Culture, Health & Sexuality, 2015 Vol. 17, No. 3, 374–389, http://dx.doi.org/10.1080/13691058.2014.968806

Identifying factors that influence pregnancy intentions: evidence from South Africa and Malawi Emily Evensa*, Elizabeth Tolleyb, Jennifer Headleyb, Donna R. McCarraherb, Miriam Hartmannb, Vuyelwa T. Mtimkuluc, Kgahlisho Nozibele Manenzhec, Gloria Hamelad, Fatima Zulue and FEM-PrEP SBC Preparedness Research Groups in South Africa and Malawi a

Health Services Research, FHI 360, Durham, USA; bSocial and Behavioral Health Sciences, FHI 360, Durham, USA; cSetshaba Research Centre, Soshanguve, Pretoria, South Africa; dUNC Project, Tidziwe Centre, Kamuzu Central Hospital, Lilongwe, Malawi; eJohns Hopkins Research Project, Blantyre, Malawi (Received 6 February 2014; accepted 20 September 2014) In developing-country settings, pregnancy intentions are often assessed using a series of questions from the Demographic and Health Surveys, yet research conducted in several countries yields conflicting results regarding these questions’ ability to predict pregnancy. Conducted in Malawi and South Africa, this study identified individual, partner and societal factors that influence desire for pregnancy, and women’s ability to achieve their intentions. Data come from interviews and focus-group discussions conducted prior to the FEM-PrEP HIV-prevention trial with women from communities at high risk of HIV infection. Cultural norms regarding contraceptive use and childbearing influenced both women’s desire for pregnancy and ability to achieve those goals. Partner’s expectations for pregnancy, financial concerns, family composition and contraceptive experiences were additional influences. Actively planning for pregnancy was not a salient concept to the majority of participants. Results support the call for a multidimensional measure of pregnancy intention that reflects the variety of factors that influence intentions, highlight the fluid nature of many women’s reproductive health decision making and challenge the notion that all fertility decisions are the result of conscious action. Additional work on how women’s plans for pregnancy are achieved would be programmatically more useful than current measures of intention. Keywords: pregnancy; intentions; women; Malawi; South Africa

Introduction Understanding and measuring pregnancy intentions – defined as women’s desires or aims related to pregnancy – is important to family planning and HIV-prevention research and programmes. At the aggregate level, reproductive health programmes measure pregnancy intentions in order to assess unintended pregnancy and unmet need for contraception to help evaluate programme success and to determine where additional efforts are needed to help women achieve their reproductive goals. In addition, HIV-prevention trials have assessed pregnancy intentions in order to exclude potential study participants who desire to be pregnant within the study timeframe. Pregnancy is a concern because of the unknown effects of product use on an unborn foetus and because – in effectiveness trials – high rates of pregnancy reduce study power due to the required study product withdrawal

*Corresponding author. Email: [email protected] q 2014 Taylor & Francis

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(Raymond et al. 2007). Conflicting results from studies using dichotomous measures of fertility intentions call into question the validity of standard approaches to assessing pregnancy intentions and highlight the variety of influences on women’s reproductive aims. This paper presents a framework for a multi-dimensional conceptualisation of pregnancy intentions, based on empirical data from Malawi and South Africa, in order to improve understanding of factors that influence women’s desire for pregnancy and their ability to achieve them. Background Most standard measures of pregnancy intentions are based on assessing woman’s cognitive plans regarding pregnancy. In global health research, the most common measure of intentions is comprised of two standardised questions from the Demographic and Health Surveys (DHS): ‘Do you want to have a/another child or would you prefer not to have any (more) children?’ and ‘How long would you like to wait before the birth of a/another child?’ Studies conducted in developing countries have yielded conflicting results regarding the validity of these questions in predicting subsequent pregnancies (Vlassoff 1990; Tan and Tey 1994; Bankole and Westoff 1998; McCarraher, Bailey, and Martin 2005). While work in Malaysia found these questions to be good predictors of subsequent pregnancy, research studies in Morocco and Bolivia found them to be poor predictors (Tan and Tey 1994; Bankole and Westoff 1998; McCarraher, Bailey, and Martin 2005) In Malaysia, Tan and Tey (1994) found that only 12% of women who answered ‘no’ to the question ‘Do you want to have any (more) children?’ had a subsequent birth over a threeyear period. Of those unsure whether they wanted another child, approximately 40% had a birth, while more than half of those wanting another child gave birth within three years. In contrast, using Bolivia panel data from 1994 and 1997, McCarraher, Bailey and Martin (2005) found that 82% of births occurring between the two surveys were to women who stated that they wanted to postpone pregnancy for more than three years or forgo childbearing altogether. The standard measures of intentions have two shortcomings. First of these is the failure to consider the many factors demonstrated to influence women’s desire for pregnancy in developing-country settings. Several socioeconomic factors affecting intentions and their achievement have been identified by previous research, including a woman’s: age (Tan and Tey 1994; Roy et al. 2003; Myer, Morroni, and Rebe 2007); educational attainment and poverty status (Tan and Tey 1994; Williams, Abma, and Piccinino 1999); number of living children (Gipson and Hindin 2007; Myer, Morroni, and Rebe 2007; Raymond et al. 2007); the sex of those children (Vlassoff 1990); experience with child mortality (Montgomery et al. 1997; Roy et al. 2003; Gipson and Hindin 2007); marital or partnership status (Tan and Tey 1994; Schoen et al. 1999; Williams, Abma, and Piccinino 1999; Barrett and Wellings 2004); and the intentions of a women’s husband or partner (Tan and Tey 1994; Lasee and Becker 1997; Bankole and Singh 1998; Gipson and Hindin 2007). Finally, family members, particularly parents-in-law, have also been found to influence both fertility intentions and reproductive behaviours (Castle et al. 1999). The second shortcoming of standard measures of intention is that they assume – regardless of cultural setting – that fertility intentions are pre-defined and rationally determined. The concept of planning is based in what van der Sijpt (2014, 278) calls western ideas of ‘individual rights, autonomous action and rational choice’ with the understanding that when individuals are free to act in accordance with their intentions,

