Pregnancy intention and contraceptive use among HIV-positive Malawian women at 4-26 weeks post-partum: A nested cross-sectional study

PLoS ONE, Volume 14, No. 4, Year 2019

Interpretation

Background Avoiding unintended pregnancies through family planning is a WHO strategy for preventing mother to child transmission of HIV (PMTCT) and maternal morbidity/mortality. We investigated factors associated with unintended index pregnancy, unmet contraceptive need, future pregnancy intention and current contraceptive use among Malawian women living with HIV in the Option B+ era. Methods Women who tested HIV positive at 4–26 weeks postpartum were enrolled into a cross-sectional study at high-volume Under-5 clinics. Structured baseline interviews included questions on socio-demographics, HIV knowledge, partner’s HIV status/disclosure, ART use, pregnancy intention and contraceptive use. Logistic regression was used to determine factors associated with outcomes. Results We enrolled 578 HIV-positive women between May 2015-May 2016; median maternal age was 28 years (y) (interquartile-range [IQR]: 23–32), median parity was 3 deliveries (IQR: 2–4) and median infant age was 7 weeks (IQR: 6–12). Overall, 41.8% women reported unintended index pregnancy, of whom 35.0% reported unmet contraceptive need and 65.0% contraceptive failure. In multivariable analysis, unintended index pregnancy was higher in 35y vs. 14-24y (adjusted Odds Ratio [aOR]: 2.1, 95% Confidence Interval [95%CI]: 1.0–4.2) and in women with parity 3 vs. primiparous (aOR: 2.9, 95%CI: 1.5–5.6). Unmet contraceptive need at conception was higher in 14-24y vs. 35y (aOR: 4.2, 95%CI: 1.8–9.9), primiparous vs. 3 (aOR: 8.3, 95%CI: 1.8–39.5), and women with a partner of unknown HIV-status (aOR: 2.2, 95%CI: 1.2–4.0). Current contraceptive use was associated with being on ART in previous pregnancy (aOR: 2.5, 95%CI: 1.5–3.9). Conclusions High prevalence of unintended index pregnancy and unmet contraceptive need among HIV-positive women highlight the need for improved access to contraceptives. To help achieve reproductive goals and elimination of MTCT of HIV, integration of family planning into HIV care should be strengthened to ensure women have timely access to a wide range of family planning methods with low failure risk. This is a cross-sectional study nested within a nationally representative cohort of HIV-positive Malawian women who were enrolled at 4–26 weeks post-partum in the National Evaluation of the Malawi PMTCT Programme (NEMAPP) study. The parent NEMAPP study used a multistage cluster design to randomly select 54 health facilities across Malawi where mother-infant pairs were consecutively consented, interviewed, and screened for HIV; women testing HIV-positive were invited to participate in the cohort study. In this cross sectional sub-study, we enrolled HIV-positive women presenting with their 4-26-week-old exposed infants at the Under-5 clinics of three government health facilities (1 hospital and 2 health centres) that were purposefully selected because of their large patient volumes and representation of urban and rural settings. Women were interviewed at enrolment on socio-demographics, clinical characteristics, index and future pregnancy intentions and contraceptive use by trained health facility staff using structured questionnaires (S1 Appendix). We defined unintended index pregnancy as the pregnancy of a present 4–26 weeks old infant, which was unwanted or mistimed at the time of conception. Unmet contraceptive need was defined as the proportion of women whose index pregnancy was unintended, but did not report contraceptive use at the time of conception. Future pregnancy intention was defined as the desire to have another child within or after 12 months from the time of enrolment. Current contraceptive use was defined as the proportion of women who were fertile, sexually active and were using a method of contraception to stop child bearing or delay pregnancy for the next 12 months. We designed standardized questionnaires to record socio-demographics, clinical characteristics and family planning-related outcomes of study participants. Exposure variables included age, parity, previous child death, education level, religion, HIV test in index pregnancy, HIV result if tested in index pregnancy, disclosure of HIV status to partner, known HIV status of partner, partner’s HIV result if known, ART in previous pregnancy, timing of ART, health status at ART initiation, and health status at enrolment. Data were pooled across the three sites and the site population effects were not modelled. Our sample also included a small group of women who tested positive during enrolment but reported HIV-negative during index pregnancy, suggesting that they seroconverted later during pregnancy or post-partum. Descriptive statistics were used to characterise study participants and estimate the proportion of each outcome, stratified by socio-demographic and clinical characteristics. Exposure variables which had statistically significant 95% confidence intervals (95%CI) Mantel-Haenszel crude odds ratio for at least one comparison group were considered as potential factors for association with study outcome. We included each potential factor in multivariate logistic models using a step-wise forward algorithm at the significance level of a Likelihood Ratio Test, P <0.05 [25]. Final multivariate logistic models controlled for confounders and risk factors which included age, parity, education level, religion, timing of ART, known HIV status of partner, partner’s HIV result if known, HIV result if tested in index pregnancy, ART in previous pregnancy, health status at ART initiation and future pregnancy intention. Any two given variables were also checked for collinearity, and one variable was omitted if its variance inflation factor was greater than five. Analyses were carried out using Stata version 14.0 (StataCorp, College Station, TX, USA). Ethical approval was obtained from the Malawi National Health Sciences Research Committee (NHSRC, #1262), the Centers for Disease Control and Prevention Center for Global Health Associate Director for Science (#2014-054-7) and the University of Toronto Research Ethics Committee (#30448). Participants provided written informed consent to enrol in the study.

