Fertility and HIV Infection : Fertility Decision-making Challenges of Mutually- Disclosed Discordant Couples and Young People

Background: Sexuality and reproduction in mature generalised HIV epidemics pose significant dilemma to both HIV infected and negative people. Sexually active young people and HIV serodiscordant couples are faced with difficult decision-making about procreation and HIV transmission. Insufficient data exists about fertility decision-making and how to handle sexuality and fertility among the HIV-infected youth and mutually disclosed discordant couples. Aim: To explore the influence of HIV on fertility decision-making among young people and people in HIV-discordant relationship in Uganda Methods: The four studies used qualitative (focus group discussions - study I, II, and III) and quantitative methods (semi-structured questionnaire - study III and IV). We explored the views of the youth on reasons for high fertility in Uganda and how decisions are made among the youth in the general population (study I) and among HIV-infected youth (study II). A cross sectional study (study III) assessed fertility decision-making among the discordant couples, and a prospective cohort (study IV) assessed how HIV-infected and negative youth sustain their fertility decisions over a period of one year. Thematic and content analysis were used for qualitative data and uni-variate, bi-variate and multivariate analysis for the quantitative data. Results: Patriarchy, culture and religion contribute to sustaining high fertility in Uganda (paper I). The majority (57%) would like to have children but have to grapple with the dilemma of HIV transmission to partner (paper II and III). Less than a half (44%) among the HIV-infected youth compared to two thirds (61%) among the HIV-negative youth made a consistent fertility decision, OR = 0.52 (0.38, 0.70). In total, 24% among the HIV-negative and 18% among the HIV-infected continued to use contraception throughout the year, OR 0.63 (0.41, 0.98), while 12% and 28% among the HIV-negative and infected respectively did not use contraception, OR 2.80 (1.80, 4.36) (paper IV). Conclusions: Young people in central Uganda are still strongly influenced by the patriarchal, cultural and religious norms with the male gender enjoying a superior position. This compels women to desire many boys for their security and happiness (paper I). Many HIV serodiscordant couples in central Uganda desire to have children and are planning to conceive but the highest desire for children is among the young people (paper III, IV). The desire to have children hinders safe sex practice among HIV sero-discordant couples (paper II). The discordant couples committed to condom use have to risk HIV transmission, or look for a sero-concordant partner to get children. Others seek high-risk concurrent partnerships for children and sexual pleasure (paper II). HIV infected youth are not empowered to practice or sustain consistent contraceptive use or adopt preventive strategies (paper I, IV). The current dialogue with health workers is not increasing contraceptive use, especially among the HIV-infected youth (paper IV). Implications: Uganda s cultural norms still favour high fertility and having HIV infection cannot remove the quest to fulfil patriarchal obligations. If not assisted, PLHIV will continue to practice high-risk sex to reproduce. A multi-sectoral approach uniting cultural, political and public institutions is needed to design programs that may stem the HIV epidemic. Strengthening family planning services should include planning for conception for the PLHIV. Critically, in addition to the need for the cultural re-learning processes to desire less children, we need to introduce low-cost harm reduction techniques for reproduction (timed intercourse, sperm washing) to assist PLHIV who want to have children to do so with minimal HIV transmission

To use or not to use a condom: A prospective cohort study comparing contraceptive practices among HIV-infected and HIV-negative youth in Uganda