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they will attain their desired fertility outcomes. Qualitative research on childbearing decision making and fertility intentions in the UK and USA has begun to challenge the notion that fertility decisions are the result of conscious actions and that intended pregnancy is the goal of all women (Barrett and Wellings 2002, 2004; Esacove 2008). Work in developing-country settings has also begun to challenge notions of rationalitybased reproductive decision making, but data supporting this is more limited (Lasee and Becker 1997; Castle et al. 1999; Johnson-Hanks 2005; Gipson and Hindin 2007; van der Sijpt 2014). Recent research has highlighted the need for more nuanced measurement and understanding of intentions. Noting how conventional measures of intentions mask complex mental and social forces that drive behaviour, Bachrach and Morgan (2013) have developed a cognitive-social model of fertility intentions and suggest that combining existing survey measures with measures of social structures and the structural environment – such as women’s age, income and family composition – could help identify how intentions are formed and realised. Similarly, Speizer et al. (2013) have demonstrated the need for more nuanced measures of intention in order to identify women with ambivalent desires for future fertility who may benefit from family planning. To address these shortcomings, we propose a distinction between the terms intentions – women’s desires or aims related to pregnancy – and their plans – the method or steps for achieving their intentions. This study contributes to the literature on the formation and measurement of fertility intentions as well as strengthening understanding of how intentions are achieved. Using data from women in Malawi and South Africa, the paper has two objectives: (1) to identify individual, partner and societal-level factors that influence women’s intentions for pregnancy and (2) to identify factors that affect women’s ability to achieve their intentions (their plans). Study data Data come from the sociobehavioural and community (SBC) preparedness research conducted in several sites prior to implementation of the FEM-PrEP trial, a pre-exposure prophylaxis clinical trial that was designed to assess the effectiveness and safety of daily use of combined oral emtricitabine and tenofovir to prevent HIV infection among highrisk women. Preparedness research was conducted to gather data to ensure that the trial met community needs and to inform trial procedures (Van Damme et al. 2012). Several research and community activities were conducted, including semi-structured interviews (SSIs) and focus-group discussions (FGDs) with potential study participants to understand their pregnancy experiences, future pregnancy plans and contraceptive use experiences; these research activities were initially analyzed to inform contraceptive counselling during the trial. The data for this analysis are from Lilongwe and Blantyre, Malawi, and Pretoria and Cape Town, South Africa,1 collected in 2007 and 2008. Both SSIs and FGDs were conducted in each of the four study sites (see Table 1). Two types of individual interviews were conducted: those to assess pregnancy intentions and others on contraceptive use. The data collection guides for the SSIs and FGDs were semi-structured. Interviewers modified the content and sequence of questions in order to probe individual participants’ specific responses to prior questions; therefore, not all topics are addressed in a similar manner across SSIs. A total of 199 participants were included. Additionally, demographic data were gathered for all participants through a quantitative survey conducted prior to the interviews or focus groups.

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Table 1. In-depth interviews, by type, and focus-group discussions.

Blantyre Lilongwe Cape Town Pretoria Total participants

Pregnancy intentions (SSIs)

Contraceptive use (SSIs)

Pregnancy intentions (FGDs)

10 10 15 10 45

10 10 10 11 41

4 4 4 4 113

Note: SSIs ¼ semi-structured interviews, FGDs ¼ focus-group discussions.

