Contraceptive use following unintended pregnancy among Ugandan women living with HIV

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Abstract

Background

Preventing unintended pregnancy is critical for women living with HIV (WLWH) to safely achieve their reproductive goals. Family planning services should support WLWH at risk of repeat unintended pregnancies. We examined the relationship between unintended pregnancy and subsequent contraception use among WLWH in Uganda.

Study design

This was a retrospective analysis of data from a longitudinal cohort of individuals initiating antiretroviral therapy (ART), restricted to women with pregnancy (confirmed via urine β-hcg testing) between 2011–2013. The exposure of interest was intended vs unintended pregnancy, and the outcome was self-report of modern contraceptive use (hormonal methods, intrauterine device, sterilization, and/or consistent condom use) at 12 (range 6–18) months post-partum. A log-binomial model was used to estimate relative risks of modern contraceptive use post-partum based on intent of the index pregnancy, adjusted for age, socioeconomic status, education, relationship and HIV status of pregnancy partner, contraceptive use prior to pregnancy, years since HIV diagnosis, ART regimen, and CD4 cell count.

Results

Among 455 women, 110 women reported 110 incident pregnancies with report on intent. Women had a baseline median age of 29 years, baseline CD4 count 403 cells/mm ³, and were living with HIV for 3.8 years. Fifty pregnancies (45%) were reported as unintended and 60 (55%) as intended. Postpartum, 64% of women with unintended and 51% with intended pregnancy reported modern contraception (p = 0.24). In adjusted models, there was no association between pregnancy intent and post-partum contraception. However, contraceptive use prior to the referent pregnancy was positively associated with post-partum contraceptive use (aRR 1.97 (95% CI 1.12–3.48, p = 0.02), while higher baseline CD4 cell count was associated with lower post-partum contraceptive use (aRR 0.95, 95% CI 0.90–0.99, p = 0.02).

Conclusions

Almost half of incident pregnancies among WLWH in this cohort were unintended. Experiencing an unintended pregnancy was not associated with post-partum contraceptive use. Creative strategies to support contraceptive uptake for birth spacing and prevention of unintended pregnancies in the post-partum period are needed.

Related collections

Most cited references 30

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Estimating wealth effects without expenditure data--or tears: an application to educational enrollments in states of India.

Deon Filmer, Lant H. Pritchett (2001)

Using data from India, we estimate the relationship between household wealth and children's school enrollment. We proxy wealth by constructing a linear index from asset ownership indicators, using principal-components analysis to derive weights. In Indian data this index is robust to the assets included, and produces internally coherent results. State-level results correspond well to independent data on per capita output and poverty. To validate the method and to show that the asset index predicts enrollments as accurately as expenditures, or more so, we use data sets from Indonesia, Pakistan, and Nepal that contain information on both expenditures and assets. The results show large, variable wealth gaps in children's enrollment across Indian states. On average a "rich" child is 31 percentage points more likely to be enrolled than a "poor" child, but this gap varies from only 4.6 percentage points in Kerala to 38.2 in Uttar Pradesh and 42.6 in Bihar.

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Reproductive Intentions and Outcomes among Women on Antiretroviral Therapy in Rural Uganda: A Prospective Cohort Study

Jaco Homsy, Rebecca Bunnell, David Moore … (2009)

