Fertility Desire and Associated Factors among People Living with Human Immune Virus on Anti-Retro Viral Therapy Southern Ethiopia

  

    
Variable
    
Fertility desire
    
Crud Odds Ratio

      (95% CI)
    
Adjusted Odds Ratio

      (95%CI)
    
P-value
  
  

    
No
    
Yes
  
  

    
Age of the participants
    
 
    
 
    
 
    
 
    
 
  
  

    
18-30 years
    
11
    
107
    
7.964 (4.107, 15.441)**
    
2.971 (1.06,8.27)*
    
.037
  
  

    
= 30 years
    
131
    
160
    
1
    
1
    
 
  
  

    
Sex
    
 
    
 
    
 
    
 
    
 
  
  

    
Male
    
46
    
140
    
2.301 (1.501, 3.521)**
    
2.677 (1.272, 5.633)**
    
.009
  
  

    
Female
    
96
    
127
    
1
    
1
    
 
  
  

    
Educational status
    
 
    
 
    
 
    
 
    
 
  
  

    
No formal education
    
88
    
114
    
0.273 (0.090,0.830)*
    
0.368 (0.038, 3.525)
    
.321
  
  

    
Primary education
    
35
    
94
    
0.565 (0.180, 1.778)
    
0.718 (0.072, 7.195)
    
.386
  
  

    
Secondary education
    
15
    
37
    
0.519 (0.151, 1.784)
    
0.361 (0.032, 4.098)
    
.778
  
  

    
College and above
    
5
    
19
    
1
    
1
    
 
  
  

    
Monthly income
    
 
    
 
    
 
    
 
    
 
  
  

    
<1000 EBR
    
84
    
60
    
0.131 (0.060, 0.287)**
    
0.283 (0.081, 0.953)*
    
.042
  
  

    
1000-5000 EBR
    
47
    
144
    
0.563 (0.257, 1.232)
    
1.125 (0.336, 3.772)
    
.848
  
  

    
>5000 EBR
    
9
    
49
    
1
    
1
    
 
  
  

    
Knowledge about PMTC
    
 
    
 
    
 
    
 
    
 
  
  

    
Yes
    
97
    
224
    
2.094 (1.277, 3.434)
    
0.847 (0.262, 2.737)
    
.782
  
  

    
No
    
39
    
43
    
1
    
1
    
 
  
  

    
At least one ANC follow up /partners if male
    
 
    
 
    
 
    
 
    
 
  
  

    
Yes
    
52
    
75
    
0.667 (0.429, 1.038)
    
0.690 (0.287, 1.659)
    
.407
  
  

    
No
    
80
    
173
    
1
    
1
    
 
  
  

    
Pressure from the community
    
 
    
 
    
 
    
 
    
 
  
  

    
Yes
    
47
    
111
    
1.457 (0.951, 2.231)
    
.654 (0.287, 1.488)
    
.311
  
  

    
No
    
95
    
154
    
1
    
1
    
 
  
  

    
Spouse HIV test result
    
 
    
 
    
 
    
 
    
 
  
  

    
Negative (discordant)
    
16
    
96
    
4.252 (2.347, 7.703)**
    
2.790 (1.199, 6.491)*
    
.017
  
  

    
Positive
    
90
    
127
    
1
    
1
    
 
  
  

    
Partners fertility desire
    
 
    
 
    
 
    
 
    
 
  
  

    
Yes
    
63
    
224
    
6.450 (4.04, 10.273)**
    
8.740 (3.488, 21.90)**
    
.000
  
  

    
No
    
78
    
43
    
 
    
1
    
 
  
  

    
Discussion with healthcare worker
    
 
    
 
    
 
    
 
    
 
  
  

    
Yes
    
89
    
200
    
1.778 (1.147, 2.756)*
    
1.914 (0.655, 5.595)
    
.235
  
  

    
No
    
53
    
67
    
 
    
1
    
 
  
  

    
Partners pressure
    
 
    
 
    
 
    
 
    
 
  
  