<p>Abstract</p> <p>Background</p> <p>Unwanted pregnancy and HIV infection are issues of significant concern to young people. Limited data exists on contraceptive decision-making and practices among HIV-infected and HIV-negative young people in low resource settings with generalized HIV epidemics.</p> <p>Methods</p> <p>From July 2007 until April 2009, we recruited, and followed up over a one year period, a cohort of 501 HIV-negative and 276 HIV-infected young women and men aged 15-24 years residing in Kampala and Wakiso districts. We compared contraceptive use among HIV-infected and HIV-negative young people and assessed factors associated with contraceptive decision-making and use, using multivariate logistic regression modelling to estimate odds ratios (OR) and 95% confidence intervals (CI).</p> <p>Results</p> <p>Contraceptive use among sexually active HIV-infected young people was 34% while it was 59% among the HIV-negative group. The condom was the most frequently used method of contraception. Only 24% of the HIV-infected used condoms consistently compared to 38% among the negative group OR 0.56 (95% CI 0.38, 0.82). HIV-infected young people were more likely to discuss safe sex behaviour with health workers OR 1.70 (95% CI 1.13, 2.57), though its effect on fertility decision-making was not significant. Throughout the year's follow-up, only 24% among the HIV-negative and 18% among the HIV-infected continued to use contraception while 12% and 28% among the HIV-negative and infected respectively did not use contraception at all. At multivariate analysis, the HIV-infected young people were less likely to maintain contraceptive use. Other factors independently associated with sustained contraceptive use were age of the respondent, marital status and being a male. Conversely, HIV-infected young people were less likely to initiate use of contraception. Being married or in a relationship was associated with higher odds of initiating contraceptive use.</p> <p>Conclusion</p> <p>Compared to the HIV-negative group, sexually active HIV-infected young people are less likely to use contraception and condoms. Initiating or sustaining contraceptive use was also significantly less among the HIV-infected group. Strengthening family planning services and developing new innovative ideas to re-market condom use are needed. Policy and guidelines that empower health workers to help young people (especially the HIV infected) express their sexuality and reproduction should urgently be developed.</p

My partner wants a child: A cross-sectional study of the determinants of the desire for children among mutually disclosed sero-discordant couples receiving care in Uganda

<p>Abstract</p> <p>Background</p> <p>The percentages of couples in HIV sero-discordant relationships range from 5 to 31% in the various countries of Africa. Given the importance of procreation and the lack of assisted reproduction to avoid partner transmission, members of these couples are faced with a serious dilemma even after the challenge of disclosing their HIV status to their spouses. Identifying the determinants of the decision to have children among sero-discordant couples will help in setting reproductive intervention priorities in resource-poor countries.</p> <p>Methods</p> <p>We conducted a survey among 114 mutually disclosed sero-discordant couples (228 individuals) receiving HIV care at four centres in Greater Kampala, between June and December 2007. The data we collected was classified according to whether the man or the woman was HIV-positive. We carried out multivariate logistic regression modelling to determine factors (age, gender, and the influences of relatives and of health workers, ART knowledge, and disclosure) that are independently associated with a desire for children.</p> <p>Results</p> <p>The majority, 59%, of the participants, desired to have children. The belief that their partner wanted children was a major determinant of the desire to have children, irrespective of the HIV sero-status (adjusted odds ratio 24.0 (95% CI 9.15, 105.4)). Among couples in which the woman was HIV-positive, young age and relatives' expectations for children were significantly associated with increased fertility desire, while among couples in which the man was positive; knowledge of ART effectiveness was associated with increased fertility desire. Availability of information on contraception was associated with decreased fertility desire.</p> <p>Conclusions</p> <p>The gender of the positive partner affects the factors associated with a desire for children. Interventions targeting sero-discordant couples should explore contraceptive choices, the cultural importance of children, and partner communication.</p

A Cascade Model of Mentorship for Frontline Health Workers in Rural Health Facilities in Eastern Uganda: Processes, Achievements and Lessons

Background: There is increasing demand for trainers to shift from traditional didactic training to innovative approaches that are more results-oriented. Mentorship is one such approach that could bridge the clinical knowledge gap among health workers. Objectives: This paper describes the experiences of an attempt to improve health-worker performance in maternal and newborn health in three rural districts through a mentoring process using the cascade model. The paper further highlights achievements and lessons learnt during implementation of the cascade model. Methods: The cascade model started with initial training of health workers from three districts of Pallisa, Kibuku and Kamuli from where potential local mentors were selected for further training and mentorship by central mentors. These local mentors then went on to conduct mentorship visits supported by the external mentors. The mentorship process concentrated on partograph use, newborn resuscitation, prevention and management of Post-Partum Haemorrhage (PPH), including active management of third stage of labour, preeclampsia management and management of the sick newborn. Data for this paper was obtained from key informant interviews with district-level managers and local mentors. Results: Mentorship improved several aspects of health-care delivery, ranging from improved competencies and responsiveness to emergencies and health-worker professionalism. In addition, due to better district leadership for Maternal and Newborn Health (MNH), there were improved supplies/medicine availability, team work and innovative local problem-solving approaches. Health workers were ultimately empowered to perform better. Conclusions: The study demonstrated that it is possible to improve the competencies of frontline health workers through performance enhancement for MNH services using locally built capacity in clinical mentorship for Emergency Obstetric and Newborn Care (EmONC). The cascade mentoring process needed strong external mentorship support at the start to ensure improved capacity among local mentors to provide mentorship among local district staff