Women were eligible for inclusion in the SBC research if they were at high risk of HIV exposure, using a broad definition of having, on average, at least one sex act per month in the past three months. Study staff also recruited women who were believed to exchange sex for money or gifts. Women could be HIV-positive, HIV-negative or have an unknown HIV status. All participants were at least 18 years old. South African participants were identified for SSIs and FGDs through bars and other related establishments identified during community mapping research, as well as through family planning and well-baby clinics. In Malawi, participants were recruited through establishments identified during community mapping activities, health centres and family planning clinics. Approximately 50% of all participants had children. The FGDs were segmented by parity (women with children and those without) as well as by women’s age. Both FGDs and IDIs were designed to investigate women’s views of women in their community, not their personal experiences. Methods We conducted qualitative analysis, emphasising an in-depth and inductive approach. The un-coded transcripts were first read in their entirety. Four co-investigators coded the data in order to identify factors influencing pregnancy intentions and plans; deductive codes were developed a priori based on findings from the study’s initial literature review. Inductive codes were developed to mirror language and themes emerging from the texts. Periodic inter- and intra-coder reliability checks were conducted to ensure agreement on systematic coding of data. Approximately 20% of all transcripts were subject to inter-rater reliability. To manage and analyse data, QSR International’s NVivo 8 qualitative data software package was used. Once coding was completed, the co-investigators generated reports for each code. Different dimensions of the coded theme, how sub-groups differed and hypotheses about how the theme in question related to other coded themes were examined. Data reduction was undertaken to distil information by using matrices and other visual displays in order to extract the most essential concepts and relationships. Additionally, a quantitative matrix was constructed to look at patterns of relationships between desire for children (classified as now, later, never, unsure) and factors thought to influence pregnancy intentions and plans. Analysis of the matrices allowed for the identification of how often certain themes emerged. We used Social Ecological Theory to identify contextual domains that influence pregnancy intentions and plans. This theory posits that individuals are nested within multiple layers of influence and, together, these levels affect behaviour (McLeroy et al. 1988). Using the literature and our data, we identified three levels of factors that shape a woman’s desire and ability to become pregnant or avoid pregnancy: societal, partner and

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individual. Societal factors include expectations of marriage and conventions related to childbearing. Partner factors encompass a sexual partner’s attitudes towards future pregnancy, as well as the nature of couple communication and decision-making processes. Individual factors relate to a woman’s desire to become pregnant to fulfil her own sense of self or purpose. In the remainder of this paper, we describe in greater detail the relationship between pregnancy intentions and plans and the various levels of influence, from the more distal societal norms and values, to intermediate interpersonal influences and, finally, to proximal individual experiences and practices. Ethical review Ethical approval for the original sociobehavioural and community (SBC) preparedness data was obtained from the local ethical review boards in each study site and the FHI 360 ethical review committee. The study protocol for the secondary data analysis reported here was approved by and conducted in full compliance with the reviews of the institutional review board at FHI 360. Results Data from a total of 199 women is included here, 113 in FGDs and 86 in SSIs. Results are presented in aggregate for both South Africa and Malawi and only mentioned by country when they differ substantially. Few differences between data from FGDs and SSIs emerged. Description of the study population Using the most recent population-level data available for both countries, 74% of women aged between 15 and 49 were married in Malawi (United Nations Department of Economic and Social Affairs Population Division 2013) and 46% of these women were using a contraceptive method (UNICEF 2010a). In South Africa, 61% of women aged 15 – 49 were married (United Nations Department of Economic and Social Affairs Population Division 2013) and 60% of women in union (married or with stable partners) were currently using a contraceptive method (UNICEF 2010b). HIV prevalence among adults aged 15 to 49 is estimated at 10% in Malawi compared to 17% in South Africa (UNICEF 2010a, 2010b). The average age among all participants was 26 (see Table 2). Participants had between one and six years of education, with women in South Africa having more education on Table 2. Participant demographic characteristics.

Age range (years) Average age (years) Highest level of education range (years) Highest level of education, average (years) Marital status (%) Never married Married Living with partner, not married Separated/divorced/widowed

Malawi

South Africa

All participants

18 – 35 25 1–6 3

18 – 46 28 2–6 5

18 – 46 26 1–6 4

15 43 2 40

84 9 3 4

50 25 3 22

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average than women in Malawi (five years versus three). Marital status differed dramatically between the two countries. Women in Malawi were much more likely to be married than South African women: 15% of women in Malawi had never been married, compared to 84% of women in South Africa. Very few women in either country were living with a partner without being married. Data on desire for future pregnancy were available for participants in the SSIs only (n ¼ 45); 44% of these women desired a child in the future, with rates similar in both countries (43% Malawi and 46% South Africa). Only 12% of women (13% Malawi and 11% South Africa), reported they were unsure about becoming pregnant in the future (data not shown). Pregnancy intentions Most women reported strongly held intentions regarding pregnancy. Among the 86 participants in the SSIs (data were not available for the FGD participants), 86% of women reported that they ‘definitely wanted a child’ or ‘definitely did not want a child’ in the future. Prospective planning for pregnancy was uncommon for most of the study population, however. Most women described their plans for childbearing as fluid over time and contingent on many factors: only 4 out of the 86 women participating in individual interviews described their last pregnancy as planned. Planning to prevent pregnancy was slightly more common. A minority of participants reported themselves to be active, adherent contraceptive users, some with and some without the involvement of a partner. The quote below illustrates the notion that not all fertility decisions are the result of conscious action and that planning for pregnancy is not the goal for most women: Participant: Now, I can say that I will have this number of children, but in the future it can be found that it is not like that. Interviewer: What do you mean? Participant: Maybe the number of children I am to give you today may exceed [the number I will have]. I cannot tell you what will happen in the future. There might be a change. (Malawian interview participant, married with one child)

