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Background: Little is known about the impact of knowledge of HIV serostatus on pregnancy intention and contraceptive use in high-HIV-burden southern African settings in the era of widespread antiretroviral treatment availability. Methods: We analyzed interview data collected among 473 HIV-uninfected and 468 HIV-infected pregnant and recently postpartum women at two sites in southern Botswana. Participants were interviewed about their knowledge of their HIV status prior to pregnancy, intendedness of the pregnancy, contraceptive use, and future childbearing desires. Results: The median age of the 941 women was 27 years, median lifetime pregnancies was 2, and 416 (44 %) of pregnancies were unintended. Among women reporting unintended pregnancy, 36 % were not using a contraceptive method prior to conception. Among contraception users, 81 % used condoms, 13 % oral contraceptives and 5 % an injectable contraceptive. In univariable analysis, women with unintended pregnancy had a higher number of previous pregnancies (P = <0.0001), were less educated (P = 0.0002), and less likely to be married or living with a partner (P < 0.0001). Thirty-percent reported knowing that they were HIV-infected, 48 % reported knowing they were HIV-uninfected, and 22 % reported not knowing their HIV status prior to conception. In multivariable analysis, women who did not know their HIV status pre-conception were more likely to report their pregnancy as unintended compared to women who knew that they were HIV-uninfected (aOR = 1.7; 95%CI: 1.2-2.5). After controlling for other factors, unintended pregnancy was not associated with knowing one's HIV positive status prior to conception (compared with knowing one's negative HIV status prior to conception). Among women with unintended pregnancy, there was no association between knowing their HIV status and contraceptive use prior to pregnancy in adjusted analyses. Sixty-one percent of women reported not wanting any more children after this pregnancy, with HIV-infected women significantly more likely to report not wanting any more children compared to HIV-uninfected women (aOR = 3.9; 95%CI: 2.6-5.8). Conclusions: The high rates of reported unintended pregnancy and contraceptive failure/misuse underscore an urgent need for better access to effective contraceptive methods for HIV-uninfected and HIV -infected women in Botswana. Lower socioeconomic status and lack of pre-conception HIV testing may indicate higher risk for unintended pregnancy in this setting.
This was a planned analysis of baseline data collected in a prospective observational cohort study of child health and neurodevelopment (“Tshipidi” study: a Setswana word meaning “a journey of a thousand miles begins with one step”). This study was funded by the National Institute of Mental Health at the National Institutes of Health, R01MH087344. In total, 475 HIV-uninfected and 474 HIV-infected pregnant and recently postpartum women aged 18 years and older and their infants were enrolled between 2010 and 2012 at 28 antenatal clinics and 5 maternity wards in two locations in Botswana: the capital city Gaborone and in the large village of Mochudi, which is 45 km North of Gaborone. As part of the main cohort study, mothers and infants were followed for two years to evaluate the effect of maternal HIV status on child health and neurodevelopmental outcomes. Participants were enrolled antepartum (n = 805 (84.8 %)) or within seven days of delivery (n = 144 (15.2 %)). The current analysis utilizes data from structured questionnaires administered privately at enrollment by trained study nurses at the time of enrollment. To measure pregnancy intendedness, the primary outcome, all women were asked “Were you trying to become pregnant when you conceived the baby?” This yielded a combined category of unintended pregnancy, which included mistimed and unwanted pregnancies, irrespective of whether contraception was being used. Women who reported that they were not trying to become pregnant at the time of conception were also asked whether they were using contraception and the specific contraceptive method type was documented. We considered women as having experienced contraceptive failure or misuse (including poor adherence), if they reported that the current pregnancy was unintended and that they were using contraception prior to the pregnancy. Women were considered as having an unmet need for family planning if they reported that the current pregnancy was unintended and that they were not using contraception prior to the pregnancy. Women’s self-reported knowledge of HIV status prior to becoming pregnant was recorded as “known HIV-infected”, “known HIV-uninfected” or “unknown HIV status.” HIV status at the time of study enrolment was also determined by confirmatory testing on all participants. We performed basic descriptive analyses, including a comparison of study enrolment characteristics stratified by maternal knowledge of HIV serostatus prior to becoming pregnant, and intendedness of pregnancy. We used logistic regression to estimate univariable and multivariable-adjusted odds ratios (OR) and 95 % confidence intervals (CI) for pregnancy intendedness. We considered several covariates that likely temporally preceded the current pregnancy and birth and might also be associated with knowledge of HIV status prior to becoming pregnant and pregnancy intendedness. Therefore, we included all of the following variables in the multivariable-adjusted model as potential confounders: enrollment site, age, relationship status, educational level, employment status, income, household size, household assets, and lifetime number of pregnancies and history of a child dying after birth but before five years of age. All statistical analyses were conducted using SAS software version 9.3 (SAS Institute, Cary, NC). In secondary analyses, we used the same process to assess the relationship between a) maternal knowledge of HIV serostatus prior to becoming pregnant and contraceptive use and b) HIV status at enrollment and future childbearing desires in multivariate-adjusted analyses. Ethics approval for the Tshipidi study was obtained from the Office of Human Research Administration (OHRA) at the Harvard School of Public Health and the Health Research Development Committee at the Botswana Ministry of Health. All women provided written informed consent prior to study participation. Only unique study identifiers were used in the database.
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