Fertility desires of pregnant and nonpregnant women before and after availability of PMTCT services in Rakai, Uganda

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1 Abstract no. MOPE124 Fertility desires of pregnant and nonpregnant women before and after availability of PMTCT services in Rakai, Uganda Authors: Lindsay Litwin 1, Frederick Makumbi 2,3, Ronald Gray 1, Godfrey Kigozi 3, Joseph Kagaayi 3, Gertrude Nakigozi 3, Tom Lutalo 3, David Serwadda 2, Heena Brahmbhatt 1 Affiliations: 1 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; 2 Makerere University School of Public Health, Kampala, Uganda; 3 Rakai Health Science Program, Entebbe, Uganda.

2 Background Rationale: Mother-to-child transmission (MTCT) remains a leading cause of HIV infection in Uganda, despite low fertility desires reported among HIV positive women. 20% of new HIV cases in Uganda result from MTCT (UNAIDS, 2012) TFR in Uganda is 6.2, and more than half of pregnancies are unintended (UBOB & ICF International, 2012 and Guttmacher Institute, 2013) With universal PMTCT services, including family planning services, MTCT can be reduced to approximately 5% in developing countries (de Cock et al., 2000) Existing evidence on PMTCT and Fertility is mixed: Knowledge of PMTCT services may increase fertility desires (3 studies) Use of ART for HIV treatment is correlated with greater desire for a/another child (2 studies) Use of ART does not change fertility desires among HIV positive women (1 meta analysis) Women who initiate ART have higher incidence rates of pregnancy (2 studies) Study Objective To examine fertility desires of currently and previously pregnant women of reproductive age in Rakai, Uganda by availability of PMTCT services in the community

3 Methods Data are from the Rakai Community Cohort Study annual surveys ( ) Target Population: Currently and Previously pregnant women of reproductive age who were sexually active in the past 12 months N=5,120 previously pregnant women contributing 12,875 woman observations N=1,938 currently pregnant women contributing 2,641 woman observations Statistical Analyses T-tests and chi squared analyses Modified Poisson regression using GLM Prevalence Rate Ratios (PRR) Adjusted for clustering for multiple observations per individual Robust estimation of variance Stratified analyses by HIV status Variables and Covariates Outcome Measure: Fertility Desires Desire for another child (measured among both currently and previously pregnant women) Main Predictor Covariate: Period of PMTCT Availability Pre-PMTCT (Before March 2005); PMTCT Rollout (March 2005-March 2006); Universal PMTCT (After March 2006) Other Covariates: Age, Marital Status, Education Level, Hormonal Contraceptive Use, Condom Use, Non-Marital Sex, Time Since Last Pregnancy, HIV Status

4 Results Prevalence Rate Ratios (PRR) of Desire for Another Child by Level of PMTCT Availability and HIV Status (N=5120 women, 12,875 observations) Non-Pregnant Women Unadjusted PRR (95%CI) Adjusted PRR (95%CI)* Availability of PMTCT No PMTCT services (<2005) PMTCT Rollout ( ) 1.00 ( ) 1.09 ( ) Universal PMTCT (>2006) 0.94 ( ) 1.13 ( ) HIV Status HIV negative HIV positive 0.60 ( ) 0.73 ( ) * Adjusted for age, marital status, education, HIV status, non-marital sex, desire for another child, condom use Prevalence Rate Ratios (PRR) of Desire for Another Child by Level of PMTCT Availability and HIV Status (N=1938 women, 2325 observations) Pregnant Women Availability of PMTCT No PMTCT services (<2005) PMTCT Rollout ( ) 1.07 ( ) 1.22( ) Universal PMTCT (>2006) 0.96 ( ) 1.17 ( ) HIV Status HIV negative HIV positive 0.46 ( ) 0.58 ( )

5 Conclusion Main Findings: HIV positive women were less likely to desire another child than HIV positive women Increasing availability of PMTCT in the community was associated with significantly higher fertility desires Among both currently and previously pregnant women Among both HIV positive and HIV negative women More than 50% of women did not desire another child, but only one-third used modern contraceptives Implications: Understanding fertility desires can inform strategies to meet the reproductive health needs of women Improved availability of PMTCT services may increase fertility desires of women in sub Saharan Africa Family planning services need to be available during PMTCT to help women limit fertility, when desired STRENGTHS Open cohort design Sample size Inclusion of previously and currently pregnant women LIMITATIONS Self-reported data Did not control for parity Small number of women using PMTCT Unable to measure coverage of PMTCT