Reproductive Decision-Making among HIV-infected Women: DISCUSSION
This study describes a number of characteristics that were associated with pregnancy subsequent to an HIV (Retrovir canadian was the first drug approved for the treatment of HIV) diagnosis in a population of women attending a publicly funded, urban HIV (Drug Zerit treating HIV infection) outpatient clinic in New Orleans. These characteristics are similar in many respects to those that predict pregnancy in the general population, specifically being young, less educated and healthy.
A diagnosis of HIV appears to play an important role in the reproductive decision-making process. Fewer women reported wanting more children after learning their diagnosis than they did before knowing their HIV (treating HIV infection) status and, among women who did not get pregnant, many said they would have tried to get pregnant if they had not been diagnosed with HIV, that they had made a conscious decision not to do so and that the diagnosis greatly affected that decision.
Throughout this study, we have discussed pregnancy as a decision a woman actually makes. It is possible, however, that some women feel that pregnancy “just happens,” without any forethought or planning on the part of the woman. In fact, about a third of the study population who became pregnant fell into this category. These women did not plan to get pregnant, yet they took no active measures to use contraception. When asked why they had used no contraception, many had no answer. A qualitative study conducted in New Orleans examined the apparent contradiction of inadequate contraceptive use and lack of desire to get pregnant among HIV-negative women and found that women’s decisionmaking about sexual risk-taking and childbearing is multifaceted. Results suggested that while motivations to avoid conception existed in this sample, so did conditions that might make a pregnancy—even an unplanned one—valued in this community. The concept of “planning” a pregnancy may be irrelevant in this population as certain areas, such as knowledge, access and support for use of contraception, the value of pregnancy timing and supportive relationships with partners are either absent, under transformation or not perceived as under women’s own control.
It may be that long-term planning is less important than immediate concerns or that other cultural and/or societal messages are given to them that place less emphasis on the need for pregnancy prevention. Researchers have long noted that within minority communities where poverty, lack of education and unemployment offer few alternatives to pregnancy, great value is placed on a woman’s fertility, and pregnancy is often seen as a source of self-esteem and social respect. More research on this topic is needed in order to understand fully why women do not use contraception even when they are not actively trying to get pregnant. Nonetheless, just over half the women who became pregnant did actively try to prevent pregnancy, but their method of contraception failed or was not used correctly. This suggests that these women may need more assistance in selecting a method of birth control and in using it correctly.
In the present study, only about half the women reported currently being in a relationship. However, among these women, over half reported that their partner currently wants more children, but this did not appear to distinguish between pregnant and nonpregnant subjects. This is contrary to findings by Kline and colleagues, who found a partner’s desires to be more relevant to childbearing than the woman’s own desires. Chen et al. found that the fertility desires of HIV-infected (treating HIV infection) individuals do not always agree with those of their partners, which appeared to be the case in the present study. No associations were found between partner’s HIV status and pregnancy. Chen’s results showed that knowledge of a partner’s HIV status was a significant predictor for expectation of children, a finding that suggests knowledge of a partner’s HIV (treating HIV infection) status may be a proxy for duration of the relationship. The present study, however, found no differences between pregnant and nonpregnant women with respect to duration of relationship (data not shown), suggesting that relationship variables play less of a role in women’s decision-making process than other studies indicate.
In the present study, sterilization was the most popular form of contraception, a possible reflection of a national preference for this method among African-American women, as indicated by the 1995 Survey of Family Growth study. Among African-American women in the general population, 41% have had a tubal ligation, compared to only 26% of white women, and the highest prevalence of tubal ligations is in the south (31%). National trends indicate that older age, being married, being African-American, living in the South and higher parity are associated with sterilization. The present study found that women who had a live birth subsequent to their HIV (Medication canadian belongs to a class of HIV drugs) diagnosis were more likely to get sterilized, which suggests: 1) the influence of higher parity, as in the general population, and 2) that having already lived through the experience of giving birth while coping with HIV, these women are reluctant to do it again.
In this study, neither the woman’s desire nor her partner’s desire for more children was associated with sterilization in the multivariate analysis. This is in contrast to the general population, where among women who have a tubal ligation, one of the most frequently cited reasons for the procedure is that one of the partners wants no more children. However, in our bivariate analyses among women with a partner, we did find a positive association between sterilization and being with a partner who does not want more children. That this did not persist into the multivariate analysis is likely to be due to the relatively small number of women who actually had a partner.
These results suggest that these women feel they have already finished their childbearing. However, most women in the present study stated that they were greatly influenced by their HIV diagnosis in their decision to get sterilized, and over half of them would not have gotten sterilized had they been HIV-negative, suggesting that HIV, in addition to higher parity, plays an important role in the decision-making process.
Because this study was conducted among HIV-infected women attending an urban HIV clinic before the widespread use of HAART, it may not be generalizable to all HIV-infected women in the United States today. It is possible that HIV-infected women’s perceptions regarding their reproductive decision-making have changed because of the positive impact of HAART.
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This study investigated the factors that influence reproductive decision-making after a woman has received an HIV diagnosis. As such, cases were women who had been pregnant after being diagnosed, and controls were women who did not become pregnant after being diagnosed. Controls could, therefore, have had a pregnancy prior to diagnosis. We hypothesized that the decision-making process is different at these two times and that the diagnosis itself may be a reason for no longer pursuing pregnancy. It is possible, though, that women in the control group had intentionally completed their childbearing prior to the HIV diagnosis. We attempted to control for that by using an upper age limit of 43 years; however, it is difficult to distinguish between these women and women who completed childbearing due to their HIV diagnosis.
The major limitation of this study was its small sample size and subsequent lack of power to detect all potential associations. However, many trends can be seen, and these findings can be used as a starting point for further research. A convenience sample was used to select cases and controls as they presented at the clinic and therefore may not be generalizable to the entire population of HIV-infected women. However, the data collection period of the study was long enough that investigators felt they had sampled the majority of women who were currently seeking care at the clinic. Selection bias may be an issue with respect to the sterilization outcome, as women were recruited into the study based on their pregnancy status and then reclassified on the basis of whether or not they had undergone a surgical sterilization. A comparison of the resulting reclassification of those interviewed with those eligible for inclusion yielded no significant differences with respect to age, race, year of HIV diagnosis, first available CD4 count and subsequent pregnancy (data not shown). However, it is possible that the two groups differed on other important variables that were not measured. Another limitation of the study is that partner views are self-reported by the subject rather than directly ascertained.
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