    
Yes
    
39
    
165
    
4.546 (2.904, 7.115)*
    
2.352 (1.028, 5.385)*
    
.043
  
  

    
No
    
101
    
94
    
 
    
 
    
 
  
  

    
Pressure from family/parents
    
 
    
 
    
 
    
 
    
 
  
  

    
Yes
    
36
    
124
    
2.718 (1.727 4.278)**
    
1.584 (0.690, 3.636)
    
.278
  
  

    
No
    
101
    
128
    
1
    
1
    
 
  
  

    
Current FP utilization
    
 
    
 
    
 
    
 
    
 
  
  

    
Yes
    
88
    
198
    
1.758 (1.124, 2.749)**
    
1.502 0.583, 3.867)
    
.399
  
  

    
No
    
50
    
64
    
 
    
1
    
 
  
  

    
Spouse HIV testing status
    
 
    
 
    
 
    
 
    
 
  
  

    
Yes
    
105
    
223
    
1.820 (1.061, 3.124)*
    
5.981 (0.305, 17.162)
    
.239
  
  

    
No
    
30
    
35
    
 
    
 
    
 
  
  

    
No of children Have
    
0.715 (0.630, 0.811) **
    
0.713 (0.564, 0.903) **
    
.005
  
  

    
** indicates significant association at P<0.01,* indicates significant association at P< 0.01-0.05.
  

Table 5: Multivariable analysis of factors associated with fertility desire among PLWHIA.

Qualitative Findings

Desire of fertility and the reason behind: Qualitative data was analyzed using thematic analysis, and all the responses from the interview were transcribed and translated manually before the actual analysis. The responses were categorized into four different themes (“have a desire for fertility,” “not have a desire for fertility,” “pressure from community,” and “pressure from family and partner”), and the descriptions were made based on the themes of the data.

In-depth interviews with seven key informants on Mother Support Group (MSG) in a health institution who have both their life or lived experience of fertility desire and medication impact and their working challenges on fertility desire , clients who have been following medication for a long time, experienced and discordant clients’ experience and yielded similar results for clients.

One of the respondents of a 29-year-old woman on ART for 11 years stated that“……I have a great fertility desire that led me to divorce my first husband after staying with him for eight years and also with my second husband for one year, but I did not give birth to either. I also married by family pressure the third husband, and currently we have a two-year-old child who is non-reactive, including my discordant partners. As she stated, she did not use any family planning methods properly, with the exception of an emergency contraceptive method that she used intermittently……”

A respondent, on the other hand, offers another reason for wanting to have children. The interviewer cited family, community, and partner pressure as the most common reasons. According to one of the 34 elderly women, MSG, who has three children but one is HIV positive and on ART treatment follow up, said that:-

“……There is pressure from my community, especially my friends. They push me to have a baby because we spend the day working together, and they tell me what to do because I am still young. And now that treatment for HIV has intensified, children are less likely to become infected. My husband, also on ART treatment for the past 15 years, wants me to have children, so I am very worried, but my experience was good using the jaddel long acting family planning method as a preventive measure.........….”.

In contrast to the quantitative data analysis results, respondents in the in-depth interview stated that community pressure is the most important factor influencing fertility desire. As a result, a 28-year-old man, on ART for six years, and his wife, who has an HIV negative result, raised the issue of community peruse, which leads to marriage conflict:

“…..In my society, if you do not even have a child, you are not considered a human being. So, having children is necessary. A child gives you a name and honor in the community. In addition, the child assists the parents in their old age. You are also aware that if you do not have children, other people are going to come and start taking over your property when you die…..”

He also added another reason that is similar to another 45-year-old man on ART for ten years with his wife, responding that they were raising him as the reason for their desire for fertility.

“……Children are always referred to as the wielders of the lineage. As a result, if you do not have a child, no one will be modeled after you. When your child has a child, he or she will name him or her after you. Again, if you do not have children, you will not have someone to care for you in your old age……”

Furthermore, partner pressure, particularly husband pressure, is one of the reasons for women’s desire for fertility. Because quantitative analysis revealed a significant relationship between male and female desire, partner pressure, and desire for fertility, she also brings up the family’s influence on her husband:

Another respondent, a 29-year-old woman, suggested that the reason was a financial and income issue rather than a fear of HIV transmission and child infection. This suggests that HIV positive clients are unconcerned about mother-to-child transmission of the virus.

