AIDS Care, 2015 Vol. 27, No. 7, 870–875, http://dx.doi.org/10.1080/09540121.2015.1007115

HIV-seropositivity is not important in childbearing decision-making among HIV-positive Ghanaian women receiving antiretroviral therapy Amos K. Laara*, Araba E. Taylora and Bismark A. Akasoeb a

Department of Population, Family, & Reproductive Health, School of Public Health, University of Ghana, Legon, Accra, Ghana; Catholic Bishop’s Secretariat, Health Office, Bolgatanga, Ghana

b

(Received 21 September 2014; accepted 8 January 2015) Women in their reproductive years make up about 50% of all HIV-positive persons globally. These women, just as their HIV-negative counterparts, wield the right to procreate. However, HIV infection and lack of appropriate information on reproductive options may negatively impact women’s procreative decision-making. This study assessed fertility intentions of HIV-positive women receiving antiretroviral therapy (ART) in southern Ghana. Quantitative methods were used to collect data from HIV-positive women receiving ART at four treatment centers. HIV-positive aged 18–49 years, and receiving ART were selected using systematic random sampling technique. Three hundred eighteen women were interviewed after informed consent. We used univariate analysis to generate descriptive tabulations for key variables. Bivariate analysis and logistic regression modeling respectively produced unadjusted and adjusted associations between background attributes of respondents and their childbearing decision-making. All analyses were performed using IBM SPSS Statistics for Windows, Version 20.0. Irrespective of age, reproductive history, and duration of HIV diagnosis, 46% of the women were desirous of procreating. The bivariate level analysis shows that women in their late reproductive ages (30–39 years) had the strongest desire to procreate (p < 0.001). After controlling for a number of covariates, primiparous and secundiparious women were about twice as likely to desire children (aOR = 2.553; 95% CI 1.480–4.401), and so were women aged 30–39 years (aOR = 2.149; 95% CI 1.202–3.843). Of 54% women who do not wish to procreate, achievement of desired family size (64.3%) was more popular a reason than fear of vertical transmission of HIV (7.5%), poor health status (5%), and pregnancy-related complications (1.6%). Keywords: fertility intentions; childbearing decision-making; HIV-seropositivity; ART; Ghana

Introduction The rate of HIV-related morbidity and mortality has decreased profoundly since the widespread availability of antiretroviral (ARV) drugs (UNAIDS, 2013). According to a recent global AIDS epidemic update, there were 35.3 million persons living with HIV/AIDS and over 50% of the infected adults were women in their reproductive age (UNAIDS, 2013). To those who qualify, reproduction is a natural right. Every person, regardless of their health status may at a time deemed appropriate by them, wish to express this fundamental right. Persons infected with HIV are right-bearers. In line with this reasoning, two separate studies involving ARVexposed HIV-positive women in their reproductive ages found that a good number of them were sexually active, and desirous of having children (Aska, Chompikul, & Keiwkarnka, 2011; Loutfy et al., 2009). Some of the women (HIV-positive women living in Ontario, Canada), according to Loutfy et al. had taken certain steps such as seeing a doctor and not using any contraceptive in order to conceive. On the contrary, Kanniappan et al. showed that HIV diagnosis influences the reproductive choices of women (Kanniappan, Jeyapaul, & Kalyanwala, 2008). *Corresponding author. Email: [email protected] © 2015 Taylor & Francis

A related study conducted in the UK among HIVpositive women receiving treatment revealed that most of them desired to have more children (Cliffe, Townsend, Cortina-Borja, & Newell, 2011). Some of these women had tried unproductively to become pregnant and even resorted to medical treatment to help achieve their desires. About a third of the women specifically stated that being diagnosed of HIV did not affect their fertility decision-making (Cliffe et al., 2011). Another study conducted in rural Mozambique to compare the fertility intentions of HIV-positive and HIV-negative clients reported that HIV-positive clients were less desirous of having children. Such decisions were associated with age, parity, HIV status, economic status, and educational level of clients (Hayford, Agadjanian, & Luz, 2012). Some of these women were also on antiretroviral therapy (ART). It is worthy of note that the childbearing decision-making of women on ART (as reported above) may vary with those who lived during the pre-ART era. Beyond the above-mentioned clinical and individual level determinants of childbearing decision-making are contextual sociocultural determinants. For instance, in most African countries the value of a woman is mostly

AIDS Care measured by her fertility. Heys et al. discuss some of these societal level factors including pressure placed on women, especially married ones to give birth (Heys, Kipp, Jhangri, Alibhai, & Rubaale, 2009). Other contextual influencers of childbearing decision-making are quality of reproductive health counseling HIV-positive clients receive from health care providers. A recent Ghanaian study indicated that many HIV-positive clients receiving care from selected facilities in southern Ghana were not told about reproductive or contraceptive options (Laar, 2013). This study did not document the perspectives of HIV-positive persons on the subject. Our paper presents the considerations that the Ghanaian HIVpositive woman on ART makes in her childbearing decision-making.

