Factors associated with pregnancy and pregnancy resolution in HIV seropositive women

Soc. Sci. Med. Vol. 40, No. 11, pp. 1539-1547, 1995

Pergamon

0277-9536(94)00280-0

Copyright © 1995ElsevierScienceLtd Printed in Great Britain.All rights reserved 0277-9536/95 $9.50+0.00

FACTORS ASSOCIATED WITH P R E G N A N C Y A N D P R E G N A N C Y RESOLUTION IN HIV SEROPOSITIVE WOMEN

A N N A KLINE, j J E N N I F E R STRICKLER 2 and J U D I T H K E M P F 3 INew Jersey Department of Health, Campus Demonstration Project, Meadowview Hospital--W5, 595 County Avenue, Secaucus, NJ, U.S.A., 2Tulane University, New Orleans, LA, U.S.A. and 3University of Medicine and Dentistry, New Jersey, U.S.A. Abstract--This study examines factors associated with pregnancy and pregnancy resolution among 238 HIV-infected women, 55 of whom experienced a recent pregnancy since learning of their HIV positive serostatus. Results suggest the importance of psychosocial and cultural factors, particularly those involving the primary sex partner, to reproductive decision-making in HIV-infected women. They also indicate a consistency of reproductive behavior before and after HIV infection, suggesting that the infection itselfdoes not significantly alter existing childbearing trends. Biomedical considerations relating to the mother's health status and the risk of transmission to the child have a greater impact on decisions surrounding pregnancy resolution than they do on the probability of becoming pregnant. Key w o r d s - - A I D S , women, pregnancy, reproductive decision-making

INTRODUCTION There has been a dramatic increase in the incidence of HIV infection in women and children in the past decade. In the last five years, female AIDS cases in the United States have more than quadrupled, rising from 6381 cases in 1988 to over 27,000 in 1992 [I, 2]. A similar increase has been reported in cases of pediatric AIDS, which have risen from 1681 cases in 1989 to 4249 cases in 1992 [2, 3]. Recent estimates suggest that by the year 2000, > 80,000 mothers, children and adolescents will be infected with HIV [4]. The alarming rise in the numbers of HIV infected women and children has resulted in a major public health effort directed at preventing the perinatal transmission of AIDS. Because currently almost all pediatric AIDS cases are acquired perinatally, public health strategies have focused on primary prevention of HIV infection in women, as well as on widespread prenatal screening, education and counseling to help high-risk and HIV-infected women make informed choices about pregnancy. Typically, pregnancy counseling of HIV-seropositive women in medical settings treats HIV infection as a purely biomedical phenomenon. Emphasis is placed on communicating the pertinent medical facts surrounding HIV infection and childbearing, with a particular focus on the probable transmission risk and medical consequences should the child be found to be infected. Recently, however, researchers have questioned the extent to which childbearing conforms to a rational biomedical model of reproductive choice. The notion

that prenatal testing and HIV counseling will, by themselves, promote 'informed decisions' about pregnancy ignores the variety of psychosocial and cultural influences that color the reproductive decision-making process [5-7]. With the exception of Cowan et al. [8] studies generally indicate that HIV status is not a factor in women's decisions to continue or terminate pregnancy [9--14]. Rather, such factors as gender role expectations, religious beliefs, the advice of family members and spouse or partner, attitudes about abortion and prior abortion history, the desire for children and the emotional benefits associated with childbirth may be more relevant to reproductive decision-making in this population [6, 8, 10-14]. If reproductive counseling efforts with seropositive women are to succeed, they must be based on an understanding of the complexity of cultural and psychosocial processes underlying pregnancy decisions. To date, there has been a paucity of published data on the reproductive behavior of HIV-infected women, and all published studies have been limited by small sample size in their attempts to generalize about the impact of social and cultural factors on reproductive behavior. Existing research has focused predominantly on HIV-positive women's decisions to terminate or continue pregnancy [6, 9-11, 13, 14], with little attention given to factors affecting the likelihood of becoming pregnant [5, 11]. Studies suggest that HIV-positive women who terminate their pregnancies are more likely to have HIV-related clinical symptoms [5, 9], or to have children, or know children, who were sick or died from

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AIDS [6, 12] than women who continue their pregnancies. Furthermore, Pivnik et al. [5] found that the likelihood of pregnancy termination increased as time since diagnosis increased, possibly due to the greater probability of the onset of clinical symptoms. However, factors unrelated to HIV infection are also salient to the reproductive behavior of HIV-positive women: women who become pregnant or carry a pregnancy to term are more likely to be childless, to have a history of miscarriages, or to be separated from children placed in foster care [5, 6, 11, 12]. On the other hand, women are more likely to terminate a current pregnancy if they have had an induced abortion in the past [14, 15]. In this paper we examine the relative influence of biomedical vs sociocultural considerations on the reproductive behavior of 238 HIV seropositive women. We explore the relative impact of medical and psychosocial factors on both the probability of becoming pregnant among women aware of their serostatus and on their subsequent decisions regarding termination or continuation of the pregnancy. In attempting to elucidate influences on the reproductive process, we focus on three central issues. First, we present a profile of who becomes pregnant in the context of HIV infection, examining if, and in what ways, women who become pregnant knowing they are HIV-infected differ from HIV-infected women who do not become pregnant. Second, we attempt to understand why HIV-infected women become pregnant, assessing the relative influenc~of biomedical and sociocultural factors on the decision to conceive. Finally, we examine how women respond to their pregnancies, exploring what factors influence decisions regarding pregnancy continuation or termination in this population. METHODS

