Factors Associated With Repeat Pregnancy Among Women in an Area of High HIV Prevalence in Zimbabwe

Women's Health Issues 21-3 (2011) 222–229

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Original article

Factors Associated With Repeat Pregnancy Among Women in an Area of High HIV Prevalence in Zimbabwe Nancy Smee, MPH, PhD a, Avinash K. Shetty, MD b,*, Lynda Stranix-Chibanda, MBChB, MMED c, Mike Chirenje, MD, FRCOG c, Tsungai Chipato, MBChB, MRCOG c, Yvonne Maldonado, MD d, Carmen Portillo, PhD e a

University of San Francisco School of Nursing, San Francisco, California Wake Forest University Health Sciences, Winston-Salem, North Carolina UZ-UCSF Collaborative Program in Women’s Health, Harare, Zimbabwe d Stanford University School of Medicine, Palo Alto, California e University of California, San Francisco School of Nursing, San Francisco, California b c

Article history: Received 18 April 2010; Received in revised form 27 September 2010; Accepted 10 November 2010

a b s t r a c t Background: This study examined predictors of repeat pregnancy among women from the Prevention of Mother-toChild Transmission of HIV (PMTCT) program in Zimbabwe. Methods: The study was conducted at urban antenatal clinics in Chitungwiza, a high HIV prevalence urban town on the outskirts of Harare, Zimbabwe. Using a cross-sectional design, 79 HIV-positive and 80 HIV-negative women who had participated in a PMTCT program in their index pregnancy were interviewed in Shona using a standardized questionnaire 24 months after delivery of their index pregnancy. Logistic regression was used to determine whether a relationship exists between repeat pregnancy and HIV status, socioeconomic status, age, Fertility Attitude Score, and previous pregnancy outcomes. Results: In multivariate analysis, factors associated with an increased likelihood of repeat pregnancy were death of a child (odds ratio [OR], 3.9; 95% confidence interval [CI], 1.25–12.52; p ¼ .0019), miscarriage (OR, 3.4; 95% CI, 1.23–9.34; p ¼ .019), and each additional child (OR, 4.6; 95% CI, 1.89–11.52; p ¼ .001). Decreased likelihood of repeat pregnancy was associated with decreased rank order of living conditions (OR, 0.75; 95% CI, 0.55–0.95; p ¼ .021), each additional year of age (OR, 0.86; 95% CI, 0.77–0.97; p ¼ .012), and higher Fertility Attitude Score (OR, 0.76; 95% CI, 0.64–0.91; p ¼ .002). Conclusion: HIV status alone was not significant as a predictor of repeat pregnancy. Women’s childbearing intentions are not influenced by the risk of mother-to-child transmission of HIV (MTCT) in this population. Future research is needed to address the cultural attitudes and sexual practices of HIV-positive women in order to minimize the threat of MTCT. Copyright Ó 2011 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.

Introduction Fertility rates remain high in resource-limited countries most severely affected by HIV/AIDS (Chama, Morrupa, & Gashau, 2007). HIV-infected women in sub-Saharan Africa continue to seek pregnancy at the same rate as their uninfected peers (Moyo & Mbizvo, 2004; Sedgh, Larsen, Spiegelman, Msamanga, & Fawzi, Funded by the Women’s Global Health Imperative, The Gordon and Betty Irene Moore Foundation, The HIV/AIDS Nursing Care and Prevention T32 Training Fellowship, and The University of California, San Francisco Century Club. * Correspondence to: Avinash K. Shetty, MD, Wake Forest University Health Sciences, Medical Center Blvd, Winston-Salem, NC 27103. Tel: 336-716-2740; fax: 336-716-9699. E-mail address: [email protected] (A.K. Shetty).

2005). Women of childbearing age account for nearly half of those infected with HIV (UNAIDS, 2008). Without interventions to prevent mother-to-child transmission of HIV (PMTCT), 12% TO 40% of HIV-infected women will transmit infection to their infants (Paintsil & Andiman, 2009), and it is estimated that 15.7 million African children will be orphaned by 2010 (UNAIDS, 2008). Fertility and reproductive behavior among HIV-infected women is poorly understood and one of the most complex problems facing health care providers and policy makers (Cooper, Harries, Myer, Orner, & Bracken, 2007). Fertility desires are influenced by many variables, including demographic, health, stigma-associated, psychosocial, and cultural factors (Myer, Morroni, & Rebe, 2007; Nebie et al., 2001). Although

