HIV-positive women who are ART users (29.2%) and nonusers (24.1%) in West Ethiopia by Polisi et al. This high proportion of fertility desire in our study may reflect the peer and family pressure of having a child in Indian society despite one's HIV status. Since HIV disclosure is associated with stigma and discrimination, and hence, these women might be pressurized by family who were unaware of their HIV status leading to the increased fertility desire among them. Furthermore, the preference for a male child can be a contributing factor.
Unmet need for family planning among HIV-positive women is one of the essential components which contributes to unwanted pregnancy and vertical transmission of the virus to a child. The study reported total unmet need of 17% comprising 11.3% of unmet need for limiting and 5.7% of unmet need for spacing. Our results are consistent with unmet need among married women in DR Congo (17.6%) and South Ethiopia (19.1%) but lower than findings from Amhara (24.6%), Lesotho (31.3%), and Uganda (45.1% and 30.9%). This discrepancy can be attributed to the fact that HIV is more prevalent in women in Sub-Saharan Africa. According to UNAIDS 2016 estimates, women accounted for 56% of new HIV infections among adults in Sub-Saharan Africa, that might have contributed to higher unmet need among them. Our figure is higher than the unmet need for family planning in the general population as reported in the report of NFHS-4. It reported the total unmet need of 12.9% in India, including 7.2% unmet need for limiting and 5.7% unmet need for spacing. In Delhi, it was observed to be 15.8% (unmet need for limiting of 10.9% and unmet need for the spacing of 4.9%). This difference can be explained by the fact that in this study, majority (90%) of women were in the younger reproductive age group (18–35 years), whereas NFHS assesses unmet need only among women who are married and was represented by reproductive age group of 15–49 years, a group whose contraceptive needs and fertility intentions are likely to be very different from those of younger married women.
In this study, we elicited that the prevalence of using any modern method of contraceptive was 85% which is higher as compared to the NFHS-4 data for India (47.8%) and Delhi (47.3%). The higher prevalence in our study can be attributed to the fact that women receiving HIV treatment and care have more regular contact with health-care professionals and they have an opportunity to discuss and commence use of contraception. This could also be because most of the women opt for condoms as their preferred contraceptive choice after being diagnosed with HIV that can increase the overall contraceptive use among them.
Our findings are also in coherence with studies done in Mumbai by Joshi et al., Ghana (85%), South Africa (78%), Southeast Nigeria (73.1%), and Uganda (77.9%). On the contrary, contraceptive use was found to be lower in studies done in West Ethiopia (56.7%), Malawi (51.2%), Nigeria (56.2%), Kenya (53.3%), Ghana (42.6%), Amhara (45.7%), and Ethiopia (56%) among HIV-positive women. The relatively low rate of contraceptive use in these studies may be due to the perceived fear of side-effects associated with some contraceptive methods. Various sociocultural and religious prohibitions, lack of access to the family planning services, and partners opposition to use any method might have also affected the contraceptive use among them.
In contrast to our study, Chakrapani et al. found a higher contraceptive use (95%) among HIV-positive women in a study done in five Indian states (Tamil Nadu, Andhra Pradesh, Maharashtra, West Bengal, and Uttar Pradesh). Similar findings (96%) were observed in South Africa by Oni et al. The higher use may be due to the active promotion of contraceptives during the posttest counseling and subsequent follow-up visits.
The use of modern contraceptives among HIV-positive women may be high in our study, but many of them were not using family planning methods consistently and thus remain at risk of getting pregnant. The prevalence of consistent contraceptive use in our study was found to be 74.5% that points to the fact that many women were not using condom correctly and consistently as a contraceptive. Consistent contraceptive use was also found to be low in other studies in Uganda (58.2%) and DR Congo (35.5%).
Women who had no HIV-positive child were 2.4 times more likely to use the contraceptive method consistently than women who had one or more HIV-positive children in our study. This finding was not assessed by other studies. This could be because women having HIV-positive child in our study were few (14%) and they are afraid of having an unintended pregnancy resulting in an HIV-positive child in future. The study also found that women with an HIV-negative partner had two times odds of using consistent contraception than women who had HIV-positive partner. Similar findings were observed by Ezechi et al. and Heard et al. in France. This might be because in a seroconcordant relationship, in which both partners are HIV positive, the zeal to use contraception to protect the partner from HIV infection is no longer there and thus irregular use of condom. However, considering the possibility of transmitting other strains of HIV and drug resistance strains to an infected partner more efforts need to be put in place to correct the wrong notion. On the contrary, Worke et al. found that women who had HIV-negative partner were 76% less likely to use contraception. The reason might be due to the presence of high partner's opposition in their study setting. Men often play decisive roles in either supporting or hindering the use of contraceptives by their spouses. Thus, communication with a partner is vital to remove challenges such as partner opposition in fertility-related decisions, including the choice of modern family planning. This is in line with our finding that those who discussed contraceptive with their partner were ten times more likely to use consistent contraceptive than those who did not discuss. Our findings were consistent with studies done by Nattabi et al. and Wanyenze et al.
The present study has its own set of limitations. First, it was a cross-sectional study so no real-time temporal association could be established between the contraceptive use and the risk factors. Second, it was a quantitative study and some aspects, especially related to fertility desires and contraceptive use can be brought out better by qualitative studies. Third, there are high chances of having social desirability bias that might have resulted in over-reporting of contraceptive use.
| Conclusion|| |
Unmet need for family planning among HIV-positive women is one of the essential components which contributes to unwanted pregnancy and vertical transmission of the virus to a child. With efficient use of contraceptive methods among HIV-positive women, especially condoms, we can avert the unintended pregnancies and avoid the sexual transmission of HIV to their partners.
We would like to acknowledge the ART staff and all the participants for their full support and cooperation for this research work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]