Sample Between 1989 and 1992, 385 HIV-infected women were enrolled in a federally-funded research and demonstration project aimed at reducing perinatal HIV transmission. Women were recruited from the 16 major medical and social service agencies providing services to HIV-infected women in three high HIV-prevalence cities in northern New Jersey. Staffmembers at cooperating agencies were instructed to invite all known HIV-infected women to participate. A total of 78 of the 385 participants enrolled in the longitudinal study reported having experienced at least one pregnancy since learning of their HIV seropositive diagnosis. Of these 78, 23 had experienced *Those women who did not carry their pregnancies to term were not current prenatal clinic attendees. They had been recruited for the study from a prenatal clinic during an earlier pregnancy which occurred before they were aware of their HIV positive serostatus.

a pregnancy at some time in the past, 30 were currently pregnant at the time of study enrollment and 25 became pregnant subsequent to enrollment. In order to obtain the most current data possible, we decided to consider for comparison purposes only those 55 women who were either currently pregnant or who became pregnant after study enrollment. We further eliminated from the larger group of study participants all women who had been sterilized prior to diagnosis and who were over age 45. This left a final sample of 238 HIV-infected women, 55 of whom had become pregnant since diagnosis and 183 of whom had not. Because we consider only recent pregnancies, a relatively large percentage of our group of women pregnant since diagnosis were recruited from prenatal clinics, creating a disproportionate distribution of our two subgroups across referral sites. Thus, while only 22% of the entire sample were recruited from prenatal clinics, over 47% of the group of women pregnant since diagnosis were recruited from this source. Because we were concerned that women seeking prenatal care may differ from women receiving other types of services (such as drug treatment), we compared the prenatal and non-prenatal portions of our sample on certain key demographic and behavioral characteristics. Within the subgroup of women pregnant since diagnosis, tests of significance, using X2 and Student's t where appropriate, found no significant differences between women recruited from prenatal clinics and women recruited from other sites on such factors as age, education, race/ethnicity, marital status, length of time since diagnosis, frequency of sexual activity, work status, numbers of previous pregnancies and former or current drug use. However, women from prenatal clinics were clearly self-selecting with respect to pregnancy termination: 96% of those who got pregnant carried the pregnancy to term*. Of the women recruited from other agencies or women who did not become pregnant until follow-up, only 13 of 28, or 46%, with a known pregnancy outcome chose to carry the pregnancy to term. Thus, our sample is skewed in favor of women selecting not to have an abortion. Since women who have abortions are likely to differ from those who have births, an analysis of the correlates of pregnancy based on a sample that overrepresents pregnancies which result in births would be biased toward those factors which are associated with continuing pregnancy. In effect, this problem is similar to that of nonresponse in survey samples, where nonresponse is associated with the outcome variable [16, 17]. This issue is resolved by the use of a sample weighting scheme (post-stratification weights) which compensates for the fact that the sample contains too few women who have abortions. All analyses will be based on a weighted sample, where the sampling weights are determined by the proportion (46%) of women recruited from sources other than the prenatal clinics who carry their pregnancies to term. It should be noted that the analysis is somewhat sensitive to the

Pregnancy and pregnancy resolution in HIV seropositive women representativeness of the proportion we use; however, this method clearly improves on the alternative of using an unweighted sample. Furthermore, the proportion of women in the current sample who chose to continue their pregnancies (46%) is similar to the 50% continuation rate reported in previous studies [10, 14].

Procedures Data for our study were gathered by means of a standardized questionnaire administered by an interviewer at baseline and at 6-month intervals up to a period of two years (for a maximum of 4 follow-up interviews). Women were offered $15 for participating in each interview, which was approximately one hour in length. The number of follow-up interviews each woman received depended on both her date of enrollment (women enrolled later in the study were eligible for fewer follow-ups) as well as the success of study retention efforts. On average, interviewers maintained an 80% follow-up rate throughout the study.