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HIV-infected women are counseled to use condoms consistently, compliance is generally poor in sub-Saharan Africa (Cooper et al., 2007; Duerr, Hurst, Kourtis, Rutenberg, & Jamieson, 2005; Nakayiwa et al., 2006; Peltzer, Chao & Dana, 2009). Zimbabwe has one of the highest HIV-positive rates among women of childbearing age (UNAIDS, 2008). Despite the increasing availability of antiretroviral prophylaxis, only 30% of all HIV-positive pregnant women in Zimbabwe received PMTCT interventions in 2006. (Zimbabwe Ministry of Health, 2006). Therefore, promotion of family planning services among HIVinfected women is critical for prevention of unintended pregnancies and to reduce the risk of mother-to-child transmission of HIV (Reynolds, Janowitz, Wilcher & Cates, 2008). The literature has gaps in the areas of correlates and predictors for pregnancy intent among HIV-infected women in subSaharan Africa (Nattabi, Li Jianghong, Thompson, Orach, & Earnest, 2009). Data are very limited in Zimbabwe regarding fertility desires and intentions among people living with HIV/ AIDS (Moyo & Mbizvo, 2004); to our knowledge, there is no published report on this topic focusing on HIV-positive women participating in PMTCT programs. This study examined predictors of repeat pregnancy among women from the PMTCT program in Zimbabwe. Methods Study Design Between January 2002 and December 2003, using a standardized questionnaire we conducted a cross-sectional survey of 80 HIV-negative and 79 HIV-positive women who had participated in a PMTCT program 24 months after delivery of their index pregnancy. Study Site The study was conducted at antenatal clinics in Chitungwiza, a high-density urban town on the outskirts of Harare, the capital city of Zimbabwe. Since 2002, the antenatal clinics offer a nevirapine-based PMTCT program led by peer counselors (people living with HIV/AIDS) who offer support and mentorship to newly diagnosed HIV-positive mothers (Shetty et al., 2008). At the time of the study, the prevalence of HIV infection among antenatal attendees was w21% (Zimbabwe Ministry of Health, 2006). Maternal HIV status was determined on-site using two rapid tests in parallel (Uni-Gold Test, Trinity Biotech, Jamestown, NY; and Determine HIV1/2 test, Abbott Laboratories, Abbott Park, IL) on each blood sample, and a third test (OraQuick, Abbott Laboratories) as a tie breaker. Women received their test results the same day during extensive individual posttest counseling. Prenatal care occurred in one of four municipal clinics for all study participants. HIV-positive and HIV-negative women followed the same antenatal/postnatal clinic visit frequency protocol. HIV-infected women were counseled by peer counselors regarding PMTCT interventions including single-dose nevirapine prophylaxis, exclusive breastfeeding for 6 months according to WHO guidelines, mother–infant follow-up and enrolment into support groups (Shetty et al., 2008). HIV-positive and HIV-negative women were seen at 6 weeks for a postpartum clinic visit and received counseling regarding reproductive health services, including contraceptive choices and consistent

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condom use if HIV positive. Additionally, they were encouraged to start on progestin-only birth control pills if breast feeding. HIV-positive mothers and their babies were followed monthly after delivery for 18 months. HIV-exposed infants were started on co-trimoxazole at 6 weeks postpartum to prevent Pneumocystis jirovechi infection. Because no polymerase chain reaction testing was available at the site to determine infant HIV infection status, rapid HIV testing was performed on infants at the age of 18 months.

Study Participants All women with known HIV status attending antenatal clinics in Chitungwiza were invited to participate in this cross-sectional study and administered the survey. To be eligible, women had to be 18 years of age, have received antenatal care and participated in a PMTCT program at the study site, have a known address in the community, were at least 24 months after delivery of their index pregnancy, and received an HIV test result. Sample Size and Participant Recruitment Seventy-nine HIV-positive women who had participated in a PMTCT intervention in their index pregnancy and 80 HIVnegative women from the same clinic populations were surveyed 24 months after the delivery of their index pregnancy to participate. Because of the paucity of studies on this topic, effect size could not be confidently predicted; however, a sample size of at least 79 in each group was chosen because it yielded 80% power with an effect size of 0.740 using a two group t-test with a 0.050 two-sided significance level (Dixon & Massey, 1983). All women had a documented HIV test result before enrollment and interviews. The sampling frame included selecting the next woman who was HIV negative after a woman was HIV positive. Women were invited to participate into the study by peer counselors in the antenatal clinics. The eligible participants were interviewed in Shona (the local language) by three trained research assistants using a standardized questionnaire translated from English into Shona by two bilingual experts. Interviews were conducted in a private office in the clinics. Confidentiality and anonymity was ensured by removing all participant identifiers including names. Measures A questionnaire was developed and demographic data, index pregnancy information, follow-up information, and measures of fertility attitudes were collected. In the index pregnancy information and the follow-up information, maternal and infant characteristics were collected as well as subsequent pregnancy and contraceptive practices data. The Fertility Attitude Scale consisted of an eight-item optimized scale using factor analysis that measured the women’s agreement/disagreement on attitudes about why HIV-positive women continue to get pregnant (Table 1). Before comparative or logistic regression analysis, the variable derived from the Attitudes About Fertility and HIV Inventory on the questionnaire was subjected to exploratory factor analysis and configured as an optimized Fertility Attitude Score as part of the psychometric analysis. This single factor had an Eigenvalue of 3.65 while explaining 45.58% of variance.