Contraceptive experience Family planning use was common among SSI participants: 88% of women reported having used contraception in the past (96% in South Africa, 80% in Malawi) and 66% reported current use (61% in South Africa, 73% in Malawi). Contraceptive use was more common among study participants than women in general in both countries; this is likely due to the fact that all participants were sexually active and some were recruited through family planning clinics. Study participants generally viewed contraception as effective and the benefits of family planning were widely espoused. Contraception was used both for spacing and limiting births; in both South Africa and Malawi, women reported current family planning use even when they desired a pregnancy in the future, indicating the desire and ability to space births. In South Africa, women who had experience with a modern method of contraception were less likely to want a pregnancy than those who had not previously used a modern method. In Malawi, however, there appeared to be no relationship between previous use of a modern contraceptive method and decreased desire for fertility. Societal influences Pro-natalist norms were a strong influence on women’s pregnancy intentions. The expectation that all women have at least one child was widespread and desire for

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childbearing was universal. Some women felt that bearing children was their responsibility or that God created women to bear children. God was also seen as deciding who becomes pregnant and whether a pregnancy ends successfully. The desired number of children was greater in Malawi than in South Africa. Pregnancy and parenting were widely seen as defining women as adults and worthy of respect. Most women perceived significant benefits to childbearing. Children were commonly seen as enriching their family’s lives by providing emotional joy and assistance with household chores or financial support, especially when parents become older. This was particularly true in Malawi. Additionally, in Malawi, children were seen as essential for the successful growth and development of the nation: . . . really and truly, every woman would like to have a child, even if it is [just] one, like myself. I’m planning to have one child . . . it is important, so that you have a child in your house to send wherever you want . . . and when that child has grown he will look after you when you are an elderly person and you can no longer do things on your own maybe because of your health. (South African interview participant, unmarried with no children) It is important to have children at home, because we Malawians believe that once one has children, she or he is rich. Children are taken to be wealth, because they help in many things. For example, when the parents grow old, the children will be able to feed and clothe their parents for they are the ones who are strong and the parents weak. (Malawian focus-group discussion participant, married)

Viewing children as adding value was not always synonymous with women’s desire for pregnancy; both women who desired children and those who did not expressed the belief that children enrich parents’ lives. There may be a threshold effect such that once women have one or more children they no longer desire more, despite their belief in the value and necessity of having children. Social conventions regarding childbearing were commonly linked to marriage, with the expectation that every marriage produce children and that a first pregnancy should occur soon after marriage. Women with no children, particularly married women, were viewed suspiciously and often subject to ridicule. Pressure to bear children was common and failure to do so brought guilt and shame, while pregnancy was often greeted with enthusiasm and support from family.

Attitudes towards contraception Social perceptions regarding contraceptive use exerted a strong influence on women’s plans for achieving their childbearing intentions. Concerns over contraception, including misconceptions discouraging family planning use, were plentiful. Together, these could exert an influence on contraceptive use, which in turn could influence women’s ability to achieve their intentions. The fear that family planning causes infertility – a condition stigmatising in both Malawi and South Africa – was also commonly cited as a reason for contraceptive non-use and discontinuation. Finally, societal norms regarding the timing of contraceptive use also influenced plans for pregnancy. Study participants, particularly those in Malawi, expressed specific ideas regarding the suitable time to begin family planning use; contraceptive use before marriage and the birth of a first child was not seen as appropriate: Interviewer: When do you think is the right time to start using contraception? Is it before giving birth, after giving birth, before marriage or when married? Participant: When married and you have children because there’s no way one can be using contraception while she has no child. (Malawian focus-group discussion participant, divorced)

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HIV-related concerns Societal norms regarding HIV and childbearing reflected the high HIV prevalence of the two study settings; concern over HIV and AIDS was common, with 25% of women stating that HIV affected their intentions for pregnancy. The direction of the influence HIV exerted on pregnancy intentions was not consistent, however. While some women reported wanting children earlier in their childbearing years because they feared that contracting HIV was inevitable, many others felt that the prospect of becoming infected with HIV decreased their desire for children and increased the risk associated with pregnancy for both women and babies. The belief that HIV-positive women should not get pregnant at all was also voiced, though stigmatising attitudes towards HIV-positive women who bore children were not frequently expressed. HIV testing was a specific worry: most participants felt that women should be tested for HIV prior to becoming pregnant or giving birth. However, some women reported being fearful of becoming pregnant, because they did not want to be tested for HIV – routinely administered as part of antenatal care: Interviewer: Of the women you know, how necessary is it for them to have children in a few years to come? Participant: It’s necessary for them to have children now before AIDS gets the women first. (Malawian focus-group discussion participant, unmarried) Interviewer: Is it important or not important for woman in your community to become mothers? Participant: It is not important anymore. Interviewer: Why are you saying it is not important anymore? Participant: Because HIV is all over; there is no need to have children who have HIV. I don’t want to have sick children. (South African focus-group discussion participant, unmarried)