Measures Dependent variables. This analysis divides the reproductive process into two stages: becoming pregnant and carrying the pregnancy to term. In our analysis of who becomes pregnant we contrast those women who became pregnant during the study with those who did not. In analyzing pregnancy outcome, we contrast women who had an induced abortion with those who had a birth. The few women who miscarried or whose pregnancy outcome was unknown were classified into the abortion or birth categories if their intention was known; otherwise they were excluded from this part of the analysis, leaving a sample size (unweighted) of 49 women with known outcomes. Independent variables. We focus on five specific areas of possible influence on reproductive choice: biomedical factors; reproductive intentions; pregnancy history and experiences with previous children; drug use; and sociodemographic characteristics. We also control for exposure to pregnancy. A more detailed description of the operationalization of these variables is presented in the Appendix. Biomedical factors. We include in this category variables likely to affect women's perceptions of the risk of transmission to the child. These include a measure of the respondent's health status, constructed as a scale from a list of 30 self-reported symptoms adapted from the Hopkins Symptom Checklist [18] and supplemented with symptoms associated with HIV-related illness. We include the length of time since HIV diagnosis, which should affect the woman's emotional adjustment to her HIV status and her perception of the severity of the disease. We also consider the woman's partner's HIV serostatus, and whether or not she had one or more children who were either ill, or had died, as a result of HIV-related disease.

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Reproductive intentions. These variables measure the woman's intentions with respect to future childbearing as well as her perception of whether or not her partner wants to father more children. Pregnancy history/previous children. These variables are included in the analysis to examine hypotheses linking pregnancy to the absence of, or separation from, existing children. This category of variables thus includes number of previous live births and induced abortions, number of miscarriages and number of children in foster care. Drug use. These variables measure current and lifetime use of crack and injected drugs. They also measure the exchange of sex for drugs and/or money. Although we use two separate questions to elicit information on sex for drugs and money, we combine them for analytic purposes based on several considerations. First, analysis reveals that women who report exchanging sex for drugs are virtually the same women who report exchanging sex for money (r = 0.722, P < 0.000). Further, crosstabular analysis reveals no significant differences in drug use or the use of condoms in the context of prostitution among women exchanging sex for drugs vs sex for money. Moreover, it should be noted that our sample does not include any women currently working as professional prostitutes. Rather, all the women in our study engaged in prostitution in the context of drug use, using sex only sporadically as a means of either obtaining drugs directly, or obtaining money to buy drugs, depending on which was more readily available at the moment. Sociodemographic characteristics. The sociodemographic characteristics we consider include marital status, education, race/ethnicity and employment status. Because current theories suggest that the cultural value attached to motherhood is particularly influential in minority communities [7, 14, 19], we explore associations between being black, hispanic and white and decisions to become pregnant and to continue or terminate the pregnancy. Exposure to pregnancy. We also control for several measures of the likelihood of conception, including respondent's age, frequency of sexual activity, current use of birth control other than condoms, current use of condoms and lifetime contraceptive use. Use of condoms and birth control are measured with respect to the primary sex partner only, since very few women report having more than one partner. Because we include women in our sample who were pregnant at enrollment, we are forced to utilize cross-sectional as well as longitudinal data in our analysis. Our longitudinal data includes data collected at the 6-month interval immediately prior to either the last interview (for women who did not become pregnant) or the interview at which the pregnancy was disclosed (for women pregnant at follow-up); however, for women pregnant at enrollment, we must rely on data collected at baseline. While all data thus reflect a time frame within 6 months of the current

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pregnancy, there is a possibility that data collected on currently pregnant women at baseline may be biased by changes in attitudes and behaviors associated with the pregnancy itself. Variables likely to be affected by pregnancy include health status, frequency of sexual activity, drug use and attitudes about wanting additional future children. In order to test for the possible effects of pregnancy, we compared women pregnant at follow-up with those pregnant at baseline on these specific items. No significant differences were found between the two groups.

Table 1. Characteristicsof sample(N= 238) Characteristic Average or percent (Range: 18--45) Mean age 32.4 (Range: 5-16) Mean education 1lth grade Race/ethnicity Black 58.0% Hispanic 14.3% White 23.9% Other 3.8%

Data analysis

Mean years sinceHIV infection 2.0 Mean No. of previous (Range: 0-1 I) pregnancies 3.3 Sexuallyactive last 4 weeks 53.4% Consistentbirth control use last 4 weeks 65.3%* Consistentcondom use last 4 weeks 46.2%** Wants babyin future 16.8% *N= 101,whichincludesonlywomennot pregnantat interviewwho reported beingsexuallyactivein the previous4 weeks. **N= 117,whichincludesonlywomenwho reported beingsexually active in the previous4 weeks