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2) index pregnancy data, 3) follow-up/repeat pregnancy data, and 4) Fertility Attitude Scale. Each category had several variables (Table 2).

Table 1 Fertility Attitude Scale Reasons why HIV-positive women get pregnant again To conceal their HIV status. They do not believe their HIV status. Out of a need for love. Out of a need for financial security. Because drugs at the clinic will keep their baby safe. The researchers will keep their baby safe. They want to have babies while the researchers are there. They do not see themselves as a real woman if they are not a mother.

Demographic Characteristics

Statistical Analysis The data was analyzed using the SPSS for Windows 14 (SPSS Inc., Chicago, IL). We used t-tests, chi-square tests, and analysis of variance to compare the two groups of HIV-positive cases and HIV-negative controls on all variables including demographics, index pregnancy, follow-up/repeat pregnancy, and Fertility Attitude Scores. Because a dichotomous categorical dependent variable of pregnancy yes/no with independent variables varying from nominal to continuous was used, a forward stepwise binary logistic regression with best model construction occurring over four blocks was employed. This resulted in seven independent variables. All of the variables were tested based on initial literature search. Multiple logistic regression analysis was used to determine whether a relationship exists between repeat pregnancy and HIV-status, socioeconomic status, age, Fertility Attitude Score, and previous pregnancy outcomes. Ethical Approval This study was approved by the Medical Research Council of Zimbabwe and the human subjects committee at the University of California, San Francisco. Written consent was obtained from all study participants. Results HIV-positive (n ¼ 79) and HIV-negative (n ¼ 80) women were compared within the four broad categories of 1) demographics,

The overall mean age was 27.7 years (SD ¼ 5.0); all participants were between 18 and 40 years old. HIV-positive women were on average 3.5 years older [t (157) ¼ 4.70; p < .001] than the HIV-negative women (Table 2). There was no significant difference in educational levels, place of residence, or socioeconomic status between the two groups at the time of index pregnancy.

Index Pregnancy Data The two groups differ in number of children at the time of the index pregnancy (Table 3). HIV-positive women were twice as likely to have had a prior miscarriage compared with HIVnegative women (16.7% vs. 7.4%). Likewise, the HIV-positive women were more likely to have lost a child or to have a child who was not thriving. Of the 159 children born from the index pregnancies, HIV-positive women reported an 88.6% (n ¼ 70) alive and thriving rate, whereas HIV-negative women reported a 96.3% (n ¼ 78) rate. The babies born to HIV-negative mothers were significantly more likely [chi square (90) ¼ 2.54; p ¼ .01] to be alive and thriving up to 2 years after delivery than were the babies born to HIV-positive mothers. The death rate of the index pregnancy child was 7.6% (n ¼ 6) of the HIV-positive cases, whereas no index pregnancy children had died 2 years after delivery in the HIV-negative group. HIV-positive women were significantly [t (14414) ¼ 4.50; p < .001] more likely to have already had a child than the HIV-negative women. Birth complications were significantly higher [chi square (19.4) ¼ 2.15; p ¼ .04] in the HIV-positive women with 20.3% (n ¼ 16) of the women reporting birth complications compared with 8.6% (n ¼ 7) of the HIV-negative women reporting complications, even though maternal third trimester weight and infant birth weights did not differ between the two groups.

Table 2 Comparative Demographic Data HIVþ (n ¼ 79)

Age (yrs) Education level (index) Primary school Secondary school High School Tertiary Education level (current) Primary school Secondary school High School Tertiary Where living (index) Rent house Rent room Own house Staff quarters Relatives other

Control (n ¼ 80)

Total (n ¼ 159)

Mean (SD)

Percentage (n)

Range

Mean (SD)

Percentage (n)

Range

Test Value

df

p-Value

29.5 (4.6)

d

20–40

26.0 (4.8)

d

18–37

4.70

157

0.001

d d d d

15.2 (12) 82.3 (65) 2.5 (2)

d d d d

d d d d

18.5 (15) 80.2 (65) 0 1.2 (1)

d d d d

d d 1.11 d

d d

d d 0.35 d

d d d d

15.2 (12) 81.0 (64) 3.8 (3)

d d d d

d d d d

18.5 76.5 1.2 3.7

(15) (62) (1) (3)

d d d d

d 1.45 d d

d

d d d d d d

5.1 (4) 45.6 (36) 7.6 (6) 11.4 (9) 13.9 (11) 16.5 (13)

d d d d d d

d d d d d d

2.5 39.5 11.1 0 11.1 35.8

(2) (32) (9)

d d d d d d

d d 3.51 d d d

d d

Test value ¼ t-test, chi-square test, or one-way ANOVA as appropriate.

