Factors Associated with Pregnancy Intentions Amongst Postpartum Women Living with HIV in Rural Southwestern Uganda

Comprehensive HIV treatment and care makes it safer for women living with HIV (WLWH) to have the children they desire, partly through provision and appropriate use of effective contraception. However, nearly one third of WLWH in-care in a large Ugandan cohort became pregnant within 3 years of initiating ART and half of these incident pregnancies (45%) were unplanned. We therefore describe future pregnancy plans and associated factors among postpartum WLWH in rural southwestern Uganda in order to inform interventions promoting postpartum contraceptive uptake. This analysis includes baseline data collected from adult WLWH enrolled into a randomized controlled trial to evaluate the effect of family planning support versus standard of care at 12 months postpartum in southwestern Uganda. Enrolled postpartum WLWH completed an interviewer-administered questionnaire at enrolment. Among 320 enrolled women, mean age, CD4 count, and duration on ART was 28.9 (standard deviation [SD] 5.8) years, 395 cells/mm3 (SD = 62) and 4.6 years (SD = 3.9), respectively. One-hundred and eighty nine (59%) of women reported either personal (175, 55%) or partner (186, 58%) desire for more children in the next 2 years. Intentions to have more children was strongly associated with partner’s desire for more children (AOR = 31.36; P < 0.000), referent pregnancy planned (AOR = 2.69; P = 0.050) and higher household income > 150,000 Shs per month (AOR = 1.37; P = 0.010). Previous use of modern contraception (AOR = 0.07; P = 0.001), increasing age (AOR = 0.34; P = 0.012), having > 2 own children living in a household (AOR = 0.42; P = 0.021) and parity > 2 (AOR = 0.59; P = 0.015) were associated with reduced odds of pregnancy intention. Our findings highlight the role male partners play in influencing pregnancy intentions postpartum and the importance of engaging men in sexual and reproductive health counselling about child spacing for the health of women, children, and families. This should be addressed alongside key individual-level social, demographic, economic and structural factors within which couples can understand risks of unplanned pregnancies and access effective contraceptive methods when they need or want them. This analysis includes baseline data collected from WLWH enrolled in a randomized controlled trial in southwestern Uganda. The parent trial aims to evaluate the effect of family planning support versus standard of care on contraceptive use at 12 months postpartum ({“type”:”clinical-trial”,”attrs”:{“text”:”NCT02964169″,”term_id”:”NCT02964169″}}NCT02964169). All study procedures were conducted at the Mbarara Regional Referral Hospital (MRRH), a publicly-funded teaching hospital in rural southwestern Uganda serving 10 districts with a population of over 5 million people. The hospital delivers over 12,000 babies annually, with a maternal HIV prevalence of 10.2% (MRRH records). This study was initiated in October 2016 and enrolment ended in May 2017. Follow-up of participants is ongoing. Eligible participants were WLWH women ≥ 18 years of age, admitted in a postnatal ward at MRRH within 5 days postpartum regardless of pregnancy outcome and qualified for any family planning methods available. The exclusion criteria included: (1) HIV negative, (2) history of hypersensitivity to latex, (3) no male sexual partner and/or not anticipating one for the next 2 years, (4) only sexual partner has had vasectomy and (5) inability to complete informed consent process as assessed by the study nurses. Trained research assistants (RAs) approached WLWH in postnatal ward at least 12 h after delivery. RAs obtained voluntary written informed consent from all eligible participants. All consenting participants gave written informed consent, or for those who could not write, a thumbprint was made on the consent form. We screened 378 WLWH and enrolled a total of 320 who were equally randomized into the intervention arm (Family planning support) and standard of care (control group) between October 2016 and May 2017. These women are being followed for 1 year. All participants completed baseline interviewer-administered interviews and phlebotomy for CD4 cell count and to confirm HIV sero-status. Interviews were conducted by two trained research assistants fluent in English and the main local language in a private office space. Each interview took about 30–45 min. Data was collected electronically. A transport refund of $3 was given on each visit. The primary outcome of interest, pregnancy intention in the next 2 years, was assessed using the CDC Pregnancy Risk Assessment Monitoring System Instrument [9–11]. This particular question was asked in two ways, (1) through a Linkert scale (5-point) asking women to agree or disagree with a given statement, “I still want to give birth to more children in the next 2 years”. To create a binary response, agree or strongly agree was coded as “yes” while all other responses, including “neither agree or disagree”, were coded as “no”. A second question was, “Would you like to have another child/children in the next 2 years?” with an expected response of yes/no. Regression analysis of both responses from the two questions generated identical outcomes, thus confirming the internal validity and consistency of the two measures. For the current analysis, we used responses for the direct question, “would you like to have another child/children in the next 2 years?” as our primary outcome of interest referred to as “pregnancy intention”. A blood sample was drawn at baseline to confirm the HIV status and measure CD4 cell count. A structured face-to-face questionnaire was completed at enrollment to collect information on socio-demographics, depression, health [12], reproductive history, partnership dynamics (e.g. HIV serostatus disclosure, partner HIV-serostatus), perception, use and knowledge of contraception, decision making [4, 6, 13–18], food insecurity [19, 20], alcohol use in the last 9 months [21], HIV stigma [22], and social support [23]. A primary partner was defined either as the “main partner”, who is also a regular sexual partner, or the most recent sexual partner if no main partner was named. Modern family planning was defined as use of contraceptive pills, male/female Condoms, diaphragm, cervical cap, intrauterine device (IUD), contraceptive implant, injectables & emergency contraception methods to limit or space the number of children one would wish to have. We describe demographic and clinical data for the cohort using standard descriptive statistics. We assessed the prevalence and covariates of reporting pregnancy intentions in the next 2 years. The Household Food Insecurity Access Scale (HFIAS) was calculated as recommended [24]. Univariable logistic regression was used to assess unadjusted associations between covariates and pregnancy intentions, expressed using crude odds ratio and 95% confidence intervals. Variables with p value ≤ 0.10 in unadjusted analyses were considered for inclusion in a multivariable logistic regression analysis. Variables examined in the unadjusted model found to be collinear were selectively excluded from the multivariate models or added one at a time to observe their respective effect. A sub-analysis to establish the effect of partner pregnancy intentions was also done. Statistical significance was defined at the level of p ≤ 0.05. All data analyses were performed using STATA version 12.0 (Statacorp, College Station, Texas, USA). This study was approved by the Institutional Review Council of Mbarara University of Science and Technology and Uganda National Council of Science and Technology, and registered with clinicaltrials.gov ({“type”:”clinical-trial”,”attrs”:{“text”:”NCT02964169″,”term_id”:”NCT02964169″}}NCT02964169).