Menu
Menu
Menu
Menu
Historically, women living with HIV (WLWH) have been vulnerable to biased advice from healthcare workers regarding contraception and childbearing. However, antiretroviral therapy (ART) has made motherhood safer, prompting a re-examination of whether contraceptive services enable the realisation of WLWH’s reproductive intentions. We use longitudinal quantitative data on contraceptive choice and use, and childbearing intentions collected in (up to) six interviews between entry into antenatal care (ANC) and 18 months post-partum from a cohort of 471 ART-initiated WLWH in Cape Town, South Africa. Thirty-nine of these women were randomly selected for in-depth interview where they described experiences of contraception services and use. We find high prevalence of injectable contraceptive (IC) use after birth (74%). With increasing post-partum duration, greater proportions of women discontinue this method (at 18 months 21% were not using contraception), while desires for another child remain stable. We find little consistency between method choice and use: many women who elected to use the intrauterine device, sterilisation or oral contraceptives at first ANC visit are using IC after birth. Women commonly report receiving an IC shortly after birth, including those who had previously chosen to use another method or no method. Among WLWH, injectables dominated the contraceptive method mix. Despite a human rights-grounded policy and attempts to introduce new methods, contraceptive services in South Africa remain largely unchanged over time. Women are frequently unable to make autonomous contraceptive choices. Despite low desires for future pregnancy, we observed high rates of contraceptive discontinuation, resulting in heightened risk of unintended pregnancy.
We used the concept of “quality of care”20 as an underlying basis for the study in order to examine the extent to which contraceptive services are meeting the needs of WLWH. We used three out of the six dimensions outlined by Jain21 in their quality of care framework for family planning services: choice of contraceptive methods, information given to the user and provider–client relations. (The remaining three elements in this framework are the technical competence of providers, patient follow-up mechanisms and an appropriate constellation of family planning services). The framework outlines how contraceptive users should have access to long-term and short-term contraceptive methods, hormonal and non-hormonal methods and both female- and male-controlled methods. With regard to information and counselling, users should be given information about contraindications, risks, benefits and side effects of the various methods. The dimension of provider–client relations describes how users should feel trusting and positive about their interactions with healthcare staff.21 We examined the quality of care in terms of its impact upon women’s patterns of contraceptive use, as well as the extent to which women are able to realise their right to reproductive autonomy.22 This was a mixed-methods study that used quantitative data from the Maternal-Child Health Antiretroviral Therapy (MCH-ART) study (a randomised trial evaluating strategies for delivering HIV care and treatment services to pregnant and post-partum WLWH) and qualitative data from in-depth interviews conducted with a subset of women enrolled in the MCH-ART cohort. The MCH-ART study took place at the Midwife Obstetric Unit (MOU) at the Gugulethu Community Health Centre (CHC) in Cape Town, South Africa. The CHC serves a historically disadvantaged community with a high burden of HIV. Among women attending the CHC’s antenatal care (ANC) clinic in 2015, the HIV prevalence was 33%.23 The CHC has offered PMTCT services since 2001, and the vertical transmission rate is estimated to be 2–4%. The MCH-ART study and methods have been described in detail previously.24 Women were enrolled into the MCH-ART study if they were seeking ANC at the study clinic, were living with HIV and eligible to initiate ART. In order for them to be eligible for ongoing participation in the research post-partum, they needed to have initiated ART and be breastfeeding (the MCH-ART study also examined the effect of HIV care on breastfeeding practices). The study followed 471 women from their first ANC visit (enrolment took place between 20th March 2013 up to 3rd April 2014) until 18 months post-partum. In this research, we made use of data on contraceptive use and childbearing intentions collected during (up to) seven study visits, the first taking place at first ANC visit and the remaining six visits taking place over an 18-month post-partum period. These study visits took place separately from routine antenatal, postnatal or ART services at a large, primary-level antenatal and obstetric facility. Women participated in face-to-face interviews, where study staff administered standardised questionnaires. Data on demographic characteristics and intended future contraceptive use were collected at first ANC visit. Participants were permitted multiple responses to the question on intended future contraceptive use, which was designed to capture intentions to use dual protection (i.e. a hormonal method in combination with a barrier method). At each following visit in the post-partum period, women reported on current contraceptive use and childbearing intentions. From the contraceptive use data, we generated a variable that identified a woman’s current use of contraception that is classified in the following way: (i) none, (ii) injection (both the two-month and three-month options), (iii) IUD (either the hormonal or copper method), (iv) female sterilisation, (v) implant and (vi) oral contraceptive. Reporting of condom use as a contraceptive method was inconsistent, so we did not include these data. Childbearing intention was recorded using a 4-point scale measuring future desire, categorised as (i) unsure, (ii) definitely do not want to become pregnant in the future, (iii) may want to become pregnant in the future and (iv) definitely do want to become pregnant in the next 12 months. In order to understand women’s reproductive intentions and the relationship between reproductive intentions and patterns of contraceptive use, we examined the distribution of childbearing desires and corresponding patterns of contraceptive use at the six study visits. We then compared the percentage distribution of women’s intended method of contraception at first ANC visit with the percentage distribution of methods used at one week post-partum. This gave insight into the extent to which services are meeting women’s prenatal contraceptive intentions. We conducted 39 in-depth interviews with a subset of women who we randomly selected from the list of participants enrolled in the MCH-ART study (the audio recording of a 40th interview was faulty and could not be transcribed). These interviews took place between 12 and 29 months post-partum. During the interviews women were asked to describe their feelings about planning pregnancies, lifetime use of contraception and experiences getting contraception in clinics. We also asked questions about their pregnancy and childbearing history, their future childbearing intentions, and about HIV and its relationship with motherhood, although this data is not included in this research paper. All of the interviews were conducted in isiXhosa, away from the clinic to ensure that the respondents felt free to report any negative experiences that they may have had with healthcare workers. The interviews were recorded and then simultaneously translated and transcribed. We conducted a thematic analysis of the interview transcripts in NVivo. First, two members of the research team separately coded 10 transcripts. Both researchers worked independently to identify and highlight key concepts and ideas to build initial codes. Second, they both collaborated in revision, editing, renaming and regrouping of these early codes to form the final coding structure used for the main analysis. This final coding structure was used to code the remaining 29 interview transcripts. In addition to the creation of codes, we wrote analytic memos which recorded our ideas about patterns, categories, concepts and themes in the data.25 These further informed the analysis of the transcripts. Ethical clearance for this study was given by the University of Cape Town Human Research Ethics Committee and the Columbia University Institutional Review Board (IRB). All participants provided written informed consent prior to participation, and women participating in the qualitative component signed an additional consent for the in-depth interview.
N/A
