Demand for Modern Family Planning among Married Women Living with HIV in Western Ethiopia

Introduction People living with HIV (PLHIV) have diverse family planning (FP) needs. Little is reported on FP needs among women living with HIV in Ethiopia. Thus, the objective of the study was to assess the demand for modern FP among married women living with HIV in western Ethiopia. Methods A facility-based cross-sectional survey was conducted on 401 married women living with HIV selected from Nekemte Referral Hospital and Health Center, Nekemte, Oromia, Ethiopia. Convenience sampling of every other eligible patient was used to recruit respondents. Data were collected using a pretested, structured questionnaire. We first calculated frequency and percentage of unmet need, met need and total demand by each explanatory variable, and performed chi-squared testing to assess for differences in groups. We then fitted logistic regression models to identify correlates of unmet need for modern FP at 95% CL. Results The proportion of respondents with met need for modern FP among married women living with HIV was 61.6% (30.7% for spacing and 30.9% for limiting). Demand for family planning was reported in 77.0% (38.2% for spacing and 38.8% for limiting), making unmet need for modern FP prevalent in 15.4% (7.5% for spacing and 7.9% for limiting). Whereas age 25–34 years [adjusted odds ratio (AOR) (95% confidence interval (CI))  = .397 (.204–.771)] was protective against unmet need for modern FP, not having knowledge of MTCT [AOR (95% CI)  = 2.531 (1.689–9.290)] and not discussing FP with a partner [AOR (95% CI)  = 3.616(1.869–6.996)] were associated with increased odds of unmet need for modern FP. Conclusions There is high unmet need for modern FP in HIV-positive married women in western Ethiopia. Health care providers and program managers at a local and international level should work to satisfy the unmet need for modern family planning.


Introduction
Over 50% of the 33.3 million HIV-positive people are women within the reproductive age [1]. Women account for 59% of the people Living with HIV (PLHIV) in Ethiopia [2]. Although HIV prevalence and fertility rates in Ethiopia are among the highest in the world, little is known about how HIV infection affects the met and unmet need for modern family planning [2]. Prevention of unintended pregnancies among HIV infected women is among the four key pillars for comprehensive prevention of mother to child transmission (PMTCT). This could be achieved with the use of contraception [3,4].
HIV-infected women have a heightened need for guidance from health care providers prior to an attempt for pregnancy because of the potential risks of transmission to the partner while trying to conceive and to the infant during pregnancy, delivery and breast feeding [5,6]. Providing HIV-infected women with HIV care, opportunities to plan and space pregnancies, and quality pregnancy care including PMTCT services improve health outcomes for both mothers and infants [7]. Effective programs to prevent perinatal HIV transmission would, if accessed by all women in need, prevent approximately 300,000 HIV transmissions annually [8,9].
However, there is considerable evidence that HIV infected women have high rates of unmet need for contraception [2,10,11,12,13]. Previous studies in Ethiopia have focused on demand and unmet need for family planning among married women in general population [2,14]. We conducted a survey of women at an HIV clinic in Ethiopia to learn about unmet need and demand for modern family planning among married women living with HIV. The objective of the study was to assess demand for modern family planning and extent of unmet need for family planning among women living with HIV in Western Ethiopia. We intend that results of this study could assist policy makers, health managers and implementers to design appropriate strategies to address family planning needs for people living with HIV in this setting.

Study design and setting
We performed a facility-based, cross-sectional survey among married/in union women living with HIV in western Ethiopia

Study population and participant sampling
The study population was married/in union women of reproductive age living with HIV who had at least one visit to the selected health institutions during the study period for ART services. Women living with HIV and aged 15-49 years were eligible for participation in the study. Further inclusion criteria were that they were willing to discuss certain aspects of their contraception use, and have basic information abstracted from their medical records. Clients who were severely ill were excluded from the study because it was considered they could not give necessary information. The estimated number of married/in union women attending the two ART clinics was 950. Convenience sampling was employed to select study participants using registers of patients attending each institution. Every second married/in union women was enrolled into the study.

Study questionnaire and procedures
The questionnaire was derived from related questions in the Demographic Health Survey. The questionnaire for the survey was initially developed in English, translated to local language, Afan Oromo, and checked for consistency by back translation to English by two different individuals. The questionnaire was also pretested on 5% of the total sample size in the ART units of Sibu Sire health center and Gimbi Hospital. The questionnaire was then assessed for its clarity and completeness. Some skip patterns were corrected, questions difficult to ask were rephrased and the consent form was modified. Four nurses working in the ART units of each health institution administered the questionnaire after a two-day study training. Data were entered into Epi-Info 6.04 then transferred to SPSS version 20.0 for analysis.

