Menu
Menu
Menu
Menu
Background: In settings where sexually transmitted infection (STI) and HIV prevalence is high, the postpartum period is a time of increased biological susceptibility to pregnancy related sepsis. Enabling women living with HIV to avoid unintended pregnancies during the postpartum period can reduce vertical transmission and maternal mortality associated with HIV infection. We describe family planning (FP) practices and fertility desires of HIV-positive and HIV-negative postpartum women in Swaziland.Methods: Data are drawn from a baseline survey of a four-year multi country prospective cohort study under the Integra Initiative, which is measuring the benefits and costs of providing integrated HIV and sexual and reproductive health (SRH) services in Kenya and Swaziland. We compare data from 386 HIV-positive women and 483 HIV-negative women recruited in Swaziland between February and August 2010. Data was collected on hand-held personal digital assistants (PDAs) covering fertility desires, mistimed or unwanted pregnancies and contraceptive use prior to their most recent pregnancy. Data were analysed using Stata 10.0. Descriptive statistics were conducted using the chi square test for categorical variables. Measures of effect were assessed using multivariate fixed effects logistic regression model accounting for clustering at facility level and the results are presented as adjusted odds ratios.Results: Majority (69.2%) of postpartum women reported that their most recent pregnancy was unintended with no differences between HIV-positive and HIV-negative women: OR: 0.96 (95% CI) (0.70, 1.32). Although, there were significant differences between HIV-positive and HIV-negative women who reported that their previous pregnancy was unwanted, (20.7% vs. 13.5%, p = 0.004), when adjusted this was not significant OR: 1.43 (0.92, 1.91). 47.2% of HIV-positive women said it was mistimed compared to 52.5%, OR: 0.79 (0.59, 1.06). 37.9% of all women said they do not want another child. Younger women were more likely to have unwanted pregnancies: OR: 1.12 (1.07, 1.12), while they were less likely to have mistimed births; OR: 0.82 (0.70, 0.97). Those with tertiary education were less likely to have unwanted or mistimed pregnancies OR: 0.30 (0.11, 0.86). Half of HIV-positive women and more than a third of HIV-negative women reported that they had been using a FP method when they became pregnant with no differences between the groups: OR: 1.61 (0.82,3.41). Only short-acting methods were available to these women before the most recent pregnancy; and available during the postpartum visit. One fifth of all women received an FP method during the current visit. Among the four fifths who did not receive a method 17.3% reported they were already using a method or were breastfeeding. HIV-positive women were more likely to have already started a method than HIV-negative women (20% vs. 15%, p = 0.089).Conclusion: There are few differences overall between the experiences of both HIV-positive and negative women in terms of FP experiences, unintended pregnancy and services received during the early postpartum period in Swaziland. Women attending postpartum facilities are receiving satisfactory care. Access to a wider range of effective methods is urgently needed if high levels of unintended pregnancy are to be reduced among HIV-positive and HIV-negative women living in Swaziland. © 2013 Warren et al.; licensee BioMed Central Ltd.
Data for these analyses are drawn from a baseline study of a four-year multi-country study – the Integra Initiative: which is measuring the benefits and costs of providing integrated HIV and sexual and reproductive health services in Kenya and Swaziland [22]. The study methodology and intervention is described in detail elsewhere [23]. Respondents were recruited between February and August 2010 as part of a prospective cohort study designed to measure the effect of timing and content of an integrated HIV and PNC/FP services model. This model developed explicit linkages with FP services and relevant HIV/AIDS services, for the mother and her baby. The intervention focussed on strengthening existing postpartum consultations during pre-discharge, one week, and six-week, additional consultations were introduced at six months to enable women to access time-relevant services for themselves and their babies. Moreover, information about and encouragement to receive this full package of postpartum services was made during antenatal-care consultations to increase continuum of care of essential services. The services included repeat HIV testing for mother, HIV testing for infant and referral to HIV services for HIV positive mothers and infants, as well as referrals for clients requiring additional services. To assess the impact of service integration, the cohort of women were recruited from health facilities where they had attended for postnatal services and followed over a two year period. However this paper compares the fertility desires, family planning practices, information and services received during postnatal visits including breastfeeding, family planning counselling and uptake among HIV-positive and HIV-negative women using only the cross sectional baseline data. Ten facilities were purposively selected, based on a minimum number of postpartum women attending per month (to be able to achieve the necessary sample sizes) and the availability of HIV, PMTCT, postpartum, FP and immunisation services at these facilities. Samples of women who were at least 18 years old, lived in the facility’s catchment area, had given birth within the previous 0–10 weeks and were receiving PNC for themselves and/or their babies were recruited for interview irrespective of their HIV status. All women attending on the days of data collection were approached for interview consecutively until the requisite sample size was reached. The desired sample size of 989 was calculated to test the larger study hypothesis that exposure to the PNC model of intervention would lead to an increase in condom