Methods Design and study sites The study was descriptive cross-sectional in design and used quantitative methods of data collection. It was conducted at four health facilities in southern Ghana where ART is offered to HIV-positive clients. These health facilities are the Fevers Unit of the Korle Bu Teaching Hospital and the Tema General Hospital (both in the Greater Accra region of Ghana). The Atua Government Hospital and St Martins de Porres Hospital were the other two sites in the Eastern region of Ghana. The Korle Bu Teaching Hospital is one of the tertiary hospitals in southern part of Ghana. The Fevers Unit is affiliated to the department of medicine. This unit treats cases such as measles, rabies, chicken pox, tetanus, chronic diarrhea among others. The Fevers Unit of the Korle Bu Teaching Hospital has about 6000 patients who are currently on ART. Tema General Hospital sees about 1500 HIV-positive clients who are enrolled on ART. The Atua Government Hospital and St Martins Hospital were the first national PMTCT sites. The Atua Government hospital and the St Martins hospital has about 4800 and 4000 HIV-positive clients on ART, respectively.

Participants, sample size, sampling, and summary of field procedures The study participants were HIV-positive women between the ages of 18–49. In determining the sample size, a 95% confidence level and a 5% margin of error were assumed. Prior local studies on childbearing desires of this population were not available. Our best approximate was a study by Gyimah et al. that reported an 85% prevalence of contraceptive use among HIV-positive women (Gyimah, Nakua, Owusu-Dabo, & Otupiri, 2013). Using this, and the above assumptions, the minimum sample size was calculated to be 200. However, being part of a larger

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study with an overall sample size of 410, all of the 410 participants who met the inclusion criteria for the fertility intentions component of the study (318) were interviewed. It may be helpful to note that the minimum sample size of 200 was one of three sample sizes calculated for three distinct outcomes of the larger study that sought to determine (1) the non-prescription drug use, (2) fertility intentions, and (3) child feeding practices of HIV-seropositive persons receiving care at four selected health facilities in southern Ghana. The probability proportional to size weighting procedure was employed in the allotment of the PLHIV to the four study sites. Eligible participants were selected using the systematic random sampling technique. To do this, the master list of ART clients at each facility served as the site-specific sampling frame. The sampling interval (n) for each site was derived by dividing the total number of participants on the monthly register by the required sample at each site. The total number of clients needed from a particular study site were interviewed between May 5 and June 30 2014 by eight (8) research assistants. Ethical considerations Participation in the study conformed to the required ethical guidelines for use of human subjects. The study proposal was reviewed and approved by the Ethical Review Committee of the Ghana Health Service, Research and Development Division, Accra. Permission was granted from the facilities within which the study was conducted. Informed consent was obtained from all participants after the objectives and the methodology of the study was explained to them. In addition, participants were assured of privacy and confidentiality. Data analysis We used univariate analysis to generate descriptive tabulations for key variables. Bivariate analysis and logistic regression modeling respectively produced unadjusted and adjusted associations between background attributes of respondents and their childbearing decisionmaking. The key outcome variables assessed in this study was fertility intentions/childbearing desires (the desire to a child or children in the near future), awareness and use of contraceptives (being aware of and usage of various contraceptive options available to HIV-positive women). We employed a standard logistic regression modeling in SPSS (the “Enter” method) in our analysis. With this method, all the variables previously reported to be associated with the outcome variable or found to be associated with the outcome during the bivariate analysis were entered and a full model generated in a single step. The attributes of the

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A.K. Laar et al.

Table 1. Background attributes, sexual experience, and childbearing decision-making of participants (n = 318 unless otherwise stated). Attribute Study sitea Atua Government Hospital St Martins de Porres Hospital Tema General Hospital Korle Bu Teaching Hospital Region Greater Accra Eastern Age of respondents (years) 18–19 20–24 25–29 30–39 40–49 Marital status of respondents Single Married Divorced/separated Widowed Religious affiliation of respondents None Christian Muslim Total Respondent’s level of education No. formal education Primary JHS SHS/vocational Post-secondary/tertiary Occupation Employed Unemployed Sexual activity within last 3 months Had sex in last 3 months Never had sex within last 3 months Total Number of sexual partners None One Total Pregnancy status Ever pregnant Never pregnant Currently pregnant Yes No Total Outcome of the last pregnancy Aborted Delivered Miscarriage Total

