Research Article: Differential Impacts of HIV status on short-term fertility desires among couples in Rakai, Uganda

Date Published: January 24, 2019

Publisher: Public Library of Science

Author(s): Xiaoyu Song, Stephanie A. Grilo, Sanyukta Mathur, Tom Lutalo, Robert Ssekubugu, Fred Nalugoda, John S. Santelli, Mellissa H. Withers.


Fertility desires of female and male partners in current relationships are often correlated. We examined the influence of HIV seropositive status of female and male partners on short-term fertility desires in Rakai, Uganda, a setting with high fertility and HIV infection rates.

Participants were couples (15–49 years old) enrolled in the Rakai Community Cohort Study, from 2011 to 2013 (n = 2,291). Cohen’s kappa coefficient was used to measure the correlation of female and male partners’ short-term fertility desires (measured as ‘wanting a child in the next 12 months’), in both total sample and stratified serostatus groups. HIV serostatus and additional characteristics of female and male partners were included in Poisson regression models to estimate the rate ratios (RR) for each partner’s short-term fertility desires. Individual and partner characteristics included HIV status, partner HIV status, age in years, partner age in years, educational attainment, number of living children, community of residence, and socioeconomic status (SES).

Short-term fertility desires among female and male partners were moderately associated (Kappa = 0.37, p-value<0.001). The association was weakest among female sero-positive and male sero-negative couples (Kappa = 0.29, p-value<0.001). When adjusting for parity and other covariates in the model, women’s short-term fertility desires were significantly associated with their positive sero-status regardless of male partners’ sero-status (adjRR = 1.58, p<0.001 for F+M-; adjRR = 1.33, p = 0.001 for F+M+; in comparison with F-M-). Men’s short-term fertility desires were significantly associated with their positive sero-status, in addition to their female partners’ positive sero-status (adjRR = 1.23 with p-value = 0.022 for F-M+; adjRR = 1.42 with p-value<0.001 for F+M-; adjRR = 1.26 with p-value<0.001 for F+M+; in comparison with F-M-). When the differential effect of parity was included in the model, similar associations remained for both female and male partners when the number of living children was small, but largely reduced when the number of living children was large (3 or more). Female and male partners in couple dyads demonstrated moderate agreements about short-term fertility desires. The HIV seropositive status of female partners was most strongly associated with short-term fertility desires of both genders, and this association was even stronger for women who had few or no living children.

Partial Text

Reproduction is dyadic in nature. People incorporate their partner’s reproductive desires into their own intentions and adjust their pregnancy-seeking/avoiding behaviors.[1] In Sub-Saharan Africa (SSA), patriarchal gender norms often lead men to be the dominant influencers in decision-making issues related to fertility and family planning,[2] despite women’s central socio-biological roles in the reproduction and procreation processes.[3] Moreover, when partner desires differ, men’s preferences around pregnancy intentions, planning and prevention tend to be more influential than women’s preferences and desires.[4] Studies that fail to address the differentiating roles of men and women in fertility decisions miss opportunities to understand key relationship dynamics related to family planning and reproductive health, potentially leading to inefficient programing aimed at reducing unintended fertility and maximizing women’s reproductive choices.

We analyzed 2,291 couples; of these, 46.3% were from smaller rural trading villages (rural) with approximately 12% HIV prevalence. Approximately 18.5% were from larger trading centers serving as local and regional transport hubs (trading) with approximately 20% HIV prevalence, while the remaining 35.2% were from high risk fishing communities on Lake Victoria (fishing) with approximately 42% HIV prevalence. Based on household dwelling, 48.8% were from high SES households, 25.1% were from middle SES and 25.8% were from low SES households. About 70.1% couples were both HIV sero-negative, 16.2% were both HIV sero-positive, 7.6% were female positive only, and 6.2% were male positive only. Female partners were generally younger than their male partners: about 8.1%, 23.6%, 44.4% and 20% of women were 15–19 years, 20–24 years, 25–34 years and 35–49 years, respectively, compared to 0.7%, 9.7%, 44.6% and 44.9% of men in these same age categories. Education attainment were comparable among female and male partners in current relationships: 6.7% of women and 5% of men never went to school, while 65.4% of women and 68.4% of men had primary education, and 27.8% of women and 26.6% of men had post-primary education. As mentioned earlier, more men (52.1%), than women (0.9%), had missing information for the number of living children (since men’s data were extracted from census data rather than the RCCS survey). Among those with reported living children, female and male partners reported similar number of children, with a few more men having a larger number of children (> = 3): 50.3% women and 52.7% men had 3 or more children.

In these analyses, we found that men and women in current relationships influenced one another’s short-term fertility desires, however their agreement on what these desires should be was moderate. The lowest agreement was among couples with female sero-positive and male sero-negative partners. This group had the highest proportion of both types of disagreement (women’s desires vs. men non-desires, and men’s desires vs. women non-desires), compared to all couple’s sero-status categories. The lack of consensus in couple’s short-term fertility desires may be a lack of spousal communication around fertility desires and sexual and reproductive health, in addition to a reflection of potential instability in their relationship (perhaps as a result of HIV status). When deciding on potential pregnancies, lack of couple communication–coupled with the presence of potential relationship conflict—may also be complicated by use of family planning methods to reduce HIV transmission between partners and children.




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