There are two distinct stages in the childbearing process: becoming pregnant and carrying the pregnancy to term. We analyze the two steps separately, since somewhat different factors should influence each event. Few women actively tried to become pregnant (only three of the 55 pregnancies were planned); hence becoming pregnant is only partially a result of a conscious decision-making process*. Having an abortion, on the other hand, is likely to be the outcome of a more deliberate choice. Both parts of the analysis utilize similar statistical methods. We use measures of bivariate association (Z2 for categorical variables and t-test for continuous variables) to provide profiles of the characteristics of women likely to become pregnant or to carry a pregnancy to term. We use weighted samples (described above) to correct for the fact that our sample overrepresents women who continue their pregnancy. In order to test the robustness of our results, we compare the models for weighted and unweighted samples (not shown); they are substantively similar. We also conduct a multivariate analysis of becoming pregnant, using logistic regression to identify direct effects and to evaluate the relative importance of the explanatory variables. In developing a final model, variables were progressively deleted on the basis of a likelihood ratio test, until no insignificant variables remained. All independent variables were initially included in the multivariate model, with the exception of variables pertaining to contraception, which we consider a proximate determinant of pregnancy rather than a biomedical or social influence. While it would be ideal to conduct a multivariate analysis of pregnancy resolution, the small sample size (49 women with known pregnancy outcomes or intentions) precludes more than a simple comparison of proportions. Therefore, these findings are suggestive rather than conclusive.

*While few women deliberately and consciously became pregnant, it is likely that many others had ambivalent feelings about the prospect of pregnancy, and therefore did not actively try to prevent it. Therefore becoming pregnant is caused by a combination of: (1) being sexually active; and (2) not trying hard to prevent pregnancy.

Married or cohabiting Employed Drug use experience Ever injecteddrugs Ever usedcrack

31.9% 19.7% 58.4% 49.2%

RESULTS

Characteristics o f the study population Table 1 provides the characteristics of the study sample. The racial-ethnic background of the sample is similar to that of the female population currently most affected by HIV infection [1]. The sample is comprised largely of minority women: 58% African-American, 14% Hispanic and 24% White. Similar proportions are found for the statewide population of women with AIDS: 66% African-American; 13% Hispanic; and 21% White [20]. Over half of the sample has a history of crack or injected drug use, and they report having been diagnosed HIV positive for an average of 2 years. More than 50% of the sample were sexually active in the four weeks prior to the interview. Despite the fact that 83% reported not wanting any more children in the future, only 65% used birth control consistently and only 46% regularly used condoms.

Who becomes pregnant? Results of the univariate analysis of the determinants of pregnancy are displayed in Tables 2 and 3. In terms of conceptual categories, most of the factors which we expected to be related to pregnancy show some significant association. The exception is drug use, which seems unrelated to the likelihood of pregnancy. Women who became pregnant are younger, less educated and more sexually active than those who did not. They also report more previous pregnancies and abortions than women who did not become pregnant

Pregnancy and pregnancy resolution in HIV seropositive women Table 2. Means of continuous independent variables ( N = 244)" Variable

Pregnant since Not pregnant diagnosis since diagnosis

Soeiodemographic characteristics

Age Education (years) Medical considerations Health status (scale = 0-3)

30.6 10.9

33.0*** 11.5"

1.6 2.3

1,6 2.0

(scale = 0--4)b Pregnancy history~previous children

1.7

1.2'

Number previous live births Number previous abortions Number previous miscarriages Number of children in foster care

2.2 1.2 0.8 0.4

1,7" 0.9* 0,5 0.2

Years since positive diagnosis Sexual behavior

Frequency of sexual activity

*P<0.05. **P<0.01. ***P<0,001.

'Based on weighted sample. bFrequency of sexual activity in last 4 weeks (0=none, 1 = 1 - 2 times/month, 2 = 1-2 times/week, 3 = several times/week, 4 = everyday).

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One of the most significant findings is the effect of the woman's health status; over 60% of women with good health (number of problems reported below the median) continued the pregnancy, compared with only 30% of women with more health problems. With respect to other biomedical influences, the findings show a trend for women with children unaffected by AIDS and women aware of their HIV-positive status for one year or less to continue their pregnancies. Neither of these results is significant, however. Women who have a history of crack use or exchanging sex for drugs or money are less likely to Table 3. Percentage of women pregnant since HIV-positive diagnosis by independent variables ( N = 244)" Variable

% Pregnant since diagnosis

Sociodemographic Ethnicity

Black Hispanic White Working

and are less likely to use contraception regularly. Further, women who became pregnant are more likely to have reported wanting future children and to have partners desiring a child. They are also less likely to know their partner's HIV status. Many of these same variables also proved significant in the multivariate analysis, shown in Table 4. A woman's pregnancy history remains important, with the number of previous births and the number of previous miscarriages both having a significant positive association with pregnancy. Also remaining positively associated with pregnancy are ignorance of the partner's HIV status and having a partner who wants more children. The probability of pregnancy continues to be significantly decreased by age in the multivariate analysis. The persistent negative effect of age is probably measuring, in part, the role of biological fecundity, which declines markedly after age 35. Finally, years since diagnosis has a significant positive association with pregnancy, a relationship which may reflect greater exposure to the risk of pregnancy--obviously, a woman who has only been diagnosed for a few months has not had as much time in which to become pregnant as a woman who has been HIV positive for several years. Who carries the pregnancy to term? Approximately half of HIV-positive women who become pregnant terminate the pregnancy in abortion [10, 14]. Therefore, an examination of the correlates of continuing a pregnancy is central to improving our understanding of the dynamics of reproductive behavior among HIV-positive women. Table 5 shows the associations between the independent variables and continuing pregnancy to term. Because of the small sample size, few of the differences are statistically significant; nevertheless, they are quite informative.