Frequency

Percent

102 81 67 68

32.1 25.5 21.1 21.4

135 183

42.5 57.5

3 10 25 166 114

.9 3.1 7.9 52.2 35.8

57 170 47 44

17.9 53.4 14.8 13.8

3 295 18 316

.9 93.4 5.7 100.0

74 73 122 41 8

23.3 23.0 38.4 12.9 2.5

45 273

14.2 85.8

139 167

45.4 54.6

306

100

124 182 306

40.5 59.5 100

274 32

89.5 10.5

24 281 305

7.9 92.1 100.0

9 258 16 283

3.2 91.2 5.7 100.0

Table 1. (Continued) Attribute

Frequency

Ever avoided pregnancy Avoided pregnancy 117 Not avoided pregnancy 187 Total 304 Method used Contraception 101 Abstinence 13 Abortion 3 Total 117 Fertility intention Would like to have children in 135 future Would not like to have children in 159 future Total 294 Reasons for not wanting to have children Fear of vertical transmission 12 of HIV Fear of dying from non-HIV 3 related complications Poor overall health 8 Achieved desired family size 102 Other reasons 34 Total 159 Duration on ART/yearsb Desired family size before HIV diagnosis Desired family size after HIV diagnosis Current family size: Median

Percent 38.1 61.9 100.0 86.3 11.1 2.6 100.0 45.9 54.1 100.0 7.5 1.6 5 64.3 21.6 100 4.0 (1–15) 3.0 (0–12) 2.0 (1–2) 2.0 (0–8)

a

Values are n, %; all such values. Values are median (range); all such values.

b

model are included in the tables presented. P-value < 0.05 was used to denote statistical significance. All analyses were performed using IBM SPSS Statistics for Windows, Version 20.0.

Results Background attributes, sexual experience, and fertility intentions of participants Table 1 presents the background attributes, sexual experience, and fertility intentions of the study participants. About 50% of the respondents were married and in their late reproductive ages (30–49 years). Most of the respondents (89%) had been living with HIV for more than 12 months preceding the interview. All the 318 (100%) respondents were on potent antiretroviral medications and had at least a child. About 30% had an average of two children. Forty-six percent of the respondents were desirous of having more children. Other details are given in Table 1.

AIDS Care Associations between selected characteristics of respondents and their childbearing decision-making Tables 2 and 3 summarize factors associated with HIV-positive women’s childbearing decision-making. Outcomes from three analytic procedures (bivariate Chi-square test, simple logistic regression, and multiple logistic regression modeling) are presented together with their unadjusted and adjusted measures of association. The bivariate level analysis shows that age of the HIV-positive man, and the number of children she already has are significantly associated with her childbearing decision-making. There was, however, no association between current occupation of the respondents, study site, region of resident, place of residence of the respondents and their intentions to have children (p > 0.05). The multiple logistic regression model examines predictors of same decision-making after adjusting for a number of covariates. Our data show that the age of an HIV-positive woman (mid reproductive age [30–39 years]) is significantly associated with increased desire to

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have children (adjusted odds ratio [aOR] = 2.149; 95% CI 1.202–3.843). Additionally, women who had two or less children at the time of the study were four times as likely to want more children in future as compared to client who have three or more children (aOR = 2.553; 95% CI 1.480–4.401; Tables 2 and 3).

Discussion Overall, 54% of the studied HIV-positive Ghanaian women receiving ART are not desirous of having more children. HIV-seropositivity was not key of various reasons cited in support of their childbearing decisionmaking. Socioculturally laden reasons such as achievement of desired family size, challenges associated with raising children in old age, financial problems, and lack of sexual partner were cited. Fear of vertical transmission of HIV was cited by only a minority of women. These socioculturally driven justifications for childbearing decision-making are not new among HIV-positive

Table 2. Associations between selected characteristics of respondents and their childbearing decision-making (bivariate analysis). Characteristic Age (years) 18–24 25–29 30–39 40–49 Current occupation of respondents Unemployed Employed Study site Atua St Martins Tema Korle Bu Region Greater Accra Eastern Place of residence Urban Rural Number of children 2 or less 3 or more Contraceptive use Yes No Duration on ART Up to 6 years More than 6 years ART adherent monitor Has an ART adherent monitor Does not have an ART adherent monitor 51.9 Note: P-value is from Chi-squared test.

Intends to have children; n (%) Does not intend to have children; n (%) 9 11 82 33

(6.6) (8.1) (60.7) (24.4)

20 (14.8) 115 (85.2) 47 29 31 28

(34.8) (21.5) (23.0) (20.7)

3 9 73 74

P-value

(1.9) (5.66) (45.9) (46.5)

0.001

23 (14.5) 136 (85.5)

0.933

(33.3) (24.5) (20.8) (21.4)

0.915

59 (43.7) 76 (56.3)

67 (42.1) 92 (57.9)

0.787

70 (51.9) 65 (48.1)

81 (50.9) 78 (49.1)

0.877

103 (79.8) 26 (20.2)

70 (46.4) 81 (53.6)

HIV-seropositivity is not important in childbearing decision-making among HIV-positive Ghanaian women receiving antiretroviral therapy.

Women in their reproductive years make up about 50% of all HIV-positive persons globally. These women, just as their HIV-negative counterparts, wield ...
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