Partner influences Factors related to marriage and partnerships were key influences on both women’s pregnancy intentions and their ability to achieve those intentions; partnership status, decision-making control and financial influences were important components of partnerrelated influences on pregnancy intentions. The role of partnership status Partners and partnership status were intimately linked with desire for pregnancy. Generally speaking, women said they would ideally like to be married before becoming pregnant. As expected, this view was more common in Malawi than in South Africa, where more participants were married or had been married. Women in both countries expressed the expectation that all marriages produce children and married women commonly reported being unable to refuse a husband’s request for sex or pregnancy. Changes in partnership status also affected pregnancy intentions; newly married or remarried women were more likely to report wanting a pregnancy. Unmarried women reported they generally did not intend to become pregnant and could control both when they had sex and when they became pregnant. However, they also stated they were often at risk of unintended pregnancy resulting from being misled by men or forced into transactional sex. A woman’s desire for pregnancy was also related to the quality of a relationship; women reported lack of desire for pregnancy when there were marital troubles or a suspicion of infidelity. However, pregnancy was also viewed as a means of saving a

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troubled relationship, with women reporting that men would not divorce a woman with whom they had many children: A child strengthens the bond of marriage. A man and a wife can quarrel and fight but if there’s a child in the house [it] can make you stop fighting. (Malawian focus-group discussion participant, unmarried)

Decision making The degree to which women saw themselves as in control over reproductive decisionmaking affected their ability to achieve their plans for pregnancy. Many women reported they had control over their contraceptive use and pregnancy; women in both countries stated that their own desires were more influential than partners or ‘important others’ in fertility decision making. More than 75% of women identified themselves as having the primary influence in fertility decision making. This was often justified by women because they bore the burden of giving birth and had the primary responsibility for caring for children: I can have the power because I am the one who gives birth and also it is a woman who has more responsibilities over the children, because she is the one who takes care of them; she is most at home, seeing what the children are doing. But the husband, he just gives you money. You are the one who makes the programme of what to do at home so you have the power of deciding what number of children you want or you can even say the money you are giving me is not enough because we have more children. (Malawian interview participant, married with one child)

After women themselves, partners were seen as having the most influence on fertility decision making. Approximately half of women in both countries mentioned partners as an influence on fertility decision making. Numerous women reported that they made decisions regarding contraceptive use and pregnancy jointly with a partner; a smaller group reported that their partners make these decisions alone. Among this group, husbands were described as affecting women’s ability to achieve their intentions due to their controlling influence on contraceptive use and family size. Conversely, single women frequently expressed the view that they could control their fertility because they were not married: Interviewer: How much control do you feel you have in determining the number of children you have? Participant: Because I don’t have a husband . . . I have control, much control, because I can be able to say that at this time I have to have another child or I should not. Because I am alone, [I] am not married. (Malawian interview participant, unmarried with two children) It would be both our decision. I can’t make that decision alone and must discuss it with him. Because when you are partners, you are communicating so whatever you or he is doing you must know it and not take a decision alone. (South African interview participant, married with one child) The husband takes himself as the head of the house and always wants to lead. Whatever he says is final. Even when discussing about childbirth, he always wants to lead. That is why the views of women are not taken or considered, for they [men] think they [women] are fools. (Malawian interview participant, married with two children)

Financial influences Financial factors were a strong influence on intentions at the partner level, with 25% of women citing finances as an issue related to their desire for pregnancy. Women reported that economic concerns determined whether a woman or couple wanted children and how many children they desired. Financial preparation prior to pregnancy and childbearing – defined as having money or a husband with a good job – was highly desired. Providing

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financial support for children was identified as a primary responsibility of male partners. Expectations that men provide financially for children were not always fulfilled, however, and women saw financial stability as their own responsibility when partners were unable to provide. The influence of finances on thoughts about pregnancy was stronger in South Africa than in Malawi: Interviewer: How do women decide the number of children they are going to have? Participant: Maybe it depends to the number of children you already have and if you are working and if your partner is working. You cannot have so many children if you are not working. It also depends on the moneywise if you can afford them, so that you can be able to provide what they want. (South African interview participant, married with two children)

Individual influences Pregnancy intentions were influenced by factors at the individual level. The composition of a woman’s family – the number, age and sex of her living children – as well as her attitudes towards and experience with contraception were frequently cited as influences on childbearing plans. Many women expressed the wish to avoid pregnancy when they had achieved their desired number of children or what they viewed as large families. Women in Malawi reported wanting more children than women in South Africa. However, generally, in both countries, the desire for children decreased as the number of children a woman had increased. Women also emphasised the importance of sufficient birth spacing for both women’s health and their children’s wellbeing. However, women appeared to consider the need for birth spacing more in Malawi than in South Africa, perhaps because of larger desired and actual family size. Finally, the sex of children was often a determinant in desire for future pregnancy. Women with both male and female children often reported not wanting further pregnancies: Interviewer: Ok, you said you have two children. How do you feel about the number of children you have? Participant: I am happy because when you look at them, you will see that each had enough time for herself because there is space between them. They were not born too close to each other. The first child had enough time before the second child was born. (Malawian interview participant, married with two children)