(9) (29)

3 d

3 d d

1 d d d

d 0.23 d d d d 0.06 d d d

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Table 3 Comparative Index Pregnancy Data HIVþ (n ¼ 79) Mean (SD) Mothers antenatal weight (kg) (index) Number of miscarriages – at index Number of childrendat index Number of childrendsince index Total pregnancies (live þ misc.) at index Babies thriving (index) Yesdalive and thriving Nodalive not thriving Deceased Baby weight (index) Birth complications (index) Breast fed 1 mo

65.4 (11.4) d d 16.7 (13) Example of recall bias 74.7 (59) 25.6 (20) 79*

*

d d d 3.1 (.42) d d

Control (n ¼ 80)

Total (n ¼ 159)

Mean (SD)

Percentage (n) Range

Test Value df

p-Value

48–103 d 0–5 1–9 d

66.3 7.4 38.2 17.3 81*

d d d d d

0–4 1–5 d

0.38 1.78 4.50 4.60 d

89 157 1441 40 d

.78 .08 .001 .001 d

d d d d d d

d d d 3.0 (0.6) d d

d d d d d d

d 2.54 d 0.53 2.15 25.7

d

Percentage (n) Range

88.6 3.8 7.6 d 20.3 68.7

(70) (3) (6) (16) (44)

Follow-up Pregnancy Data Of all participants (n ¼ 159), 95.6% (n ¼ 152) attended their postpartum visit 4 to 8 weeks after delivery of the index pregnancy. There was no difference between HIV-positive women and HIV-negative women in attendance rate. Participants differed in their method of contraception [F (1) ¼ 60.78; p < .001], with more women in the HIV-negative group opting for the progestin-only pill (79.0%; n ¼ 64), whereas HIV-positive women were most likely to use condoms (49.4%; n ¼ 39) followed by the progestin-only pill (29.1%; n ¼ 23) and the combination pill (22.8%; n ¼ 18; Table 4). None of the HIV-negative controls used the combination pill, but this was probably a reflection of their 100% breast feeding and contraindication of the combination pill with breast feeding. Likewise, none of the HIV-negative controls opted for use of the Femidom female condom, whereas 11.4% (n ¼ 9) of the HIV-positive cases used this method. Use of DepoProvera injection and Norplant were roughly equal between the two groups. Both groups were equivalent in terms of resumption of intercourse at 7 to 8 weeks after delivery. However the HIVpositive group had a range of 0 to 40 weeks, whereas the HIVnegative group ranged between 0 and 20 weeks. Likewise, there was no difference between the groups in length of time to resumption of menses. Overall (n ¼ 159), 11.9% (n ¼ 19) of the participants admitted to running out of contraception during the interval between delivery of the index pregnancy and survey collection (mean time, 24 months). HIV-positive cases represented a 7.6% (n ¼ 6) rate and HIV-negative controls a 16% (n ¼ 13) rate. Even though the HIV-negative controls were twice as likely to run out of contraception, the two groups are not statistically different. Reasons for failing to use family planning methods did significantly differ between the two groups [t (24.1) ¼ 3.98; p < .001], with dizziness, breast problems, pregnancy, and vulvo-vaginal symptoms being reported more frequently by the HIV-positive group. HIV-positive cases were two times more likely to conceive again within the 24-month interval period between delivery of the index pregnancy and survey (24 pregnancies with n ¼ 79) than HIV-negative controls (14 pregnancies with n ¼ 80). The HIVpositive women conceived again significantly sooner [t (31) ¼ 3.66; p ¼ < .001)]. Mean time to conception for the HIV-positive cases was 11.3 months (SD 9.6), whereas HIV-negative controls had a mean time of 22.1 months (SD 7.0).

(11.0) (6) (31) (14)

96.3 2.5 0 d 8.6 100

50–102

(78) (2)