My partner wants a child: A cross-sectional study of the determinants of the desire for children among mutually disclosed sero-discordant couples receiving care in Uganda

<p>Abstract</p> <p>Background</p> <p>The percentages of couples in HIV sero-discordant relationships range from 5 to 31% in the various countries of Africa. Given the importance of procreation and the lack of assisted reproduction to avoid partner transmission, members of these couples are faced with a serious dilemma even after the challenge of disclosing their HIV status to their spouses. Identifying the determinants of the decision to have children among sero-discordant couples will help in setting reproductive intervention priorities in resource-poor countries.</p> <p>Methods</p> <p>We conducted a survey among 114 mutually disclosed sero-discordant couples (228 individuals) receiving HIV care at four centres in Greater Kampala, between June and December 2007. The data we collected was classified according to whether the man or the woman was HIV-positive. We carried out multivariate logistic regression modelling to determine factors (age, gender, and the influences of relatives and of health workers, ART knowledge, and disclosure) that are independently associated with a desire for children.</p> <p>Results</p> <p>The majority, 59%, of the participants, desired to have children. The belief that their partner wanted children was a major determinant of the desire to have children, irrespective of the HIV sero-status (adjusted odds ratio 24.0 (95% CI 9.15, 105.4)). Among couples in which the woman was HIV-positive, young age and relatives' expectations for children were significantly associated with increased fertility desire, while among couples in which the man was positive; knowledge of ART effectiveness was associated with increased fertility desire. Availability of information on contraception was associated with decreased fertility desire.</p> <p>Conclusions</p> <p>The gender of the positive partner affects the factors associated with a desire for children. Interventions targeting sero-discordant couples should explore contraceptive choices, the cultural importance of children, and partner communication.</p

Mode of birth in subsequent pregnancy when first birth was vacuum extraction or second stage cesarean section at a tertiary referral hospital in Uganda

Abstract Introduction The trends of increasing use of cesarean section (CS) with a decrease in assisted vaginal birth (vacuum extraction or forceps) is a major concern in health care systems all over the world, particularly in low-resource settings. Studies show that a first birth by CS is associated with an increased risk of repeat CS in subsequent births. In addition, CS compared to assisted vaginal birth (AVB), attracts higher health service costs. Resource-constrained countries have low rates of AVB compared to high-income countries. The aim of this study was to compare mode of birth in the subsequent pregnancy among women who previously gave birth by vacuum extraction or second stage CS in their first pregnancy at Mulago National Referral Hospital, Uganda. Methods This was a retrospective cohort study that involved interviews of 81 mothers who had a vacuum extraction or second stage CS in their first pregnancy at Mulago hospital between November 2014 to July 2015. Mode of birth in the subsequent pregnancy was compared using Chi-2 square test and a Fisher’s exact test with a 0.05 level of statistical significance. Results Higher rates of vaginal birth were achieved among women who had a vacuum extraction (78.4%) compared to those who had a second stage CS in their first pregnancy (38.6%), p < 0.001. Conclusions and recommendations Vacuum extraction increases a woman’s chance of having a subsequent spontaneous vaginal birth compared to second stage CS. Health professionals need to continue to offer choice of vacuum extraction in the second stage of labor among laboring women that fulfill its indication. This will help curb the up-surging rates of CS