Statistical analyses
We first calculated frequency and percentage of unmet need, met need and total demand by each explanatory variable, and performed chi-squared testing to assess for differences between groups. We then fitted logistic regression models to identify correlates of unmet need for modern family planning (see definition below). Bivariate analysis was performed between unmet need and each of the independent variables separately. To control for possible confounding variables, multivariable logistic regression was done. All variables which had association Demand for Modern Family Planning in bivariate analysis (P-value ,0.05) were included in the multivariate model. The strength of association between unmet need for modern family planning and independent variables was expressed in odds ratio (OR) through a 95% confidence interval.
Our primary outcome of interest was unmet need for modern family planning. Unmet need for modern family planning was defined as any sexually active woman with HIV who said they wanted to stop childbearing, delay their next birth by at least two years, or were unsure when to have a child but were not using a modern method of family planning. Family planning refers to the use of modern contraceptives or natural techniques to limit or space pregnancies. Modern family planning methods included the pill, female and male sterilization, IUD, injectables, implants, male and female condom, and diaphragm. Pregnant or amenorrheic women were also considered to have an unmet need if their current or most recent pregnancy was unwanted or mistimed, and they were not using a method of family planning. For amenorrheic women, only those who gave birth in the last six months were included [16]. Pregnant and postpartum women may not have had or known they had HIV at the time of that pregnancy which may have slight difference on level of unmet need. Four pregnant or amenorrheic women reported contraceptive failure (one who wanted to limit and three who want space). They were excluded from the analysis.
The explanatory variables included in the model were sociodemographic factors (income, education, religion, occupation, and functional radio and/or TV), number of children, time since HIV positive diagnosis, recent CD4, duration on ART, current pregnancy status of respondent, current fertility desire, and discussion on family planning, fecundity. Duration of HIV diagnosis, CD4 counts and length of time on ART were abstracted from medical records.
Women who never used contraception, and not had a birth in past five years, reported they ''can't get pregnant'' or have had a hysterectomy were considered infecund for this study. We defined satisfied demand as the percentage of met need to total demand. Knowledge of MTCT was defined as knowing of transmission from mother to child during any of the following; a) pregnancy b) labour and delivery or c) breast feeding. Pregnancy intendedness was categorized as a) wanted the pregnancy at that time (want then), b) wanted later (mistimed) or c) did not want any child at all (unwanted). Respondents were asked about the frequency of discussion on family planning with a partner and the response was categorized as a) never discussed, b) rarely discussed, or c) discussed often.

Ethical considerations
Ethical approval was obtained from Ethical review committee of Wollega University, Nekemte, Ethiopia. A formal letter for permission and support was written to health institutions. The purpose of the study was clearly explained to concerned bodies. In order to keep confidentiality of patient information, only those personnel who were working in the ART unit were involved in data collection. The purpose and process of the study was explained to all participants. Written informed consent was obtained from all study participants. They were informed that their participation was voluntary and they were free whether or not to participate, or to withdraw at any time and for any reasons without any penalty either personnel or affecting their future medical care. For study participants aged less than 18, we received written informed consent from the respondents themselves because respondents were married and mature minor. The consent procedure was approved by the ethics committee for all including aged less than 18 years.

Socio-demographic characteristics
We approached 403 study participants, of whom 401 responded to the questionnaire for a response rate of 99.5%. Sixty percent of respondents were in the age group of 25-34 years with a mean age of 29.4 years (SD65.4 years, Table 1). A majority of the study participants were residing in an urban area (81.3%).The proportion of women with no formal education was 42.6%. Seventy five percent of the respondents earned monthly family income of less than 1275 Ethiopian birr (ETB) (about $67 USD).