Study participants also expressed specific ideas regarding the ideal timing for childbearing. Women in their late-teenage years or early-twenties were viewed as physically and mentally mature enough for childbearing; pregnancy before this or much after was viewed as difficult for women and hazardous to their health: . . . a person should get pregnant at a right time, maybe get pregnant when you are married – not . . . have a child whilst you are still a child. (South African interview participant, married with one child) When a woman is either very old or very young . . . women face complications during pregnancy and delivery. Women who die during delivery are mostly of these ages, which [are] very old or very young. (Malawian focus-group discussion participant, married)

Attitudes towards contraception Individual perceptions and experiences with contraceptive use exerted a strong influence on women’s plans for achieving their childbearing intentions. Concerns over contraception in general were strong, with close to 70% of women expressed concern over side-effects: and effectiveness, concerns being more frequently expressed among

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current contraceptive users in Malawi than in South Africa. While women widely viewed contraception as effective, a small proportion reported that contraception does not work, either in general, or for them specifically. Some women reported becoming pregnant because they did not, or would not, use contraception, even if they did not want to become pregnant, due to health concerns and fear over contraceptive side-effects: Interviewer: Why do you think this happens that they should have more children than they want to? Participant: Because they fail to use family planning methods. There are some who are afraid. I can be using the . . . injectable and I can tell my friend and she can say ‘I’ve heard that the injection hurts’, or it causes backache or maybe [it] fail[s] to work. So, someone cannot go to get the injectable because of that. They end up just giving birth. (Malawian interview participant, unmarried with no children)

Financial influences Financial factors were a strong influence on intentions at the individual level, with women planning, or perceiving the need to plan, pregnancies based on their financial resources. While male partners were seen as a primary resource for financial support, women, particularly in South Africa, commonly reported they based family size determinations on their own ability to support children in case a partnership dissolved. Similarly, women often expressed the desire to finish schooling prior to becoming mothers. Conversely, pregnancy was not desired when there were economic problems or a lack of financial security. Some women reported having children to increase their financial security in old age and some describe how grown children provide economic support to their mother, parents or even their whole village: There are some people who say ‘I want to have this number of children for I will be able to provide all the necessities to my children.’ But, if I am to have many children, then I will not be able to support my family according to my financial standing. So it is better to choose the number of children you know you will be able to manage. (Malawian interview participant, married with one child)

Discussion This study was designed to identify factors that influence desire for pregnancy among women in South Africa and Malawi who participated in preparatory activities for an HIVprevention clinical trial. Our analysis determined there are two sets of influences on reproductive behaviours: factors that influence women’s goals or plans for pregnancy, which we call intentions, and factors that affect women’s ability to achieve those intentions, which we call plans. We used Social Ecological Theory to determine whether factors influence pregnancy intentions and plans at the societal, partner and individual levels. Some factors were found to exert their influence on pregnancy intentions at multiple levels, for example, while norms surrounding contraceptive use influence women at the societal level, individual attitudes towards and experience with contraception function at the individual level. Similarly, finances influenced women’s thoughts on childbearing at both the individual and partner level and partnership status was important at the societal and partner levels. Factors influencing pregnancy intentions Many of the factors identified in the literature as influencing women’s pregnancy intentions were found to be key to the development of women’s desires or aims related

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to pregnancy in this population. These include: pro-natalist norms, HIV-related concerns, partnership status and quality, financial factors and a woman’s family composition. Social norms surrounding fertility were found to be central to women’s plans for pregnancy. Nearly universal expectations for childbearing and strong social penalties for those who do not become parents influence women – especially those with no children – to become pregnant. HIV-related concerns were another factor influencing pregnancy intentions. They were most often mentioned at the individual level, with women expressing concern over the inevitability of HIV infection and the potential to infect their children. The salience of HIV and its influence on pregnancy intentions may be a result of the study sample – participants were selected from communities at high risk of HIV where an HIV-prevention trial was to be implemented. Given that the majority of HIV infections are due to heterosexual sex in both Malawi and South Africa, HIV is intrinsically an interpersonal issue. However, concern over the HIV status of a partner was not mentioned, nor did women often describe social stigma related to HIV-positive women bearing children. Partnership status – especially the transition to marriage – was associated with a desire for pregnancy. However, while women commonly reported intending to become pregnant shortly after marriage, planning for pregnancy was much less likely after the first birth. Unmarried women rarely reported intending to become pregnant. Results from Malawi emphasised the importance of marriage prior to childbearing, a finding not reflected among the South African participants. Findings on the relationship between marital status and pregnancy planning and variations in this relationship between the two countries are also supported by DHS data (MEASURE DHS 2010). The quality of a relationship was linked to intentions, with women reporting that poor quality relationships decreased or eliminated their desire for pregnancy. Several of the factors identified in our analysis as influences on women’s desires for future pregnancy are supported by previous research. We found the number, age and sex of a woman’s children were key to her pregnancy intentions. The influence of family size on future desire for children is supported by DHS data that demonstrates a decrease in desire for future fertility as woman’s number of children increases (MEASURE DHS 2010). Economic status, particularly, poverty, was also an important influence on desire for pregnancy. Factors influencing women’s plans for pregnancy The concept of active planning for a pregnancy was not common or relevant to the majority of study participants. Many women describe their reproductive health decision making as fluid and responsive to multiple factors. Moving beyond factors that influence the development of pregnancy intentions, we identified three factors that influence women’s ability to achieve their intentions: attitudes towards contraception, decisionmaking power and financial factors. As identified in the literature, contraceptive use is an important influence on plans for pregnancy. Generally, planning to prevent pregnancy was more common than planning to become pregnant, likely due – at least in part – to social pressures that dictate that all women should become mothers. Contraceptive use indicated women’s strong desires not to get pregnant, and the use of family planning for spacing and limiting births was common for women who had completed or exceeded their ideal family size or those experiencing financial difficulties.