Yes No Married or cohabiting

Yes No

29.2 42.3 28.4 33.8 29.0 37.6 26.4

Medical considerations Previous child sick or died from AIDS

Yes No Partner's HIV status

Positive Negative Unknown No current partner

49.7 28.7 23.2 35.4 52.6** 15.9

Contraceptive behaviors Consistent birth control last 4 weeks (not condoms) Yes 26.4 No 45.6* Consistent condom use

last 4 weeks Yes No

26.5 59.0***

Reproductive intentions Woman wants more children

Yes No Partner wants more children

Yes No

41.1 27.6 49.4 24.8***

Drug use Ever injected drugs

Yes No Ever used crack

Yes No Injected drugs last 4 weeks

Yes No Used crack last 4 weeks

Yes No Ever exchanged sex for drugs or money

Yes No *P < 0,05. **P<0.01. ***P<0.001.

*Univariate analysis, based on weighted sample.

28.4 32.3 30.1 29.9 30.5 29.9 22.3 30.8 25.8 32.7

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Table 4. Results of multiple logistic regressionmodeling pregnancy since HIV seropositive diagnosis' Variable

Age~ Years since diagnosisc Number previous live birthsc Number previous miscarriages' Partner wants more children Partner's HIV status unknownd

bb

Odds-ratio ¢

--0.09** 0.31"* 0.31"* 0.42** 1.02"* 1.22"**

0.91 1.36 1.36 1.52 2.76 3.39

Model X2 54.13 (6 d.f., n=236), significance=0.0000. *P<0.05. **P
***P<0.001. aBased on weightedsample. bUnstandardizedlogistic regressioncoefficient. cFor interval-level variables, the odds-ratio provided refers to the increase in the odds of becoming pregnant as the value of the variable increasesby one unit. dReferencecategoryis womenwith HIV-positive,HIV-negativeor no primary partners. This grouping is not based on theoretical considerations but, rather, on our empirical findings of a significant differencein the behavior of women with partners of unknown serostatus relative to all other women.

Table 5, Percentageof womencontinuingpregnancyby independent variables (N = 49)' Variable

% Continuing pregnancy

~p~rapine Age

29 and under 30 +

54.9 37.9

Education

Less than 12th grade 12th grade +

49.7 42.0

Ethnicity

Black Hispanic White

50.4 37.9 41.6

Marital status

Married/cohabiting Singie

54.9 39.9

Current work status

Employed Unemployed

44.8 45.9

Medical considerations Previous child sick or died from AIDS b

Yes No

28.9 45.8

Health problems

continue their pregnancy than those w h o have never engaged in these behaviors, although only the effect o f crack use is statistically significant. However, w o m e n w h o are currently injecting drugs or using crack are s o m e w h a t m o r e likely to carry their pregnancies to term. Pregnancy and childrearing history also play a role in determining pregnancy outcome. Previous a b o r t i o n is significantly associated with aborting the current pregnancy, a finding consistent with previous research on factors affecting pregnancy resolution [14]. While the findings also show a trend for w o m e n having one or m o r e children in foster care and w o m e n with no previous children to continue the pregnancy, neither o f these results is statistically significant. Surprisingly, neither the future pregnancy desire o f the r e s p o n d e n t n o r that o f her p a r t n e r appear to affect the pregnancy outcome.

Few Many

64.1 30.9**

Partner's H I V status

Negative Unknown Positive

42.7 63.3 21.3

Time since H I V diagnosis

One year or less More than one year

51.4 42.5

Reproductive intentions Woman wants more children

Yes No

47.8 44.8

Partner wants more children

Yes No

49,4 43,7

Drug use Ever used crack

Yes No

25,0 66.1"*

Ever injected drugs

Yes No

42.0 49.7

Used crack last 4 weeks

DISCUSSION This study further supports the view that a simple biomedical decision-making model is inadequate to explain the reproductive behavior o f HIV-infected women. While biomedical considerations do play a part in the dynamics o f reproduction, other socio-cultural factors must n o t be ignored. The present findings reveal several i m p o r t a n t trends that shed considerable light on the motivations and beliefs underlying reproductive decisions in the context o f H I V infection. One trend emerging from this study suggests that HIV-infected w o m e n who become p r e g n a n t defy the p o p u l a r stereotypes and media portrayals depicting them as selfish, drug-abusing and irresponsible [5]. According to the present findings, w o m e n w h o become p r e g n a n t are no m o r e likely t h a n their counterparts who d o not become p r e g n a n t to be using crack or injected drugs or to have engaged in risky drug-related sexual behavior. Univariate analysis also reveals them

Yes No

54.9 44.8

Injected drugs last 4 weeks

Yes No

61.9 44.0

Ever exchanged sex for drugs or money

Yes No

37.9 49.4

Pregnancy history/l~revious children Number of previous live births

None One or more

61.9 43.9

Number of previous abortions

None One or more

51,5 24.2**

Number of previous miscarriages

None One or more

44.8 46.6

Any children in foster careb

Yes No *P<0.05. **P<0.01. •Based on weightedsample. bN=44 women who have had at least one child. ~Nffi43 women who have a current partner.