(7) (81)

d .01 d d 137 .60 19.4 .04 1 .001 90

The two groups were significantly different in their intentions for more children [t (177) ¼ 7.02; p < .001] with the HIV-negative controls having a stated desire for more children than the HIVpositive cases. Of the HIV-positive women, 85% (n ¼ 67) denied wanting more children, whereas only 35.8% (n ¼ 29) of the HIVnegative controls were in this category. None of the HIV-positive women expressed an intention to have more than two additional children, whereas 3.7% (n ¼ 3) of the HIV-negative women planned three or more additional children. Likewise, the two groups were significantly different [t (144) ¼ 4.86; p ¼ < .0001] in the perceived number of children desired by their partners. In general, both groups perceived that their partners desired more children than they did. However, overall (n ¼ 159), 44.7% (n ¼ 71) of the women participants believed their partners did not desire any additional children. Participants were queried as to whether their partners had changed since the index pregnancy. Nine women (5.7%) of the sample (n ¼ 159) had changed partners. The two groups did not vary significantly in change of partner since index pregnancy [F (2) ¼ 2.23; p ¼ .11], even though all the deaths of partners were in the HIV-positive group. Place of residence was again assessed as to where the participants resided at the time of the survey. Although there was no significant difference between the groups as to place of residence during the index pregnancy, there was a significant difference for the current time [F (5) ¼ 3.26; p ¼ .008] with the HIV-positive women showing more likelihood to be in situations of diminished socioeconomic well-being. Fertility Attitude Scale No difference [t (158) ¼ 0.48; p ¼ .63] on the eight-item scale was found in attitudes about fertility between the HIV-positive women (mean score, 5.5; SD, 2.6) and the HIV-negative women (mean score, 5.3; SD, 2.4). However, women who scored higher were significantly less likely to conceive again during the 24-month interval from index pregnancy to study. Factors Associated with Repeat Pregnancy In multivariate analysis (Table 5), factors associated with an increased likelihood of repeat pregnancy were death of a child (OR, 3.9; 95% CI, 1.25–12.52; p ¼ .0019), miscarriage (OR, 3.4; 95% CI, 1.23–9.34; p ¼ .019), and each additional child (OR, 4.6; 95% CI, 1.89–11.52; p ¼ .001). Decreased likelihood of repeat pregnancy

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Table 4 Comparative Follow-Up Pregnancy Data HIV þ (n ¼ 79) Mean (SD) Attended postpartum visit Yes d No d Contraceptive method Progestin-only pill d Combination pill d Hormonal injection (Depo) d Hormonal injection (Norplant) d Condoms d Femidom (female condom) d Weeks until resumed intercourse 7.7 Weeks until menses resumed 14.12 Ran out of contraceptive d Family planning failure Bleeding problems d Abdominal pain, etc. d Dizziness/headache d Breast problems d Pregnancy d Vulva/vaginal symptoms d Conceived again time from index delivery (mos) 11.3 Number of additional children planned by participant 0 d 1 d 2 d 3 d 4 d Number of additional children desired by partner 0 d 1 d 2 d 3 d 4 d 5 d Partner changed since index pregnancy Divorced d Deceased d Where living (now) Own house d Rent house d Rent room d Staff quarters d Relatives d Other d 5.5 Fertility Attitude Scale (8 items) a ¼ 0.81

(5.1) (14.4)

(9.6)

Control (n ¼ 80) Range

Mean (SD)

Percentage (n)

Range

Test Value

df

97.4 (76) 2.6 (2)

d d

d d

93.8 (76) 6.2 (5)

d d

1.23 d

d

29.1 22.8 6.3 3.8 49.4 11.4 d d 7.6

(23) (18) (5) (3) (39) (9)

d d d d d d 0–40 0–60 d

d d d d d d 7.8 (3.3) 18.6 (25.5) d

79.0 0 8.6 3.7 6.2 0 d d 16

d d d d d d 0–20 0–96 d

d d 60.78 d d d 0.03 1.30 3.04

d d 1 d d d 155 104 1

d d .001 d d d .97 .20 .08

8.9 3.8 2.5 1.3 6.3 3.8 d

(7) (3) (2) (1) (5) (3)

d d d d d d d

d d d d d d 22.1 (7.0)

16 (13) 4.9 (4) 1.2 (1) d d d d

d d d d d d d

d 3.98 d d d d 3.66

d 24.1 d d d d 31

d .001 d d d d .001

84.8 (67) 12.7 (10) 2.5 (2) 0 0

d d d d d

d d d d d

35.8 37.0 23.5 2.5 1.2

(29) (30) (19) (2) (1)

d d d d d

7.02 d d d d

177 d d d d

.001 d d d d

69.4 13.9 11.1 2.8 2.8 0

d d d d d d

d d d d d d

26.9 26.9 30.8 7.7 3.8 3.8

(21) (21) (24) (6) (3) (3)

d d d d d d

d 4.86 d d d d

d 144 d d d d

d .001 d d d d

d d

d d

d d

2.23 d

2

0

d d d d d d d

d d d d d d 5.3 (2.4)

13.6 0 37.0 0 13.6 35.8 d

d d d d d d d

d 3.26 d d d d 0.48

(6)

(50) (10) (8) (2) (2)

6.3 (5) 5.1 (4)

(2.6)

10.1 5.1 40.5 8.9 15.2 20.3 d

(8) (4) (32) (7) (12) (16)

were associated with decreased rank order of living conditions (OR, 0.75; 95% CI, 0.55–0.95; p ¼ .021), each additional year of age (OR, 0.86; 95% CI, 0.77–0.97; p ¼ .012), and a higher Fertility Attitude Score (OR, 0.76; 95% CI, 0.64–0.91; p ¼ .002). HIVstatus alone was not significant as a predictor of whether a Zimbabwean woman will conceive again.