AI Digest

Study Justification:

– The study aims to investigate factors associated with unintended pregnancies, unmet contraceptive need, future pregnancy intention, and current contraceptive use among HIV-positive women in Malawi.
– This research is important because avoiding unintended pregnancies is a strategy recommended by the World Health Organization (WHO) to prevent mother-to-child transmission of HIV and reduce maternal morbidity and mortality.
– The study will provide valuable insights into the prevalence of unintended pregnancies and unmet contraceptive needs among HIV-positive women in Malawi, highlighting the need for improved access to contraceptives.
– The findings will contribute to the development of strategies to integrate family planning into HIV care, ensuring that women have timely access to a wide range of family planning methods with low failure risk.

Highlights:

– The study enrolled 578 HIV-positive women between May 2015 and May 2016.
– The median age of the women was 28 years, and the median parity (number of deliveries) was 3.
– Overall, 41.8% of the women reported unintended index pregnancy, with 35.0% reporting unmet contraceptive need and 65.0% experiencing contraceptive failure.
– Factors associated with unintended index pregnancy included age (higher in women aged 35 and above), parity (higher in women with three or more deliveries), and partner’s HIV status (higher in women with a partner of unknown HIV status).
– Unmet contraceptive need at conception was higher in younger women (aged 14-24), primiparous women (those with no previous deliveries), and women with a partner of unknown HIV status.
– Current contraceptive use was associated with being on antiretroviral therapy (ART) in a previous pregnancy.

Recommendations:

– Improved access to contraceptives: The study highlights the need for improved access to contraceptives for HIV-positive women in Malawi to reduce unintended pregnancies and unmet contraceptive needs.
– Strengthen integration of family planning into HIV care: To achieve reproductive goals and eliminate mother-to-child transmission of HIV, it is recommended to strengthen the integration of family planning services into HIV care. This will ensure that women have timely access to a wide range of family planning methods with low failure risk.

Key Role Players:

– Ministry of Health: Responsible for policy development and implementation of reproductive health programs.
– Health facility staff: Involved in providing family planning services and counseling to HIV-positive women.
– Community health workers: Play a crucial role in raising awareness about family planning and providing information to women in the community.
– Non-governmental organizations (NGOs): Support the implementation of reproductive health programs and provide resources and training to health facilities.

Cost Items for Planning Recommendations:

– Training and capacity building for health facility staff: Budget for training programs to enhance the knowledge and skills of health facility staff in providing integrated family planning and HIV care services.
– Contraceptive commodities: Allocate funds for the procurement and distribution of a wide range of contraceptives to ensure availability and accessibility for HIV-positive women.
– Information, education, and communication materials: Budget for the development and dissemination of educational materials to raise awareness about family planning and promote informed decision-making among HIV-positive women.
– Monitoring and evaluation: Allocate resources for monitoring and evaluating the implementation and impact of integrated family planning and HIV care services.
– Support from donor agencies: Seek financial support from donor agencies to supplement government funding for the implementation of integrated reproductive health programs.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a cross-sectional study nested within a nationally representative cohort of HIV-positive Malawian women. The study used a multistage cluster design and enrolled a large number of participants. The study also used logistic regression to determine factors associated with outcomes. However, to improve the evidence, the abstract could provide more information on the sampling method used in the parent NEMAPP study and the representativeness of the sample. Additionally, the abstract could include information on the response rate and any potential limitations of the study.

