Unintended pregnancy, contraceptive use, and childbearing desires among HIV-infected and HIV-uninfected women in Botswana: across-sectional study

This is the first published data on unintended pregnancy, contraceptive use and HIV serostatus in Botswana, a country where 30.4 % of women of reproductive age are HIV-infected [13]. We found that both contraceptive failure (or misuse) and unmet need for family planning may have contributed to the high levels of unintended pregnancies among both HIV-infected and HIV-uninfected women, similar to findings from other recent studies in sub-Saharan Africa [10, 18]. Overall, 44 % of women from two areas of Botswana reported that their pregnancy was unintended. The Botswana 2013 Global AIDS Response Report estimated levels of unplanned pregnancy at 50 % [19]. Factors associated with unintended pregnancy in our study were similar to those found in other studies in sub-Saharan Africa [10, 20].

Reported contraceptive use prior to unintended pregnancy was high (64 %), but the methods used were exclusively short-acting requiring daily (OC), quarterly adherence (DMPA), or with every act of sexual intercourse (male condom). The vast majority of women with an unintended pregnancy (81 %), regardless of HIV serostatus, reported relying on the male condom for contraception. Our findings suggest that reliance on condoms for pregnancy prevention is not an effective strategy. This is supported by recent studies in areas of high HIV prevalence, which have shown that more effective methods of contraception are substituted for male condom-only use [20–22]. Women and couples should be informed that while male condoms are the only contraceptive method that can reduce the risk of sexually transmitted infections including HIV and that their correct and consistent use is imperative in that regard, they may have a high failure rate for pregnancy prevention. This is likely due to low levels of correct and consistent use, with a typical-use contraceptive failure rate for the male condom of about 21 % within the first year [23]. Ideally in the context of high levels of HIV infection, a dual method approach (i.e., combining condoms, male or female, with a highly effective contraceptive method) should be promoted [4].

Our data highlight the urgent need for women’s access to effective contraceptive methods that align with pregnancy intentions and reduce the potential for incorrect or inconsistent use. LARCs such as the intrauterine device (IUD) and the contraceptive implant reduce or eliminate the need for daily or per-act of intercourse adherence. The IUD is not frequently provided in Botswana’s public health sector, with its use among women aged 12–49 having peaked at 4.1 % in the late 1980’s and declining since to about 0.8 % in 2007, due to now disproved safety concerns about IUD use in the context of HIV [24]. Sterilization has never been widely practiced in Botswana (utilized among 2 % of women aged 12–49 from 1985 to 2007) [24]. Fortunately, the Botswana Sexual and Reproductive Health Department has recently prioritized increasing the supply of and demand for the LARC methods (personal communication, Sexual and Reproductive Health Division, Botswana Ministry of Health).

Further objectives of our study were to examine heterogeneity in unintended pregnancy, contraceptive use and future childbearing desires by HIV serostatus. We found that 26 % of HIV-infected women reported not knowing their HIV status prior to conception. While it is possible that some of these women did in fact know that they were HIV-infected but were not comfortable disclosing this at the time of study enrollment, this may also suggest missed opportunities for HIV diagnosis prior to pregnancy, and thus missed opportunities for pregnancy planning and safer conception or contraceptive counseling for HIV-infected women. Sixty-nine women (15 %) who reported known HIV-uninfected status before pregnancy were diagnosed with HIV during their pregnancy, possibly reflecting a high risk of seroconversion in pregnancy than has been previously reported in Botswana [25] or elsewhere (some of these women may also have known that they were HIV-infected pre-conception but not disclosed this at study enrollment, as noted above). These findings support the need for continuing HIV-prevention efforts before and during pregnancy.

Levels of unintended pregnancy were high irrespective of knowledge of HIV serostatus prior to becoming pregnant. The prevalence of unintended pregnancy was significantly higher among women who reported not knowing their HIV status (52 %) compared to those who knew they were HIV-uninfected (38 %) even after controlling for other factors. Considering that HIV-infected women generally maintain regular contact with health services and may have strong motivations to prevent pregnancy, it is discouraging that unmet needs for effective family planning were high. That women of unknown HIV status report the highest levels of unintended pregnancy is not surprising given that these women may be the least engaged with health services of any kind.

Levels of contraceptive use prior to the unintended pregnancy and method type did not differ by knowledge of HIV serostatus prior to becoming pregnant. This contrasts with recent data from Zambia [26] where contraceptive use at time of conception was higher in HIV-infected women than their HIV uninfected counterparts. Other studies from sub-Saharan Africa have shown that HIV-infected women may have poorer access to contraception than HIV-uninfected women, potentially due to barriers accessing family planning services or fear of stigma from providers [27–29]. Previous studies from Southern Africa have found that safe and effective long-acting methods are sometimes not recommended by providers or accessible to women living with HIV due to limited knowledge and skills of the health care workers providing HIV services; lack of operational guidelines; and poorly integrated reproductive health/family planning and HIV services [22, 30–32]. Historically, HIV and family planning services have been provided separately in Botswana. There are current efforts by the Botswana Ministry of Health to integrate and link strategies across health services [33]. Our data suggest that in Botswana the challenges to obtaining effective contraception may apply relatively equally to both HIV-uninfected and HIV-infected women.

Most participants (61 %) reported not wanting additional children in the future, and this was strongly and independently associated with being HIV-infected, though it is important to note that a large proportion of HIV uninfected women also reported not wanting more children. Unfortunately, we did not collect data on post-partum contraceptive counseling or use, and thus cannot comment on how women’s post-partum contraceptive use will or will not allow them to meet their stated future childbearing desires. However, the methods most widely available and promoted in Botswana at present (male condoms and OCs) are unlikely to enable many of these women to achieve their stated desires. Long-acting reversible and permanent methods are considered the most appropriate for women who do not want more children [34, 35].

It is important to note that while this study was focused on unintended pregnancy, 51 % of pregnancies were intended among women who knew that they were HIV-infected at the time of conception. When asked about future childbearing plans, 23 % of HIV-infected women reported wanting (or not knowing if they wanted) more children in the future. Research indicates that health care providers seldom discuss family planning with their HIV-infected clients [36]. Nevertheless, accumulating data, including these data from Botswana, indicate that HIV-infected women continue to seek and achieve pregnancy following diagnosis with HIV infection [17, 36–38]. Supportive, informed patient–provider communication about fertility intentions and safer conception is essential in this context.

This study has limitations. We assessed HIV status at the time of conception by self-report and did not have data on the timing of the most recent HIV test. Our pregnancy intention measure was a simplification of commonly used measures, and did not distinguish unwanted versus mistimed pregnancies, limiting direct comparison with some other studies. Reporting of pregnancy intention may have been subject to reporting bias, especially if HIV-infected women are differentially counseled to delay or avoid childbearing and over-report unintended pregnancy, and the reporting of condom use by known HIV positive women may be subject to social desirability bias. Furthermore, in our analysis of factors associated with pregnancy intention there may be unmeasured confounders that would bias our estimates of independent effect, which must be considered when interpreting the results. Finally, we did not collect information on desire for contraception prior to conception or post -partum.