Table 5 Positive and Negative Factors Associated With Repeat Pregnancy Among HIVPositive and HIV-Negative Women in Zimbabwe Variable

Odds Ratio 95% Confidence Interval p-Value

Whether are HIVþ Housing at index 0.75 Age 0.86 Fertility Attitude Scale 0.76 Whether had child death 3.9 Whether had miscarriage 3.4 Number of children 4.6 Constant/repeat pregnancy 37.1

0.52–3.88 0.55–0.95 0.77–0.97 0.64–0.91 1.25–12.52 1.23–9.34 1.89–11.52 d

Total (n ¼ 159)

Percentage (n)

.5 .02 .01 .002 .02 .02 .001 .02

(64) (7) (3) (5)

(13)

4.9 (4)

(11) (30) (11) (29)

p-Value 1

d 5 d d d d 158

.27 d

.11 d d .008 d d d d .63

Discussion Our findings show that even though HIV-positive women were on average older, more likely to have had a child before the index pregnancy, and less likely to say they planned another child or that their partner desired another child, they still conceived more frequently and earlier than did the HIV-negative controls. This finding is consistent with published studies in both resource-rich and resource-limited settings showing that fertility intentions among PLWH are strong (Cooper et al., 2007; Myer et al., 2007; Peltzer et al., 2009). In this study, HIV-infected women were twice as likely to have experienced a miscarriage. They were significantly more likely to experience birth complications during the index pregnancy and had a malnourished child or death of child during the intervening 2 years, since delivery of the index pregnancy. Data from resource-limited settings indicate that HIV-infected pregnant women are at higher risk for adverse perinatal outcomes (Coley et al., 2001; Nakayiwa et al., 2006; Suryavanshi et al, 2008).

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In this study, factors associated with an increased likelihood of repeat pregnancy among both HIV-positive and HIV-negative women were death of a child, miscarriage, and each additional living child. Our results are consistent with other reports indicating that child loss is a powerful motivator for repeat pregnancy (Moyo & Mbizvo, 2004; Myer et al., 2007; Nakayiwa et al., 2006). In our study, HIV status alone was not a deterrent to repeat pregnancy. This finding is consistent with data from other countries in sub-Saharan Africa, including South Africa (Myer, Morroni & Cooper, 2006; Myer et al., 2007), Botswana (Bussman et al., 2007), and Tanzania (Sedgh et al., 2005), where knowledge of HIV seropositive status has not entailed a reduction in subsequent pregnancy incidence. Women’s vulnerable social status, which prevents them from controlling their own sexuality and key reproductive choices (Susser & Stein, 2000), and the persistent denial of AIDS (Boerma, Gregson, Nyamukapa & Urassa, 2003) are factors that partly account for this situation. In contrast, other studies have found that HIV-positive women who know their serostatus are less likely to desire children. In a recent study from South Africa, childbearing intention was significantly lower in HIV-positive women than HIV-negative women (Peltzer et al., 2009). In Uganda, only 7% of HIVpositive women desired to have children (Nakayiwa et al., 2006). During the pre-highly active antiretroviral therapy (ART) era, pregnancy rates among HIV-positive women declined significantly in resource-rich countries (Bryant et al., 2007). Whether this is attributed to more effective family planning programs and access to modern contraception, a greater propensity for women to exercise their autonomous desire to limit pregnancy, or just a greater public outrage toward HIVpositive people desiring children is unclear. However, following the widespread availability of ART for HIV-infected pregnant women that have lowered mother-to-child transmission of HIV rates to less than 2%, and also improved health status and life expectancy, more HIV-positive women are now desiring and intending pregnancy in resource-rich settings (Bryant et al., 2007; Segurado & Paiva, 2007). The difference, however, is that they are able to conceive and deliver safely compared with HIV-infected women in resource-limited settings (Johnson, Ndhlovu, Farr, & Chipato, 2002). In this study, even though both HIV-positive and HIVnegative participants had a high stated propensity for using contraception, they differed significantly in the choice of contraceptive methods. HIV-positive women were much more likely to be using condoms (including the female condom) and a combination oral contraceptive pill, whereas HIV-negative women were largely (79%) using the progestin-only contraceptive pill. HIV-negative women were twice as likely to admit to running out of contraceptives compared with HIV-positive women. Despite fewer stated interruptions to contraception, HIV-positive women were twice as likely to conceive again within the study period, suggesting either greater propensity for contraceptive failure, lack of consistent use, or perhaps fear of stigma about admitting contraceptive lapses to interviewers. Our findings are similar to those reported in Pune, India (Suryavanshi et al., 2008), where HIV-positive women had a four-fold increase in unwanted pregnancy rate compared with HIV-negative women despite increased stated contraceptive use. The authors suggested that family pressures to continue conceiving are more than three-fold greater on HIV-positive women than HIVnegative women with pregnancy and motherhood perceived as evidence of a woman’s health (Suryavanshi et al., 2008).