Abstract

This is a cross-sectional study nested within a nationally representative cohort of HIV-positive Malawian women who were enrolled at 4–26 weeks post-partum in the National Evaluation of the Malawi PMTCT Programme (NEMAPP) study. The parent NEMAPP study used a multistage cluster design to randomly select 54 health facilities across Malawi where mother-infant pairs were consecutively consented, interviewed, and screened for HIV; women testing HIV-positive were invited to participate in the cohort study. In this cross sectional sub-study, we enrolled HIV-positive women presenting with their 4-26-week-old exposed infants at the Under-5 clinics of three government health facilities (1 hospital and 2 health centres) that were purposefully selected because of their large patient volumes and representation of urban and rural settings. Women were interviewed at enrolment on socio-demographics, clinical characteristics, index and future pregnancy intentions and contraceptive use by trained health facility staff using structured questionnaires (S1 Appendix). We defined unintended index pregnancy as the pregnancy of a present 4–26 weeks old infant, which was unwanted or mistimed at the time of conception. Unmet contraceptive need was defined as the proportion of women whose index pregnancy was unintended, but did not report contraceptive use at the time of conception. Future pregnancy intention was defined as the desire to have another child within or after 12 months from the time of enrolment. Current contraceptive use was defined as the proportion of women who were fertile, sexually active and were using a method of contraception to stop child bearing or delay pregnancy for the next 12 months. We designed standardized questionnaires to record socio-demographics, clinical characteristics and family planning-related outcomes of study participants. Exposure variables included age, parity, previous child death, education level, religion, HIV test in index pregnancy, HIV result if tested in index pregnancy, disclosure of HIV status to partner, known HIV status of partner, partner’s HIV result if known, ART in previous pregnancy, timing of ART, health status at ART initiation, and health status at enrolment. Data were pooled across the three sites and the site population effects were not modelled. Our sample also included a small group of women who tested positive during enrolment but reported HIV-negative during index pregnancy, suggesting that they seroconverted later during pregnancy or post-partum. Descriptive statistics were used to characterise study participants and estimate the proportion of each outcome, stratified by socio-demographic and clinical characteristics. Exposure variables which had statistically significant 95% confidence intervals (95%CI) Mantel-Haenszel crude odds ratio for at least one comparison group were considered as potential factors for association with study outcome. We included each potential factor in multivariate logistic models using a step-wise forward algorithm at the significance level of a Likelihood Ratio Test, P <0.05 [25]. Final multivariate logistic models controlled for confounders and risk factors which included age, parity, education level, religion, timing of ART, known HIV status of partner, partner’s HIV result if known, HIV result if tested in index pregnancy, ART in previous pregnancy, health status at ART initiation and future pregnancy intention. Any two given variables were also checked for collinearity, and one variable was omitted if its variance inflation factor was greater than five. Analyses were carried out using Stata version 14.0 (StataCorp, College Station, TX, USA). Ethical approval was obtained from the Malawi National Health Sciences Research Committee (NHSRC, #1262), the Centers for Disease Control and Prevention Center for Global Health Associate Director for Science (#2014-054-7) and the University of Toronto Research Ethics Committee (#30448). Participants provided written informed consent to enrol in the study.

Materials

https://efashare.b-cdn.net/materials/9560e0c1fe46c09b3706c8b4eb2cea5ae474cc622a96e7f94297ff9224b3c1af/pone.0215947.s001.pdf

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Integration of family planning into HIV care: Strengthening the integration of family planning services into HIV care can ensure that HIV-positive women have timely access to a wide range of family planning methods with low failure risk. This can help prevent unintended pregnancies and reduce the risk of mother-to-child transmission of HIV.

2. Improved access to contraceptives: There is a need to improve access to contraceptives for HIV-positive women. This can be achieved through various strategies such as increasing the availability of contraceptives at health facilities, training healthcare providers on contraceptive counseling, and addressing barriers to contraceptive use, such as stigma and misinformation.