Demand and unmet need for family planning
In total, 309 participants (77%) had demand for modern family planning (38.2% for spacing and 38.8% for limiting) (Figure 1). The proportion of all respondents with met need for modern family planning was 61.6% (30.7% for spacing and 30.9% for limiting). Thus, 15.4% of respondents had unmet need for modern family planning (7.5% for spacing and 7.9% for limiting). The most common modern family planning method used was condoms plus any of the other modern family planning methods 128(31.9%), followed by injectables 101(25.2%) ( Table 2).
Crude rates of family planning needs are displayed in Table 3. Women aged 35-49 had the highest proportion of unmet need for modern family planning (23.3%). Women with primary education (25(19.1%)) also had a higher prevalence of unmet need than those with higher education. Similarly, women in the lowest quantile of  In multivariable models, the following characteristics were associated with unmet need for family planning: age 25-34 years [AOR (95% CI) = .397 (.204-.771)], not having knowledge about mother to child transmission [AOR (95% CI) = 2.531 (1.689-9.290)], and not discussing family planning with a partner [AOR (95% CI) = 3.616(1.869-6.996)] (Table 4).

Discussion
This study aimed to identify demand and unmet need for modern family planning among married and in-union women living with HIV. We found that unmet need for modern family planning methods was high among HIV positive married and inunion women, reported by 15% of respondents. Our findings reinforce the fact that unmet need for family planning services among women living with HIV continues to undermine efforts to eliminate new HIV infections among children. Additional efforts to reduce unmet need and satisfy demand for family planning can eliminate HIV infections among children and reduce maternal deaths among women living with HIV in the era of better access to ART.
When compared to surveys from the general population, our reported rates of unmet need were lower than findings from Uganda [9] and Ethiopia [2]. However, when compared to studies from the HIV positive women, our results are consistent with unmet need among married women in Zimbabwe (16%) [17],higher than reports from prior demographic and health surveys in Kenya [18] but lower than findings from Uganda [19]. We also found higher rates of modern family planning (combination methods used 32%), compared to a previous report from Lesotho, which documented 6% in a similar population [20]. A possible reason for the high met need is that married women receiving HIV care have more regular contact with health care professionals. Moreover, discussions regarding family planning (emphasis on dual FP) are incorporated into the regular clinical follow-up routine of HIV patients in the study setting.
The total demand in current study was higher than findings from Ethiopia and eastern Sudan in general population [2,21]. This may be due to perceived fear of MTCT among HIV positive women [18,22]. Satisfying demand for modern family planning improves the prospects of mothers' survival.
We found a number of factors predicted rates of unmet need for family planning. In this study, age was one of the important factors associated with unmet need for modern family planning. Women within the age range of 25-34 were 0.45 times less likely to have unmet need for family planning than those found in the age range 35-49. This is consistent with Ethiopian DHS data from 2000 and 2005 among the general population [23]. The reason for low unmet need among women age 25-34 years is unclear, but could be related to perceived fears of being pregnant than older women and more likely to use FP. The other reason may be younger women are more likely to be literate than older [2] and more likely to discuss family planning with a partner than older women.
Those women who were not knowledgeable of MTCT were more likely to have unmet need for modern family planning compared to their counterpart. Women having knowledge of MTCT who had desire for more children may strive to get means to control birth. Therefore, efforts should be there to increase knowledge about MTCT among PLHIV and the general population.
In multivariate analysis those women who did not discuss family planning with a partner were also at significantly greater odds of unmet need for modern family planning. This is consistent with studies from Butajira, Ethiopia among women in the general population [14]. Men often play decisive roles in either supporting or hindering the use of contraceptives by their spouses. Thus, communication with a partner is vital to remove challenges such as partner opposition in fertility related decisions, including choice of modern family planning. Men should also be involved in the programmatic response in order to reduce unmet need among women living with HIV.
The primary limitation of the study was the use of crosssectional data, which precludes assessing the causality of the associations described. There is also a risk of social desirability bias whereby women living with HIV may over-report their contraceptive use (condom use, in particular) because of perceived pressure from health workers to practice safe sex. The question- naire was administered by nurses who were working in the clinic to minimize this bias.

Conclusions and Recommendations
In conclusion, our study demonstrates that women living with HIV in Ethiopia have high demand for modern family planning (77%), with high rates of both unmet need (15.4%) and met need (61.6%). Younger women, poor knowledge on MTCT, and lack of discussion with partners on family planning were important factors associated with unmet need for modern FP. Efforts to address the unmet need for modern family planning and rights of women living with HIV need to be strengthened. As national programs improve availability and provision of PMTCT, policy makers and funders should not ignore the continued importance of family planning. Thus, stakeholders should act to satisfy the family planning demand focusing on knowledge of PMTCT and to promote discussion about family planning among partners.