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Lack of contraceptive use, however, did not necessarily indicate a desire for pregnancy. Concerns about contraceptive side-effects were common and participant’s experience with side-effects seems to be an important influence on whether and how contraception is used. However, caution must be exercised in linking failure to use contraception or imperfect use with a desire for pregnancy. While some women’s concerns about contraceptive side-effects or other method-related issues, such as effectiveness, could outweigh concerns or inconveniences associated with pregnancy, for other women a prospectively planned pregnancy is not the goal. This underscores a key finding of this research – women may have developed thoughts related to their desire to achieve or avoid a future pregnancy, but fertility decisions that were the result of conscious contraceptive actions were uncommon. The degree to which women saw themselves as being in control over reproductive decision making was another important factor in women’s ability to achieve their plans for pregnancy. The influence of partners ran in a continuum from those women who reported that men made the decisions on contraceptive use and pregnancy, to those women who felt that decisions should be made jointly with partners, to those who reported that they were the sole decision makers. Finally, financial factors were a strong influence on plans for pregnancy, with women planning, or perceiving the need to plan, pregnancies based on their financial resources. Several other findings identified by previous research were not reflected among this population. Experience with child mortality did not emerge as an influence on pregnancy intention or plans, neither did degree of certainty with which women held their intentions. Familial preferences also were not identified as a meaningful influence. However, given the strong importance of social norms surrounding fertility, it is likely that the influence of family was subsumed in the more overarching social expectations surrounding pregnancy. Data for this study come from a relatively small sample of women identified as being at high risk for HIV and drawn from communities where an HIV-prevention trial was to be initiated. Participants’ pregnancy intentions could therefore be different from the larger general population of women in South Africa or Malawi. While individual women vary in both their risk of HIV and reproductive decision making, given that both of these countries have generalised HIV epidemics, study participants may not be significantly different from other women. Conclusion Qualitative data, such as this research, can provide important insight into relevant domains for a more sensitive measure to predict pregnancy. This study identified multiple factors influencing women’s intentions for pregnancy including: pro-natal social norms, HIVrelated concerns, partnership status and the quality of the relationship, available financial resources and demographic characteristics. As women’s intentions for pregnancy are influenced by many factors, methods of assessing intentions could be improved by expanding current dichotomous measures into multidimensional tools to capture the influence of these factors. Study findings on the rarity of women’s active planning for pregnancy highlight the possibility that the ability to operationalise pregnancy intentions is likely a separate process from their initial formation. A woman’s ability to realise her intentions are likely influenced by multiple factors, especially her attitudes towards and experiences with contraception and the degree to which she can control or influence reproductive

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decision-making. Fertility outcomes, we conclude, are the result of an interplay between intentions, plans to achieve those goals and the motivation to implement the plans. Women who become pregnant while participating in clinical trials of new HIVprevention products are usually taken off the product due to safety concerns. Indeed, high pregnancy rates contributed to the inability of several past trials to determine effectiveness of products they were testing (Raymond et al. 2007). A more sensitive approach to predicting pregnancy – one that could be easily administered within research and programmatic activities – could aid HIV-prevention trials to better screen potential participants or monitor and respond to changing pregnancy intentions during trial participation. Improved knowledge and measurement of pregnancy will also enable public health research and programmes’ efforts to understand whether, when and how women form and achieve their fertility goals. This in turn could help clinicians and women themselves gain clarity on decisions about whether or which contraceptive or fertilityenhancing measures to undertake. Like other research in Western and developing-country settings, this study provides data that challenges notions of rationality-based reproductive health decision making. While attempts to measure pregnancy intentions could likely be improved by incorporating a range of factors about a woman’s life, family and social environment, reproductive health programmes and interventions to decrease ‘unintended pregnancy’ must acknowledge that not all fertility decisions are the result of conscious actions and measures of women’s motivation to achieve their plans for pregnancy may be more useful than current measure of intention alone. Ultimately, we conclude it may be more beneficial to individual women for health professionals and the tools they use to not focus solely on whether they have or had conscious plans for pregnancy (Fischer et al. 1999). Balancing clinical and programmatic needs for predicting pregnancy with the fluid processes of navigating reproductive actions that are not based on a prospective, cognitive process common in many women is the important and difficult task ahead.