use by at least 7 percent among sexually active women over two years. A total of 886 women reported that they had been tested for their HIV status. Of these, 503 women reported being HIV-negative and 344 reported being HIV-positive; 29 women did not want to disclose their HIV status and 9 had tested but had not received their results. In addition to using self-reported status of HIV, we sought to validate these reports by examining responses to other questions to identify the services that the women had received during their previous antenatal or current postnatal visits. This process indicated that 42 women who self-reported as being HIV-negative had received HIV related services, suggesting that they were HIV-positive. This paper compares data from the subset of 386 women self-reporting as HIV-positive or assumed to be HIV-positive because of their use of HIV services, with the subset of 483 women self-reporting as HIV-negative and who had not used any HIV services. For the combined sample size of 869 women, the proportion of 44% considered to be HIV-positive mirrors the national HIV prevalence rate. Each eligible respondent, willing to be interviewed, gave their informed consent prior to being interviewed. Teams of trained research assistants conducted the interviews using hand-held personal digital assistants (PDAs) loaded with the questionnaire translated from English into siSwati. The closed-ended questions on fertility desires focussed on the number of children born, whether the woman would like to have another child or not, their desired number of children and when they would like to have their next child. Mistimed or unwanted pregnancies were determined by asking whether, during the last pregnancy, the respondent wanted to be pregnant then, wanted to wait until later or did not want any more children. Women were asked whether they were using any form of contraceptive method prior to their most recent pregnancy and if so which one(s). In addition, they were asked whether they had received any methods during the current visit, their preferred methods and the provider’s actions around FP counselling and service delivery. Women were also asked about their use of postpartum and postnatal services and previous use of STI/HIV services, including their knowledge of STI/HIV counselling and testing services and whether the provider offered counselling and testing for HIV during the current visit, whether the women accepted the test and if not why. Subsequently they were asked if they had been tested before and whether they had received the test results and were willing to disclose their status. The interviewers reiterated that providing this information was entirely optional and their response would be kept strictly confidential as no names or other identifiers were recorded on the data collection instrument; respondents were told that not disclosing their status was not a criterion for exclusion from the study and would not affect their ability to access services at the facility. Data recorded on the PDAs were imported into Microsoft Access and then into Stata 10.0 for analysis. All statistical tests were two-tailed, and interpreted at a 5% confidence level. Two methods of analysis were used. First, FP practices and service use by HIV-positive women was compared according to the time when they learnt their status in order to determine whether knowledge of being HIV-positive was an influence. Secondly, service use by all women was compared by the women’s HIV status. In both approaches, descriptive statistics were conducted using the chi square test for categorical variables; Fisher’s exact test was used for small cell sizes (<5) and a T-test was used to compare means across two groups. Measures of effect were assessed using multivariate fixed effects logistic regression model accounting for clustering at facility level and the results were presented as adjusted odds ratios or incidence rate ratios (IRR). The basic model is given by Equation (1) where πij is the probability of experiencing the outcome for individual i identified from facility j ; Xij is the vector of covariates; β is the associated vector of fixed parameters; and μj are the unobserved characteristics of individual identified from the same facilities. The key outcome variables were previous fertility preferences (unwanted or mistimed births), use of FP when previous pregnancies was unwanted, future fertility intentions, and receipt of FP during current visit. The independent variable of interest was HIV status and was dichotomized into two categories (1 = HIV-positive and 0 = HIV-negative). The model controlled for education, marital status, age and whether they knew their HIV status before or after index pregnancy. Researchers were trained on conduct of ethical procedures and monitored during fieldwork. We obtained informed consent for each study participant. All participants were given detailed information about the study including: aims, methods of study; institutional affiliations of the research; anticipated benefits, risks/discomfort and follow-up of the study; the length of the interview; the choice of not answering any questions and the right to abstain from participating in the study, or to withdraw from it at any time, without reprisal; measures were taken to ensure confidentiality and anonymity of information provided; the conduct of interviews in places of the participant’s choosing to maximize audio privacy; contact details of the study coordinator for any questions or concerns. The study was approved by the Scientific Ethics Committee of the Swaziland Ministry of Health (MOH) (approval number MH/599C), the Ethics Review Committee of the London School of Hygiene & Tropical Medicine (LSHTM) (approval number 5426) and the Population Council institutional review board (IRB approval number 444). The Integra Initiative is registered on the Clinical Trials registration site: ClinicalTrials.gov Identifier: {"type":"clinical-trial","attrs":{"text":"NCT01694862","term_id":"NCT01694862"}}NCT01694862.
N/A