54.9 38.6

Pregnancy and pregnancy resolution in HIV seropositive women to be somewhat more likely to be married or living with a sexual partner and more likely to be employed, although these differences are not significant. They are also younger than the group of women who did not become pregnant and have fewer years of education. In general, their profiles fit those of women whose life circumstances would be conducive to childbearing, regardless of serostatus. It should be noted, however, that the profile of HIV-infected women who become pregnant is likely to change as the epidemic progresses. Women surveyed in the present study may be more representative of the larger population of minority inner city women than those infected in the earlier stages of the epidemic. At the same time, the incidence of HIV infection is rapidly increasing among teens and young women, a trend which might produce an increase in the rate of childbearing after HIV infection in the future. A second pattern of results emerging from this study reveals the importance of a woman's reproductive history to her current reproductive behavior. Women who become pregnant knowing their positive status have experienced more previous pregnancies than other women, including live births, abortions and miscarriages. They are also significantly more likely to terminate their current pregnancies if they have previously had an abortion. These findings argue for a consistency of reproductive behavior over time. HIV infection does not, by itself, appear to significantly alter existing reproductive trends. These results thus seem to contradict recent theories linking pregnancy in the context of HIV-infection to the absence of, or separation from, existing children [5, 6, 11]. Although our findings suggest a weak tendency for women to continue their pregnancies if they have children in foster care or have not had a previous child, these results are not statistically significant. Moreover, the study clearly identifies other behavioral and sociocultural factors which have a decidedly more significant impact. One set of factors having an important influence on women's reproductive behavior involves the attitudes and reproductive intentions of the woman's sexual partner. Most discussions of barriers to AIDS prevention stress the impact on women of the cultural value attached to motherhood and the self-esteem associated with bearing children [7, 14, 19, 21]. While our univariate analysis suggests that the woman's desire for children is significantly related to pregnancy, the partner's desire for children shows an even stronger association. In the multivariate analysis, moreover, it is the partner's desire for children that represents the determining factor; the respondent's own desire has no direct effect. Few studies have explored male attitudes toward childbearing in minority communities and how these attitudes affect women's reproductive decisions. There is some evidence to suggest, however, that minority males are often opposed to family planning services and abortion, express more positive attitudes about SSM 40/] I - - H

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childbearing than do their female partners, and view fathering a child as "an open door to manhood" [22-24]. Selwyn et al. [14] report that women electing to terminate their pregnancies more frequently encounter resistance from significant others than do women choosing to continue. These and the present results thus suggest that male partner attitudes surrounding fatherhood may be decisive in determining whether women conceive in the context of HIV infection. Also associated with the probability of pregnancy is the partner's HIV serostatus. Women whose partners are HIV-positive are less likely to get pregnant and somewhat more likely to have an abortion than other women, a finding consistent with a biomedical model of reproductive decision-making. However, the women most likely to become pregnant and most likely to continue a pregnancy are women who are ignorant of their partner's HIV status, rather than those whose partner is HIV-negative. In the present study, 88% of women who were ignorant of their partner's serostatus and became pregnant reported that their partners had not been tested. In the remaining 12 %, partners had been tested but had not revealed their test results. The failure of male partners to be tested or discuss their test results in the context of a sexual relationship with an HIV infected woman indicates either denial about the medical and social implications of the woman's illness or important communication deficits in the relationship. In either case, the risk of pregnancy is likely to be greatly magnified. Partners who fail to communicate about HIV test results, moreover, would be unlikely to communicate effectively about other preventive issues, such as using condoms or birth control. Data from this study, in fact, indicate that women who are ignorant of their partner's HIV antibody status are signficantly less likely to use condoms than other women [25], a fact which, in itself, would increase the probability of pregnancy. An additional pattern emerging from these results is that the processes affecting the probability of pregnancy after a positive HIV diagnosis differ in several important respects from those affecting decisions regarding pregnancy continuation. In general, it appears that the emotional desires or cultural norms which prevent women from taking steps to avoid pregnancy have less impact on the decisions they make once the pregnancy has occurred. Biomedical considerations, in contrast, which have a negligible effect on pregnancy, appear to exert more influence on women's decisions once they conceive. Thus, the emotional desire for children of both the woman and her partner, which significantly influence whether or not women become pregnant, show no significant association with the decision to continue or terminate the pregnancy. The insignificance of the partner's reproductive desires is particularly surprising considering the magnitude of its impact on the probability of pregnancy. It may be that because