Pas un garçon, pas un enfant » : etude qualitative sur les impressions des jeunes gens sur la procreation en Ouganda

To understand reasons for persistent high fertility rate, we explored perceptions and influences of fertility motivation among young people from Uganda. Qualitative inquiry was used, data were organised using NVivo 2 package and latent content analysis performed. Major themes that emerged on factors that entrench high fertility included “Sustenance of ‘men’s blood’ through the male child”; “poverty, joblessness and child bearing”, and “other socio-cultural issues: religion, kin, elders and child bearing”. Factors that reduce fertility included “perception on women emancipation, job security and couple fertility communication”. Young peoples’ views on motivation for childbearing in Uganda are embedded in cultural norms and linked strongly to patriarchy, social respectability and women’s sustenance. Innovative cultural practices and programs that increase women’s social respectability such as emphasis that a girl can be heir and inherit her father’s property are needed to reduce sonpreference and fertility rates in the younger generation (Afr J Reprod Health 2010; 14[1]:71-81).Pour comprendre les raisons pour lesquelles le taux de fécondité demeuré élevé, nous avons exploré les perceptions et les influences de la motivation de la fécondité chez les jeunes gens en Ouganda. Nous avons fait une enquête qualitative et les données ont été organisées à l’aide d’un programme de NVivo 2 et nous avons fait une analyse du contenu latent. Parmi les thèmes importants que nous avons découverts concernant les facteurs qui retranchent la stérilité élevée il y avait la « préservation du sang des ‘hommes a travers un garçon » ; « la pauvreté, le chômage et la procréation », et « d’autres problèmes socio-culturels : la religion, les parents, et la procréation ». Les facteurs qui diminuent la fécondité comprennent la perception sur l’émancipation de la femme, la sécurité de l’emploi et la communication de la fécondité du couple ». Les impressions des jeunes gens sur la motivation pour la procréation en Ouganda sont gravées dans les normes culturelles et fortement liées au patriarcat, la respectabilité sociale et les moyens de subsistance de la femme. Des pratiques culturelles innovatrices et les programmes qui avancent la respectabilité sociale de la femme tel que l’accent mis sur le fait qu’une fille peut être héritière et peut hériter la propriété de son père, sont nécessaires pour réduire la préférence pour un fils et des taux de fécondité chez la jeune génération (Afr J Reprod Health 2010; 14[1]:71-81)

“I am alone and isolated”: a qualitative study of experiences of women living with genital fistula in Uganda

The study was conducted on women with a genital fistula seeking treatment at Mulago Hospital, Uganda. Data were transcribed and analysed using qualitative content analysis.Background: Globally, 2–3 million women are estimated to have a genital fistula, with an annual incidence of 50,000–100,000 women. Affected women remain silent within their communities, and their experiences often go unnoticed. Our objective was to explore the experiences of Ugandan women living with genital fistulas to understand how their lives were affected and how they coped with the condition. Methods: We conducted 8 focus group discussions (FGDs) with 56 purposively selected women with a genital fistula seeking treatment at Mulago Hospital, Uganda. Data were transcribed and analysed using qualitative content analysis. Results: Women with a fistula were living a physically changed and challenging life, living socially deprived and isolated, living psychologically stigmatised and depressed, and living marital and sexual lives that were no longer joyful. The women’s experiences were full of life changes and coping strategies, and they used both problem- and emotion-focused coping strategies to deal with the challenges. They devised ways to reduce the smell of urine to reduce the stigma, rejection and isolation. While trying to cope, the women found themselves alone and isolated. Women either isolated themselves or were isolated by society, including by close relatives and their husbands. Their sex lives were no longer enjoyable, and generally, women felt a loss of their marital and sexual rights. Conclusion: Women with a fistula make adjustments in their lives to cope with the physical, social, psychological and sexual challenges. They use both problem- and emotion-focused coping to minimise their sense of isolation, as well as the rejection and stigma associated with fistula. These findings are essential for counselling patients, families and community members affected by a fistula. In similar contexts, health programmes should go beyond fistula closure and target communities and families to reduce the stigma and isolation faced by women with genital fistula