3. Targeted interventions for specific age groups and parity: The study found that unintended index pregnancy and unmet contraceptive need varied among different age groups and parity. Developing targeted interventions for specific age groups and parity can help address the unique needs and challenges faced by these women in terms of family planning and contraceptive use.

4. Partner involvement and HIV status disclosure: The study identified partner’s HIV status disclosure as a factor associated with unmet contraceptive need. Promoting partner involvement in family planning decision-making and encouraging HIV status disclosure can help improve access to contraceptives and support HIV-positive women in making informed choices about their reproductive health.

5. Strengthening healthcare infrastructure: Improving access to maternal health requires a strong healthcare infrastructure. This includes ensuring the availability of skilled healthcare providers, adequate resources and supplies, and well-functioning health facilities. Investing in the strengthening of healthcare infrastructure can contribute to improved access to maternal health services for HIV-positive women.

It is important to note that these recommendations are based on the specific findings and context of the study mentioned. Implementing these innovations would require further research, planning, and collaboration among stakeholders in the field of maternal health.

AI Innovations Description

Based on the description provided, the recommendation to improve access to maternal health is to strengthen the integration of family planning into HIV care. This will ensure that HIV-positive women have timely access to a wide range of family planning methods with low failure risk. The study found a high prevalence of unintended index pregnancy and unmet contraceptive need among HIV-positive women, highlighting the need for improved access to contraceptives. By integrating family planning services into HIV care, healthcare providers can address the reproductive goals of HIV-positive women and contribute to the elimination of mother-to-child transmission of HIV. This can be achieved by training healthcare staff to provide comprehensive family planning counseling and services, ensuring the availability of a variety of contraceptive methods, and promoting the use of contraceptives among HIV-positive women.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Strengthen integration of family planning into HIV care: Given the high prevalence of unintended pregnancies and unmet contraceptive needs among HIV-positive women, it is crucial to integrate family planning services into HIV care. This can be done by ensuring that women have timely access to a wide range of family planning methods with low failure risk.

2. Improve access to contraceptives: To address the unmet contraceptive needs, efforts should be made to improve access to contraceptives. This can be achieved by increasing the availability and affordability of contraceptives in both urban and rural settings. Additionally, efforts should be made to educate women about the different contraceptive options available to them.

3. Enhance HIV education and partner involvement: Providing comprehensive HIV education to women and their partners can help in reducing unintended pregnancies. This includes educating them about the importance of HIV testing, disclosure of HIV status, and the role of antiretroviral therapy (ART) in preventing mother-to-child transmission of HIV. Partner involvement is also crucial in ensuring effective contraceptive use and family planning.

To simulate the impact of these recommendations on improving access to maternal health, a methodology can be developed as follows:

1. Define the indicators: Identify the key indicators that will be used to measure the impact of the recommendations. This may include indicators such as the percentage of women with unintended pregnancies, unmet contraceptive needs, and current contraceptive use.

2. Collect baseline data: Gather baseline data on the selected indicators from the target population. This can be done through surveys, interviews, or data collection from health facilities.

3. Implement the recommendations: Roll out the recommended interventions and strategies to improve access to maternal health. This may involve training healthcare providers, increasing the availability of contraceptives, and strengthening the integration of family planning into HIV care.

4. Monitor and evaluate: Continuously monitor and evaluate the impact of the implemented recommendations on the selected indicators. This can be done through follow-up surveys, data collection, and analysis.

5. Analyze the data: Analyze the collected data to assess the changes in the selected indicators after the implementation of the recommendations. This may involve statistical analysis, such as comparing pre- and post-intervention data, and calculating the percentage change in the indicators.

6. Draw conclusions and make recommendations: Based on the analysis of the data, draw conclusions about the impact of the recommendations on improving access to maternal health. Identify any gaps or areas for improvement and make further recommendations for future interventions.

7. Disseminate findings: Share the findings of the impact assessment with relevant stakeholders, such as policymakers, healthcare providers, and community members. This can help in advocating for further investment and support for interventions to improve access to maternal health.

Author

Dima Health

Statistics:

Citations: 3

Identifiers:

DOI: 10.1371/journal.pone.0215947

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Malawi

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study, Quasi Experimental Study

Study Approach:

Quantitative

Participants Gender:

Female