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condoms represent the preferred means of birth control in this population*, males have greater control over decisions surrounding contraception. Once pregnancy has occurred, however, women appear to exert greater independence and control over further reproductive decisions. Unlike contraceptive decision-making, decisions surrounding pregnancy continuation appear to be significantly influenced by biomedical concerns. Thus, while health problems are not associated with becoming pregnant, they have a significantly negative impact on continuing a pregnancy. In other words, women who have poor health are no less likely than healthy women to become pregnant, but they are significantly less likely to continue the pregnancy to term. Similarly, although the likelihood of pregnancy significantly increases with the length of time from positive diagnosis, the likelihood that women will carry their pregnancies to term tends to decrease. Our findings show that women who had known of their HIV status for at least one year may be more likely to terminate their pregnancies than newly diagnosed women, a finding which is consistent with previous research [5]. Our findings thus suggest that the probability of pregnancy increases with time since diagnosis simply because the passage of time renders conception increasingly more likely. However, the likelihood that women will choose to bear a child appears to decrease with time, possibly in response to a greater degree of illness acceptance and/or the appearance of clinical symptoms. The current findings raise a number of issues having important public health implications for the prevention of perinatal HIV infection. First, they lend further weight to the evidence that childbearing among HIV-positive women is the outcome of a complex process involving psychological and cultural factors, as well as biomedical considerations. Reproductive counseling of HIV-infected women needs to address those larger issues in women's lives which motivate choices surrounding pregnancy and childbirth. The present findings provide a profile of women who are at greatest risk of pregnancy and childbirth after receiving an HIV positive diagnosis; reproductive counseling programs need to address these underlying factors which affect women's choices and behavior. Although contraceptive use reduces the risk of conception, providing information and access to contraceptives may not reduce the pregnancy rate if other issues are not included in counseling sessions. The present findings suggest that any counseling done with women to aid and support them in reproductive *Eighty-eight percent of sexually active women who used birth control in the previous 4 weeks reported using condoms, compared to 10% who used the pill and 5% who used other methods.

decision-making will not be effective unless partner factors are taken into consideration. Counseling programs need to be sensitive to the cultural issues relevant to both men and women with respect to pregnancy and childbearing and need to address not only the woman's reproductive intentions, but those of her partner as well. As the present study indicates, the partner's desire for children may represent a more important factor in women's reproductive behavior than the wishes and needs of women themselves. Similarly, the greater likelihood of pregnancy among women unaware of their partner's HIV serostatus suggests that unplanned pregnancies might be reduced by encouraging greater disclosure by women of their HIV status to their partners, more HIV testing of all partners unaware of their serostatus and by promoting greater communication in HIV-affected couples about issues relating to prevention and reproduction. Acknowledgements--This research was supported by the

U.S. Centers for Disease Control, Center for Prevention Services, Division of Sexually Transmitted Diseases and HIV Prevention (U62/CCU203006). The authors wish to thank Stephen Hansell and Mark VanLandingham for their helpful comments and suggestions. REFERENCES

1. HIV/AIDS Surveillance Report, Year-End Edn. National Center for Infectious Diseases, Centers for Disease Control, February, 1993. 2. HIV/AIDS Update. New Jersey Department of Health, Division of AIDS Prevention and Control, Nov.-Dec., 1991. 3. HIV/AIDS Update. New Jersey Department of Health, Division of AIDS Prevention and Control, July, 1989. 4. Lipson M. Family and reproductive issues: disclosure within families. AIDS Clin. Care 5, 43, 1993. 5. Pivnik A., Jacobsen A., Eric K. et al. Reproductive decisions among HIV-infected, drug-using women: the importance of mother-child coresidence. Med. Anthrop. Q. 5, 153, 1991. 6. Kurth A. and Hutchison M. HIV reproductive decision-making, paper presented at VII International Conference on AIDS, Florence, Italy, 1991. 7. Levine C. and Dubler N. N. Uncertain risks and bitter realities: the reproductive choices of HIV-infected women. Milbank Q. 68, 321, 1990. 8. Cowan J. E., Kotloff K., Alger L. et al. Reproductive choices of women at risk of HIV infection, paper presented at the VI International Conference on AIDS, San Francisco, 1990. 9. Johnstone F. D., Brettle R. P., MacCallum L. R., Mok

J., Peuther J. F. and Burns S. Women's knowledge of their HIV antibody state: its effect on their decision whether to continue the pregnancy. Br. Med. J. 300, 23, 1990. 10. Dattell B. J., Padian N., Shannon M. et al. HIV serostatus and risk unrelated to pregnancy planning or contraceptive use, paper presented at VII International Conference on AIDS, Florence, Italy, 1991. 11. Levasseur C., Hankins C., Pineault R. et al. Factors influencing reproductive intentions in women with HIV infection, Paper presented at VII International Conference on AIDS, Florence, Italy, 1991. 12. Kurth A. and Hutchison M. Reproductive health policy and HIV: where do women fit in? Pediat. A I D S H I V Infect. 1, 121, 1990.