According to one respondent from a mother’s support group life experience, clients usually pretend to have no desire but arrive pregnant. She suggests that the main reasons for this could be partner pressure and a failure to attend counseling together.

“…..Though PLWHA informs us about their decision not to have a child, in reality, they become pregnant. And this happens mainly because both partners usually do not come to get counseling and testing at the same time to arrive at a common decision “that leads to their disclosure challenges and un-trustful life….”.

Discussion

The magnitude of fertility desire among PLWHAs on ART in Halaba Zone public health institutions was 267 (65.3%). Age under 30 years, sex, monthly income, HIV test results of spouses/partners, fertility want of couples, partner pressure, and number of children they had were all major factors in fertility desire, according to previous research [8,20,26].

In this study, the magnitude of fertility desire was higher than in previous studies in India, South Africa, and Ethiopia [27,28]. It is also the greatest when compared to prior surveys conducted in other parts of Ethiopia, with fertility desire levels of 46.8%, 40.3%, 33.4%, and 39.1%, respectively [20,21-23]. The difference could be explained by the study population (the population in this study was married), which has been found to be one of the most important predictors of fertility desire in other studies [29], socioeconomic and cultural differences, or other health-related factors such as counseling skills. Differences between regions can also be attributed to the year and the research population. Indeed, the relative rise over the earlier study could be linked to PLWHA’s health-related initiatives.

In the present study, age was an independent determinant of fertility desire among HIV-positive clients. Thus, as compared to the age group of 30 years, people aged 30 years had three times the odds of fertility desire (AOR = 2.97). A similar report was reported from other studies done in other regions of Ethiopia [30]. The reason could be that young people generally have higher sexual desire [28,31]. Aside from that, many efforts are required to make family planning services available to young females in the country’s developing regions based on their context [22, 32].

One of the factors associated with a desire for fertility was the participants’ sex. Men have a higher fertility desire as compared to female HIV patients (AOR = 2.677). This finding is supported by a study conducted in different developing countries [20,33,34]. When they die, men may have a stronger desire because they are more likely to have kids and leave something of themselves and their descendants behind when they die. As a result, it is critical that it assists policymakers and healthcare providers in increasing partners’ active participation in reproductive health decisions in order to prevent unwanted pregnancy and mother-to-child transmission. It could also be explained by the fact that women had less decision-making power than men did.

Participants with a monthly family income of less than 1000 Birr were less likely to make a fertility decision than those with a monthly income greater than 5000 Birr (AOR = 0.283).The previous studies in Zambia and Ethiopia [34,35] also identified income as the most important and most common factor that influenced childbearing decisions. This could be because PLWHAs with better income may feel that they could have the opportunity to take better care of their children. This finding is also explained by a qualitative in-depth interview with a woman who suggested that the reason was an economic and income problem and she spoke

“Balancing health and economic situation is the key to raising and educating a child, if he or she is born “this statement goes in line with another in-depth interview response done in previous study [36].

The study demonstrated that partner fertility desire and pressure were also important determinants of the current fertility decision in this study (AOR = 2.35). This was in agreement with the study in North East Ethiopia [35]. Partner desire and partner pressure, are intertwined, and the desire to have a child causes people to put pressure on their partners. This could be due to more opportunities for couples to discuss fertility-related decisions. However, according to the study results, the client’s partner’s fertility desire was found to be much higher than the client’s own decision, which could be due in part to the non-disclosure to partner [25]. Moreover, due to the cultural impact, because, in most parts of Ethiopia, having a child after marriage is obligatory, male partners want to put pressure on their wife [33]. As a result, couple and partner counseling would be beneficial in terms of HIV transmission from mother to child.