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Although 85% of HIV-positive women in our study stated that they did not plan more pregnancies, they continued to conceive again sooner and at a higher rate than HIV-negative women. Both cases and controls stated that their partners planned more children than they did; however, the two groups were significantly different in that the HIV-negative women thought their partners wanted more children than the HIV-positive group. Among HIV-positive participants in South Africa, social factors play an independent role in whether or not HIV-positive participants continued to conceive after HIV diagnosis (Myer et al., 2007). In their study, married women were more likely to conceive, especially if they did not disclose their status to partners. In a study from Burkina Faso, women were more likely to want to defer having further children once they found they were HIV positive, whereas HIV status made no difference to the reproductive plans of men (Nebie et al., 2001). In sub-Saharan Africa, where maternity is highly valued, meeting family and social obligations concerning reproduction can be more important for an HIV-positive woman than her own health and the risk of giving birth to an HIV-infected baby (Bussman et al., 2007; Nebie et al., 2001). Our results support the fact that Zimbabwean women continue to conceive whether it is their desire or not. They fulfill the wishes of their husbands and the expectations of their husbands’ families, despite their own preferences not to conceive again. Women living in cultures where most of their status is derived from their fertility cannot be expected to limit pregnancy, even if they personally desire to do so. Negotiating condom use is unlikely when women perceive themselves to be at the low end of the power gradient (Grieg & Koopman, 2003). Contraceptive counseling may prove more successful when women feel a greater sense of empowerment and control over property, economic assets, inheritance, and a greater freedom in terms of mobility, reproductive choices, and control over their sexual behaviors (Marmot, 2007). Most studies in resource-limited settings conclude that women will continue to conceive until the ideal family size is achieved, usually between four and seven children (Cohen & Montgomery, 2004). Because the number of children at the time of the index pregnancy ranged between none and five for the HIV-positive women and none and four for the HIV-negative women, it may be possible that the critical threshold for number of children was not reached by most women in this study. Because the population in Chitungwiza is almost 100% Christian and the majority are Catholic or Apostolic, which do not advocate birth control, a religious effect may also have contributed (Gregson, Zhuwau, Anderson & Chandiwana, 1998). However, the compelling drive for motherhood as a way of gaining and maintaining social status among Zimbabwean women should not be minimized (Cooper et al., 2007; Sedgh et al., 2005). In the present study, decreased likelihood of conceiving again included lower socioeconomic status, increasing age in women, and increased Fertility Attitude Score. In Zimbabwe, poverty is widespread and over 70% of adults are unemployed (Economist, 2008; World Bank, 2007). Poor salaries, difficult working conditions, political unrest, and severe and chronic shortages of food have further compounded the problem (Singh, 2005; World Bank, 2007). Further, there is a greater trend toward disrupting family units because women and children from urban settings have tended to move back to rural and tribal areas where rent does not have to be paid and subsistence farming can largely provide the diet. Therefore, at the lowest rank of housing and socioeconomic status, couples would have the greatest likelihood to be separated on a daily basis resulting in a natural

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decline in fertility as noted in our study. Advancing age (>35 years) is associated with decreased fertility among HIV-infected women (Brocklehurst & French, 1998; Desgreesdu, Msellati, & Yao, 1997). In our study, women ranged between 18 and 40 years of age; the older a woman was, the less likely she was to conceive, regardless of her HIV status. In this study, women who scored higher on the Fertility Attitude Scale had a corresponding protective effect against conceiving again. Therefore, if HIV-positive women in this setting can be aided in developing greater self-awareness surrounding their individual attitudes regarding future pregnancies, with special emphasis on what beliefs and myths might be motivating those decisions, women may be able to make a greater conscious choice regarding reproductive options as opposed to decisions made as a result of partner, family, and community expectations (Cooper et al., 2007). Women’s groups that foster education, mentoring by successful role models, social critique, and communication between participants on the topics of women’s roles in the society could have a health promotional effect. Our study has several limitations. The sample size is relatively small. All of the participants are from an urban setting utilizing four antenatal clinics thereby resulting in a selection bias and making generalization of results to other populations unclear. This study used a cross-sectional design and is, therefore, subject to the response bias and inability to clearly sequence events in time inherent in that design (Gordis, 2009). The participants were interviewed 2 years after delivery of the index pregnancy to establish factors related to childbearing intentions. Owing to the timing of the information collection, a certain amount of recall bias must be expected. Although this study attempts to elicit the difference between participants’ and their partner’s desire for future children, it does so only through the woman’s perception. Direct measurement of male partner’s attitudes would have removed this possible source of bias. CD4 counts or viral loads were not measured in the HIV-infected group owing to the lack of available laboratory support. World Health Organization staging of HIV-positive participants was not available, thereby limiting knowledge regarding their disease progression. In addition, HIV-infected women did not have access to ART in our study. A recent report from South Africa suggest that women’s and men’s attitudes are changing in favor of child bearing if there is increasing access to PMTCT interventions and combination ART (Cooper et al., 2007).

