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Prevention of unintended pregnancies is a global strategy to eliminate mother-to-child transmission of HIV. Factors surrounding unintended pregnancy among women living with HIV are not well understood. We aimed to determine the prevalence and predictors for unintended pregnancy among these women in Northern Uganda. We conducted a cross-sectional survey among 518 women using a structured questionnaire. We asked questions on socio-demographic, reproductive-related and HIV-related characteristics. We conducted multivariable logistic regression and reported adjusted odds ratios. The prevalence of unintended pregnancy was 41.1%. The predictors for unintended pregnancy were: being single (not living with a partner or being in a marital union), having five or more children and taking antiretroviral drugs for long periods of time. HIV counselling services should target women living with HIV who are not in a marital union, those having a higher parity and those who have taken ART for longer periods.
We conducted a cross-sectional study among HIV infected pregnant women between August 2018 and July, 2019. The exposures of interest were potential predictors which included socio-demographic, reproductive-related and HIV-related factors. The outcome of interest was unintended pregnancy. We calculated a sample size for detecting a difference between two independent proportions using Stata version 14.0 (StataCorp; College Station, TX, USA). We utilized the statistics, power and sample-size functions. Using the population parameter method with the test of comparing two independent means (0.576 vs. 0.315), we assumed 80% power, 95% confidence interval (CI) and 5% precision. We also assumed that 57.6% of WLH were not in a marital union33 and that 31.5% of HIV infected women were married24. On running this calculation in the statistical software, we arrived at a sample size of 464. We adjusted the sample size to 516 after accounting for a 10% non-response. We however, included 518 HIV positive pregnant women who were receiving antenatal care at Lira Regional Referral Hospital (LRRH). LRRH serves all the 8 districts of the Lango subregion in Northern Uganda. It is a government-owned health facility at tertiary level that offers health services including maternal and child health services like HIV care, antenatal care and delivery. These services are at no cost to the patients. LRRH also has an annual outpatient attendance of almost 100,000 patients, annual antenatal care attendance of about 5,000 women and conducts approximately 6–7,000 deliveries annually. HIV infected women were identified, consented and recruited consecutively through the existing Ugandan HIV treatment, care and support program for pregnant women at the PMTCT clinic located within LRRH. Women were eligible for participation if they were: 20 weeks pregnant or more, newly tested for HIV or already established in ART care. Those who were severely ill at the time of recruitment were excluded from the study and referred to appropriate care services. The interviews were conducted in Lango (the main language spoken in the study setting) or English by trained study staff. Interviews consisted of socio-demographic related, reproductive-related and HIV-related information. All measures were translated into Lango and back-translated into English to ensure accuracy and minimise interpretation bias. All procedures of the study were performed in accordance with the guidelines and regulations pertaining to all relevant approving bodies. Unintended pregnancy, the main outcome of the study, was defined in any of the following ways: a pregnancy that occurred when no more children were desired or one that occurred earlier than it was desired or one that occurred when the woman did not desire to become pregnant. We adapted questions from the London Measure of Unplanned Pregnancy, a psychometrically validated measure of the degree of intention of a current or recent pregnancy. Women were asked if the pregnancy came ‘earlier than expected’, ‘later than expected’, ‘when expected’ or ‘not desired at all’. Women who had their pregnancy at the ‘time desired’ or ‘later than expected’ were combined, labelled as the ‘intended’ category and coded 0. Women with an ‘earlier than desired’ or ‘unwanted pregnancy’ were combined into a single group, labelled “unintended pregnancy” and coded 1. Contraceptive use, was defined as any contraceptive method used in the 6 months preceding the pregnancy at the time. Unmet need for contraception was defined as those women who experienced unintended pregnancy and did not use any form of contraception 6 months prior to the pregnancy. Marital status was categorised into married and single. Those who were married or cohabiting were combined into one group, labelled “married” and coded 1. Those who were separated, divorced, widowed or not married were combined into one group, labelled “single” and coded 2. Women who had been pregnant for four or less times including miscarriages, abortions and the pregnancy at the time of the interview were collectively categorised and coded 1 for the variable “parity”, else were coded 2. Duration on treatment was categorised as “< 6 months”, “7–30 months”, “31–119 months” and “≥ 120 months”. Duration on ART of ≥ 120 months (10 years) was referred to as long-term ART use34,35 for comparability purposes. We created a composite index of wealth (socio-economic status) using principle component analysis (PCA). Because the PCA technique allows combination and ranking of a number of variables into smaller and fewer variables without prejudgment, it is considered a more accurate indicator of socioeconomic status than single items such as occupation or possession of particular items36. We used PCA on house ownership, availability of electricity in the house, source of drinking water and fuel used for cooking. Scores were obtained and categorized into four groups (quartiles) ranging from the poorest to the least poor. Data were entered into EpiData software (www.epidata.dk, version 4.4.3.1) by two independent data entrants and exported for analysis into Stata version 14.0 (StataCorp, College Station, Texas, U.S.A.). Continuous data, if normally distributed, was summarised into means and standard deviations and if skewed, was summarised into medians with their corresponding interquartile ranges. Categorical variables were summarised into frequencies and percentages. The proportion of HIV infected women with unintended pregnancies was estimated and its confidence limits calculated using the exact method. We used multivariable generalized linear model regression analysis with a logit link to estimate the adjusted odds ratios of the independent variables on unintended pregnancy while controlling for confounding. All variables with p < 0.25 at the bivariate level were included in the initial model at the multivariate analysis. All variables with p < 0.1 and those of biological or epidemiologic plausibility (from previous studies) were included in the second model. We checked for confounding by calculating the percentage change in each effect measure by removing or introducing one variable at a time into the second model. If a variable caused more than 10% change in any effect measure, then it was considered a confounder. Using the Likelihood-ratio test, we found that the first and second models were not significantly different. Therefore we adopted the second model as our final model. We used the visual inspection factor to check for collinearity among all the variables that were included in the initial model. Approval to conduct the study was granted by the Makerere University School of Medicine Research and Ethics Committee, the Norwegian Regional Committee for Medical and Health Research Ethics in the West, and the Uganda National Council for Science and Technology. Meetings were held with the Lira district health officer and LRRH director to grant administrative clearance to conduct the study. Additional meetings were held with the counsellors who work within the PMTCT clinic to introduce to them the study and its procedures and to request them to identify, mobilise and link willing participants with the research team. All participants provided written informed consent confirming their voluntary participation in the study. Those that declined participation were not penalised or denied standard health care. Confidentiality and privacy of all data collected was observed during the course of the study through restricted access.
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