Unintended Pregnancy among HIV Positive Couples Receiving Integrated HIV Counseling, Testing, and Family Planning Services in Zambia

Kristin M Wall,William Kilembe,Naw Htee Khu,Cheswa Vwalika,Bellington Vwalika,Elwyn Chomba,Rob Stephenson,Amanda Tichacek,Ilene Brill,Susan Allen,Lisa Haddad,Willem Daniel Francois Venter

doi:10.1371/journal.pone.0075353

Abstract

ObjectiveWe describe rates of unintended pregnancy among HIV positive couples in Lusaka, Zambia. We also identify factors associated with unintended pregnancy among oral contraceptive pill (OCP) using couples in this cohort.DesignData were analyzed from couples randomized in a factorial design to two family planning intervention videos.MethodsRates of unintended pregnancy were stratified by contraceptive method used at time of pregnancy. Predictors of time to unintended pregnancy among OCP users were determined via multivariate Cox modeling.ResultsThe highest rates of unintended pregnancy were observed among couples requesting condoms only (26.4/100CY) or OCPs (20.7/100CY); these rates were not significantly different. OCP users accounted for 37% of the couple-years (CY) observed and 87% of unintended pregnancies. Rates of unintended pregnancy for injectable (0.7/100CY) and intrauterine device (1.6/100CY) users were significantly lower relative to condom only users. No pregnancies occurred among contraceptive implant users or after tubal ligation. Factors associated (p<0.05) with time to unintended pregnancy among OCP users in multivariate analysis included the man wanting more children, the woman being HIV negative versus having stage IV HIV disease, and the woman reporting: younger age, no previous OCP use, missed OCPs, or sex without a condom.ConclusionsLong-acting reversible contraceptive methods were effective in the context of integrated couples HIV prevention and contraceptive services. Injectable methods were also effective in this context. Given the high user failure rate of OCPs, family planning efforts should promote longer-acting methods among OCP users wishing to avoid pregnancy. Where other methods are not available or acceptable, OCP adherence counseling is needed, especially among younger and new OCP users.Trial registrationClinicalTrials.gov NCT00067522

Highlights

Though the Total Fertility Rate (TFR), or average number of births a woman has in her lifetime, has declined in sub-Saharan Africa from 6.5 in 1950 to 5.1 in 2010, this trend has not been sufficient to address the region’s rapid population growth of 2.5% per year [1]
The majority (87%) of all unintended pregnancies occurred among women using oral contraceptive pill (OCP), who accounted for 37% of the CYs observed (Table 1)
OCP users were on average 28.4 years of age for women and 34.4 years of age for men, and couples had an average of 2.1 living children at baseline

Summary

Introduction

The Demographic and Health Surveys estimate that 10–65% of all pregnancies in the region are unintended, varying by country and age group [2]. Preventing unintended pregnancy via contraception, a key public health challenge, reduces maternal and child mortality, rates of abortion, and poverty while improving socioeconomic status, access to education, and gender equity [3,4,5,6,7]. Up to an estimated 40% reduction in maternal deaths related to unintended pregnancy could be achieved with contraceptive use [6]. In countries with generalized HIV epidemics and low contraceptive use, improving family planning services among HIV positive and high-risk women is critically important to reduce unintended pregnancy and the burden of mother-to-child transmission of HIV

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Discussion

Conclusion