against conceiving again. If HIV-positive women in this setting can be aided in developing greater self-awareness surrounding their individual attitudes regarding future pregnancies, with special emphasis on what beliefs and myths might be motivating those decisions, greater conscious choice as opposed to un-empowered compliance with partner, in-law, or community expectations might be expected. Women’s groups that foster education, mentoring, social critique, and communication between participants on the topics of women’s roles in the society would have a health promotional effect. Linking health care and family planning with empowerment strategies such as assertiveness training for women, vocational training, and micro-lending opportunities for women to start small businesses would also serve to establish alternative avenues for self-esteem, economic security, and creative outlets (Kiefer, 2007). For any of these interventions to work, however, they cannot only involve reproductive age women. Special consideration as to the role male partners and in-laws play in shaping a woman’s reproductive behavior in sub-Saharan cultures is crucial. Greater involvement of male partners in antenatal care will hopefully facilitate greater responsibility taking on the man’s part, as well (Nkuoh, Meyer, Tih, & Nkfusai, 2010). In conclusion, women’s decisions related to pregnancy and childbearing are influenced by a number of contextual factors. It is important for health care providers and policy makers to understand the complex interplay between needs and vulnerabilities of HIV-infected women, and the culture in which they live. Further investigation into cultural attitudes and sexual practices of HIV-positive women is needed to minimize the threat of mother-to-child transmission of HIV. Acknowledgments This research was made possible by training grants from Women’s Global Health Imperative, The Gordon and Betty Irene Moore Foundation, The HIV/AIDS Nursing Care and Prevention T32 Training Fellowship, and The University of California, San Francisco Century Club. We want to thank Jennifer Wells and Elizabeth Montgomery (University of Zimbabwe-UCSF Collaborative Program in Women’s Health), Micah Simoyi (Chitungwiza Health Department), Departments of Obstetrics and Gynecology and Pediatrics, University of Zimbabwe School of Medicine and all the mothers who participated in the study.

Implications References Our study has many important implications for health care providers and policy makers. Integrating family planning services with PMTCT services and recognizing risk factors for repeat pregnancy is critical to prevent HIV-positive births (Duerr et al., 2005; Reynolds et al., 2008). Provision of contraception to HIV-infected women who do not wish to become pregnant is cost effective compared with other PMTCT strategies in subSaharan Africa (Reynolds et al., 2008). Programs linking reproductive health and HIV must target male partners and address gender norms that pose challenges for women’s autonomy (Duerr et al., 2005). There is a need to maximize the safety of subsequent pregnancies for women in sub-Saharan Africa that intend to conceive by universal access to ART and safe delivery care (Gruskin, Firestone, MacCarthy & Ferguson, 2008). These data showed that women who scored higher on the Fertility Attitude Scale had a corresponding protective effect

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Author Descriptions Nancy Smee has a PhD from the University of California, San Francisco and is currently an Assistant Professor at the University of San Francisco.

Avinash K. Shetty is an Associate Professor of Pediatrics and Medical Director of the Pediatric HIV Program at Wake Forest University Health Sciences, Winston-Salem.

Lynda Stranix-Chibanda is currently the project director for PMTCT studies at UZUCSF Collaborative Program in Women's Health in Harare, Zimbabwe.

Mike Chirenge is a Professor of Obstetrics and Gynecology at University of Zimbabwe College of Health Sciences and Director of the UZ-UCSF Collaborative Program in Women's Health, Harare.

Tsungai Chipato is an Associate Professor of Obstetrics and Gynecology at University of Zimbabwe and a senior researcher at the UZ-UCSF Collaborative Program in Women's Health, Harare.

Yvonne Maldonado is Professor of Pediatrics and Chief of Pediatric Infectious Diseases at Stanford University School of Medicine, Palo Alto.

Carmen Portillo is currently Professor and Chair, Department of Community Health Systems at University of California, San Francisco School of Nursing, San Francisco.