Background Antiretroviral therapy (ART) may influence the biological, social and behavioral determinants of pregnancy in HIV-infected women. However, there are limited longitudinal data on the reproductive intentions and outcomes among women on ART in Africa. Methodology /Principal Findings Using a prospective cohort design, we analyzed trends in desire for children and predictors of pregnancy among a cohort of 733 HIV-infected women in rural Uganda who initiated ART between May 2003 and May 2004 and were followed up in their homes until June 2006. Women answered in-depth social and behavioral questionnaires administered every quarter in year 1 after initiating ART, and every 6 to 12 months thereafter. Use of family planning methods was assessed at 18 and 24 months after starting ART. We tested for non-constant pregnancy incidence by using a shape parameter test from the Weibull distribution. We modeled repeated measurements of all variables related to the women's desire for children over time using a generalized estimating equation (GEE) extension to the logistic regression model. Risk factors for pregnancy were examined using Cox proportional hazards model. 711 women eligible for the study were followed-up for a median time of 2.4 years after starting ART. During this time, less than 7% of women reported wanting more children at any time point yet 120 (16.9%) women experienced 140 pregnancies and pregnancy incidence increased from 3.46 per 100 women-years (WY) in the first quarter to 9.5 per 100 WY at 24 months (p 18.5 (HR = 1.09, CI: 1.01–1.18) and not having used condoms consistently in the last 3 months (HR = 1.79, CI: 1.02–3.13) were independently associated with pregnancy. Conclusion/Significance Women on ART and their partners should be consistently counseled on the effects of ART in restoring fertility, and offered regularly free and comprehensive family planning services as part of their standard package of care.

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Unmet need for contraception: issues and challenges.

John G.F. Cleland, Sarah Harbison, Iqbal Shah (2014)

Unmet need for contraception has been a central indicator for monitoring the progress of family planning programs for 25 years. The purpose of this article is to provide a broad context for the more focused contributions that follow in this special issue. The validity and measurement of the concept of unmet need are discussed. We then present regional trends among married women since 1970. Major reductions in unmet need have been achieved, with the clear exception of sub-Saharan Africa. Less success can be claimed in addressing the needs of sexually active unmarried women, who contribute nearly 20 percent to overall unmet need in developing countries. Prominent reasons for unmet need in settings where contraceptive uptake is low include social resistance and insufficient information concerning methods. As contraceptive use increases, the importance of these reasons wanes, but concerns regarding side effects and health impact remain a barrier, and discontinued users now constitute a large proportion of those with unmet need. Drawing on these reasons, we outline measures to further reduce unmet need.

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Author and article information

Contributors

Jana Jarolimova:

ORCID: http://orcid.org/0000-0002-6787-3012

Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: Writing – original draft

Jerome Kabakyenga: Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Writing – review & editing

Kara Bennett: Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: Writing – review & editing

Winnie Muyindike: Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Writing – review & editing

Annet Kembabazi: Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Writing – review & editing

Jeffrey N. Martin: Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Writing – review & editing

Peter W. Hunt: Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Writing – review & editing

Yap Boum: Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Writing – review & editing

Jessica E. Haberer: Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Writing – review & editing

David R. Bangsberg: Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Writing – review & editing

Angela Kaida: Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – review & editing

Lynn T. Matthews: Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – review & editing

Eliud Wekesa: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 25 October 2018

Publication date Collection: 2018

Volume: 13

Issue: 10

Electronic Location Identifier: e0206325

Affiliations

[1 ] Department of Medicine, Massachusetts General Hospital, Boston, MA, United States

[2 ] Mbarara University of Science and Technology, Mbarara, Uganda

[3 ] Bennett Statistical Consulting, Ballston Lake, NY, United States

[4 ] University of California at San Francisco, San Francisco, CA, United States

[5 ] Epicentre, Médicins sans Frontières (MSF), Yaounde, Cameroon

[6 ] Center for Global Health and Department of Medicine, Massachusetts General Hospital; Harvard Medical School, Boston, MA, United States

[7 ] Oregon Health and Science University-Portland State University School of Public Health, Portland, OR, United States

[8 ] Simon Fraser University, Faculty of Health Sciences, Burnaby, British Columbia, Canada

[9 ] Center for Global Health and Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, United States

South Eastern Kenya University, KENYA

Author notes

Competing Interests: The authors have declared that no competing interests exist.

* E-mail: ltmatthews@ 123456partners.org

Author information

Jana Jarolimova http://orcid.org/0000-0002-6787-3012

Article

Publisher ID: PONE-D-18-03135

DOI: 10.1371/journal.pone.0206325

PMC ID: 6201927

PubMed ID: 30359430

SO-VID: a3098762-449c-4690-8132-f3061474a147

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 29 January 2018

Date accepted : 10 October 2018