A similar response was obtained from qualitative data, partner pressure, particularly husband pressure, which is one of the reasons for women’s desire for fertility. Because quantitative analysis revealed a significant relationship between male and desire, partner pressure, and desire for fertility, she also brings up the family’s influence on her husband: “….He is especially under pressure from his own family. They want to have many children and so, we will have one more soon….”

Participants who were discordant (their partners’ HIV test results were negative) had higher odds of fertility desire as compared to their counterparts (AOR = 2.79). This is in line with other studies conducted in other regions of Ethiopia [21,23] and Uganda [9]. This finding could be explained by the fact that partners with opposite sero-status, particularly partners with negative test results, are thought to be non-infectious. Despite the fact that HIV-discordant couples are at a 10% annual risk of contracting HIV and that a large number of new HIV infections occur in stable partnerships, most HIV prevention programs focus on reducing casual sexual partners, condom use, and increasing fidelity among married partners [37].

Similar concerns were also reflected in the in-depth interview analysis. Thus, one of the 33-year-old women who responded that her husband’s result was negative or discordant stated:“…..HIV is found in my blood. My husband is free. Our daughter is now four years old and is very happy that she is free of the virus, like our first son. I want to have two more children, a girl and a boy. Medical care and counseling have made a big difference in the past four years of my life. Both of us used the dual family planning method (condom with injectable type). A counselor working in a facility also reinforced this idea….”

Therefore, health professionals working in ART clinics should pay special attention to patients seeking VCT and provider-initiated therapy. HIV testing and counseling, as well as providing health messages about fertility and vertical transmission of HIV for discordant couples, are critical in this context to ensuring informed reproductive decisions among PLHIVs and encouraging HIV sero-status disclosure.

In this study, the number of children was identified as a significant factor (AOR = 0.713). The finding was consistent with other studies done in Ethiopia [8]. This indicates that there is a high likelihood that participants who wish to have a child will engage in pregnancy-risk behavior. In addition, HIV care and treatment may also be an effective way to raise awareness and provide advice to spouses in order to increase their involvement in reproductive health services and PMTCT. Because access to ART has increased people living with HIV’s life expectancy, ART users are willing to consider childbearing. There was no difference in the factors that influence pregnancy decisions between HIV-positive and HIV-negative people, specifically partner desire and age [35]. However, having children has great social importance in the Ethiopian context [22].

Conclusion

The highest fertility desire has been reported in PLWHA on antiretroviral treatment. Age, male sex, and discordant HIV test results are all independent predictors of fertility desire. The top reasons for having fertility desire were relationship pressure, the issue of replacing himself/herself or generational replacement, community pressure, and family monthly income.

PLHIVA should emphasize to ART/PMTCT clients and care providers the need of having an open dialogue about RH issues. HIV-positive women and men, as well as their children, should receive comprehensive, culturally relevant, and family-oriented reproductive health education. During periods of heightened reproductive desire, health-care providers should focus on the essential issue of avoiding HIV transmission from mother to child.

Abbreviation and ACRONYMS: AIDS: Acquired Immuno-Deficiency Disease; ART: Anti-Retroviral Therapy; cART: Combination Antiretroviral Therapy; EDHS: Ethiopian Demographic and Health Survey; eMTCT: Elimination of Mother to Child Transmission; FP: Family Planning; HAART: Highly Active Anti Rerto-viral Treatment; HIV: Human Immune-Virus; HMIS: Health Management Information System; ICPD: International Conference On Population & Development; IUCD: Intra Uterine Contraceptive Device; MOH: Ministry of Health; MSG: Mother Support Group; MTCT: Mother To Child Transmission; OCP: Oral Contraceptive Pill. PLHIV: People living with Human Immune Virus; PMTCT: Prevention of Mother to Child Transmission; RH: Reproductive Health; SNNPR: Southern Nations, Nationality and Peoples Region; SSA: Sub-Saharan Africa; TDIB: Traits –Desire -Intention-Behavior; UNAIDS: Joint United Nation Program on HIV/AIDS; WHO: World Health Organization

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