Pregnancy and pregnancy resolution in HIV seropositive women 13. Johnstone F. D., MacCallum L., Brettle R., Inglis J. M. and Peutherer J. F. Does infection with HIV affect the outcome of pregnancy? Br. Med. J. 296, 467, 1988. 14. Selwyn P. A., Carter R. J., Schoenbaum E. E., Robertson V. J., Klein R. S. and Rogers M. F. Knowledge of HIV antibody status and decisions to continue or terminate pregnancy among intravenous drug users. JAMA 261, 3567, 1989. 15. Bracken M. B., Klerman L. V. and Bracken M. Abortion, adoption or motherhood: an empirical study of decision-making during pregnancy. Am. J. Obstet. Gynecol. 130, 251, 1987. 16. Oh H. and Scheren F. Weighting adjustment for unit nonresponse. In Incomplete Data in Sample Surveys, Vol. 2 (edited by Madow W. et al.), pp. 143-184. Academic Press, New York, 1983. 17. Henry G. Practical Sampling. Sage Publications, Newbury Park, 1990. 18. Derogitis L., Lipman R., Rickels K., Uhlenhuth E. and Covi L. The Hopkins symptom checklist (HSCL): a self-report symptom inventory. Behav. Sci. 19, 1, 1974. 19. Amaro H. Considerations for prevention of HIV infection among hispanic women. Psychol. Women Q. 12, 429, 1988. 20. HIV/AIDS Update. New Jersey Department of Health, Division of AIDS Prevention and Control, 31 March, 1994. 21. Worth D. Sexual decision-making and AIDS: why condom promotion among vulnerable women is likely to fail. Stud. Family Plann. 20, 297, 1990. 22. Armstrong K., Kenen R. and Samost L. Barriers to family planning services among patients in drug treatment programs. Family Plann. Perspectives 23, 264, 1991. 23. Kline A., Kline E. and Oken E. Minority women and sexual choice in the age of AIDS. Soc. Sci. &led. 34, 447, 1992. 24. Kline A. Barriers to the utilization o f maternity services by black women in rural Alabama, Final Report Submitted to Maternal and Child Health Research, U.S. Department o f Health, Education and Welfare, p. 73, 1980. 25. Kline A. and VanLandingham M. HIV infected women and sexual risk reduction: the relevance of existing models of behavior change. AIDS Educ. Prevention 6, 400, 1994. APPENDIX

Operationalization of Study Variables 1. Pregnancy status ( 0 = n o t pregnant since diagnosis, 1 = currently pregnant).

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2. Respondent's health status (scale constructed o f self-reported experience o f 30 symptoms; for each symptom, 0 = not experienced, ! = experienced somewhat, 2=experienced quite a bit, 3=experienced almost all the time). 3. Length o f time since HIV positive diagnosis (in years)*. 4. One or more previous children ill or died as a result o f AIDS related disease (0--no, l = yes). 5. Frequency o f sexual activity in last 4 weeks (0 = none, l = I-2 times/month, 2 = I-2 times/week, 3 = several times/week, 4 = every day). 6. Birth control use in last 4 weeks (0 =inconsistent or no use, l =consistent use). 7. Condom use in last 4 weeks (0 = inconsistent or no use, l =consistent use)t. 8. Respondent's reproductive intentions [0=wants no (more) children, I = wants (more) children]. 9. Partner's reproductive intentions ]0 = wants no (more) children, 1 = wants (more) children]. 10. Number of previous live births. l I. Number of previous miscarriages. 12. Number of previous abortions. 13. Number of children currently in foster care. 14. Used injected drug use last 4 weeks ( 0 = n o , l =yes). 15. Used crack last 4 weeks (0=no, l =yes). 16. Ever used injected drugs ( 0 = n o , l =yes). 17. Ever used crack (0 = no, l = yes). 18. Ever exchanged sex for drugs and/or money (0 = no, l =yes). 19 Partner's serostatus ( 0 = n o current partner, l = negative, 2 = positive, 3 = unknown). 20. Marital status (0 = not married, l = married or living with sex partner). 21. Age of respondent (in years)*. 22. Education of respondent (in years). 23. Race/ethnicity o f respondent (I = black, 2 = hispanic, 3 = white). 24. Current work status of respondent (0 - not working, l =working part or full time)l".

*For women who did not become pregnant, these variables were calculated from the date of the last interview. For women pregnant at enrollment or who became pregnant at follow-up, these variables were calculated from the date of the interview at which the pregnancy was revealed. t F o r women pregnant at enrollment, these variables refer to the 4 weeks before they learned they were pregnant.