Acknowledgements The FEM-PrEP SBC Preparedness Research Groups in South Africa and Malawi comprise Khatija Ahmed, Lameck Chinula, Amy Corneli, Irving Hoffman, Laura Johnson, Michele Lanham, Bonus Makanani, Kevin McKenna, Monique P. Mueller, Josh Murphy, Caleb Parker, Joseph Skhosana and Lut Van Damme.

Funding This work was made possible by the generous support of the US Agency for International Development (USAID) under the terms of Cooperative Agreement No. GPO-A-00-05-00022-0, the Contraceptive and Reproductive Health Technologies Research and Utilization programme and the Preventive Technologies Agreement (PTA), GHO A 00 09 00016-00. The contents do not necessarily reflect the views of USAID or the United States Government. Additional funds were provided by FHI 360.

Note 1.

The FEM-PrEP trial was subsequently not implemented in Malawi or in Cape Town, South Africa.

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Re´sume´ Dans les pays en de´veloppement, les intentions de grossesse sont e´value´es avec une se´rie de questions tire´es des enqueˆtes sur la de´mographie et la sante´. Pourtant les recherches conduites dans plusieurs de ces pays aboutissent a` des re´sultats contradictoires, en ce qui concerne la fiabilite´ de ces questions pour la pre´diction des grossesses. Conduite au Malawi et en Afrique du Sud, cette e´tude a identifie´ les facteurs individuels lie´s aux partenaires et aux contextes socie´taux qui influencent le de´sir de grossesse et la capacite´ des femmes d’accomplir ce de´sir. Les donne´es proviennent d’entretiens et de groupes de discussion the´matique mene´s pre´alablement a` l’e´tude sur la pre´vention FEM-PrEP qui avait recrute´ des femmes issues de communaute´s fortement expose´es au VIH. L’e´tude a re´ve´le´ que les normes culturelles autour de la contraception et de la procre´ation influenc
aient a` la fois le de´sir d’enfant et la capacite´ des femmes d’atteindre cet objectif. Les attentes des partenaires en matie`re de grossesses, de pre´occupations e´conomiques, de composition de la famille et d’expe´riences de contraception repre´sentaient, elles aussi, des facteurs d’influence. Pour la majorite´ des participantes, la planification active des grossesses ne s’est pas re´ve´le´e comme e´tant un concept fondamental. Les re´sultats te´moignent de la ne´cessite´ d’une mesure multidimensionnelle des intentions de grossesse pouvant refle´ter la diversite´ des facteurs d’influence de ces intentions, souligner la nature fluide de la prise de de´cision de nombreuses femmes en matie`re de sante´ reproductive et contester la notion selon laquelle les de´cisions en matie`re de fertilite´ re´sultent d’une action consciente. Un travail d’enqueˆte additionnel sur l’aboutissement de la planification des grossesses par les femmes serait plus utile, au plan programmatique, que les mesures actuelles des intentions de grossesse.

Resumen En el contexto de los paı´ses en desarrollo, las intenciones de embarazo son evaluadas a partir de la aplicacio´n de una serie de preguntas asentadas en las Encuestas Demogra´ficas y de Salud; sin embargo, las investigaciones realizadas en varios paı´ses arrojan resultados encontrados respecto a la eficacia que muestran dichas preguntas a la hora de predecir las intenciones de embarazo. El presente estudio, realizado en Malaui y Suda´frica, identifico´ varios factores – individuales, sociales y de pareja– que influyen en el deseo de embarazarse y en la capacidad de las mujeres de lograr sus propo´sitos. Los datos al respecto fueron obtenidos a partir de la realizacio´n de entrevistas y de dia´logos efectuados en grupos focales. E´stos se llevaron a cabo antes de que se implementara un ensayo de prevencio´n del vih entre mujeres pertenecientes a comunidades con alto riesgo de infeccio´n, el cual fue impulsado por fem-prep. Las normas culturales existentes en torno al uso de anticonceptivos y a la maternidad, inciden tanto en el deseo de embarazo de las mujeres como en su capacidad de lograr sus propo´sitos. Otras influencias en este sentido tienen que ver con las expectativas de la pareja respecto al embarazo, las preocupaciones econo´micas, la composicio´n de la familia y las experiencias en el uso de anticonceptivos. Se constato´ que, para la mayorı´a de las participantes, la planeacio´n activa del embarazo no es una idea prominente. Los resultados del estudio respaldan el llamado a instrumentar un me´todo multidimensional para medir las intenciones de embarazo, que abarque los muchos factores que influyen en e´stas, que recalque la naturaleza cambiante de las decisiones que las mujeres toman en relacio´n a su salud reproductiva y que cuestione la idea de que todas las decisiones relativas al embarazo son el resultado de la accio´n consciente. Estudios adicionales orientados a determinar co´mo la mujer logra hacer planes en torno al embarazo pueden resultar ma´s u´tiles en lo programa´tico que los actuales para´metros utilizados para evaluar la intencio´n.

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