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

Date Published: April 23, 2019

Publisher: Public Library of Science

Author(s): Deus Thindwa, Megan Landes, Monique van Lettow, Annie Kanyemba, Ernest Nkhoma, Happy Phiri, Thokozani Kalua, Joep J. van Oosterhout, Evelyn J. Kim, Beth A. Tippett Barr, Bruce A. Larson.

http://doi.org/10.1371/journal.pone.0215947

Abstract

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.

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.

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).

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.

Partial Text

By 2017, 36.9 million people worldwide were living with human immunodeficiency virus (HIV), the majority (53.1%) in sub-Saharan Africa [1]. Malawi has one of the highest adult HIV prevalence at 9.3% [2,3], and women of reproductive age comprise 53.5% of all 15–49 year olds living with HIV in Malawi [4]. In July 2011, Malawi adopted a test-and-treat strategy for the prevention of mother to child transmission of HIV (PMTCT) for HIV-positive pregnant and breastfeeding women, known as Option B+. Early evaluations of Option B+ have shown markedly increased uptake of ART among pregnant and breastfeeding women in Malawi [5], with current PMTCT coverage estimated at 93.5% among pregnant women and early vertical HIV transmission reduced to an estimated 3.9% [6]. However, more work is required to achieve virtual elimination of mother-to-child transmission of HIV, defined as having ≤50 new paediatric infections per 100,000 live births and a transmission of either <5.0% in breastfeeding populations or <2.0% in non-breastfeeding populations [7]. Among Malawian women living with HIV who were enrolled in this study between 4 to 26 weeks after delivery, we observed that 2 in 5 self-reported unintended index pregnancy, 3 in 10 reported unmet contraceptive need at the time of index pregnancy, 1 in 4 reported future pregnancy intention, and 1 in 2 reported current contraceptive use among those without pregnancy intentions within the next 12 months. Older age and higher parity were associated with unintended pregnancy, whereas younger age and lower parity were associated with both unmet contraceptive need and future pregnancy intention. Unmet contraceptive need was also associated with unknown HIV status of partner, and current contraceptive use with being on ART in the index pregnancy. High prevalence of unintended index pregnancy and of unmet need for contraception were observed among Malawian women living with HIV in the Option B+ era. This highlights the need for improved access to contraceptive and family planning services. To help achieve reproductive goals and elimination of MTCT of HIV in Malawi, integration of family planning services into HIV care should be strengthened to ensure all women living with HIV have timely access to a wide range of family planning methods which have low failure risk.   Source: http://doi.org/10.1371/journal.pone.0215947

 

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