Pregnancy Planning Among Women Living With HIV in the US
In this US-based, multicenter, cross-sectional study, we found that the majority of pregnancies among HIV-infected women were unplanned or ambivalent. Access to medical care and discussion of fertility intentions were associated with a decreased risk of an unplanned/ambivalent pregnancy.
A strength of this study is that it included participants from several sites across the United States. The generalizability of these data are limited given only academic medical centers and sites with clinician-investigators with special interests in HIV and pregnancy were included. Therefore, findings from this study may be biased toward planning pregnancies and discussion of pregnancy intentions compared with the HIV-infected population as a whole. In addition, although our study sites were across the United States, most participants were from the southern part of the United States and most participants self-described as non-Hispanic black. However, this may be a strength of the study as the numbers of HIV infections in black women are rising, particularly in the southern United States. Previous research also indicates that black women, in general, are disproportionately affected by unplanned pregnancy compared with other racial groups.
A potential limitation of this study is social desirability bias. Women who are already pregnant may not recall or wish to recall any negative feelings they may have had regarding the index pregnancy. To diminish this bias, we used the validated LMUP scale, which is specifically designed to assess pregnancy intentions retrospectively. Another potential limitation of this observational study could be unexpected and unmeasured predictors of pregnancy intention. Given the small sample size, we may have lacked power to definitively rule out certain associations with unplanned or ambivalent pregnancies.
This study supports previously published research describing limited discussion of preconception issues by HIV care providers based on reports from HIV-infected women in the United States. A survey of 181 women attending an HIV clinic in Baltimore demonstrated that only 67% women had a general discussion about pregnancy; 31% had a personalized discussion, and the majority of all discussions were patient initiated. A comparison study between practices in the United States and Brazil also demonstrated lack of communication on the part of providers regarding pregnancy intentions in both locations. A strength of our study is that we report a modifiable variable associated with unplanned/ambivalent pregnancy and that this finding should motivate providers to discuss these topics.
Our study showed that having had a prior birth since HIV diagnosis was associated with a decreased risk unplanned pregnancy. We can speculate that this may be related to increased knowledge regarding low risk of transmission of HIV during pregnancy from past experience and, therefore, less ambivalence or fear regarding planning for a future pregnancy. Indeed, although the risk of perinatal HIV transmission is low, there is still significant stigma that women perceive related to child bearing, including fears of negative consequences toward themselves or their children related to HIV serostatus disclosure. A survey of 700 HIV-infected women geographically distributed across the United States reported that only 57% of the 159 pregnant women had a discussion regarding appropriate HIV treatment regimens before conception. Of the total women surveyed, 59% believed that society urged them not to have children.
Data reported in our study also supports previous research described from a Houston prenatal care clinic in which 34% HIV-infected pregnant women did not know the HIV status of their partner and 40% reported that their partner was HIV uninfected. In our study, 46% of the participants did not know the HIV status of their male partner and 28% presumed their partners were HIV uninfected. Most women reported disclosure of HIV status to their partners, but 26% participants reported that some or none other their partners knew their HIV status. Although we do not know whether women in this cohort used safer sex practices to conceive, it seems that a significant proportion of women were in serodifferent relationships with potential for sexual HIV transmission. Screening and prevention education for uninfected male partners is also integral to preconception counseling of HIV-infected women.
Our findings suggest that family planning—including discussions of effective contraception, pregnancy intentions, and safer conception methods—alongside with HIV-prevention education—is needed in this population both postpartum and in the primary HIV care setting. Enhanced screening for HIV to diagnose individuals with unknown serostatus and then maintaining all HIV-infected individuals on ARVs, if clinically indicated, are also key prevention measures. This type of comprehensive care can be achieved through a multidisciplinary (infectious disease, obstetrics and gynecology, primary care, social work, and nursing) awareness of the unique health needs of women with HIV. In our study, respondents were commonly seen by multiple types of providers (eg, primary care, HIV specialist, and obstetrics/gynecology) in the year before pregnancy, limiting our ability to determine which provider types were most likely to deliver family planning and prevention messages. Future studies further elucidating patient–provider communication of family planning and prevention messages could help inform this multidisciplinary delivery of care.
Based on data from this US cohort, discussion of pregnancy intentions with a healthcare provider was associated with a decreased risk of unplanned or ambivalent pregnancy. Given HIV is a chronic medical illness requiring preconception management and there are risks of sexual and perinatal HIV transmission during conception and pregnancy, our goal should be to maximize the number of planned pregnancies. Our data also suggest that a significant number of women in serodifferent relationships are conceiving without knowledge of their partner's HIV serostatus and may need additional advice to promote safer conception. Outcomes related to unintended pregnancy are similar to HIV transmission: increased risk of morbidity and mortality, adverse health outcomes for children, and poor family health. Organizations such as the Centers for Disease Control and Prevention and Infectious Diseases Society of America already endorse discussion of pregnancy intentions and contraception as part of primary medical care of HIV-infected women. Interventions that increase the provision of preconception counseling and ART use may increase the likelihood of planned pregnancy among HIV-infected women in the United States and promote options to decrease risk of HIV transmission among serodifferent couples.
Discussion
In this US-based, multicenter, cross-sectional study, we found that the majority of pregnancies among HIV-infected women were unplanned or ambivalent. Access to medical care and discussion of fertility intentions were associated with a decreased risk of an unplanned/ambivalent pregnancy.
A strength of this study is that it included participants from several sites across the United States. The generalizability of these data are limited given only academic medical centers and sites with clinician-investigators with special interests in HIV and pregnancy were included. Therefore, findings from this study may be biased toward planning pregnancies and discussion of pregnancy intentions compared with the HIV-infected population as a whole. In addition, although our study sites were across the United States, most participants were from the southern part of the United States and most participants self-described as non-Hispanic black. However, this may be a strength of the study as the numbers of HIV infections in black women are rising, particularly in the southern United States. Previous research also indicates that black women, in general, are disproportionately affected by unplanned pregnancy compared with other racial groups.
A potential limitation of this study is social desirability bias. Women who are already pregnant may not recall or wish to recall any negative feelings they may have had regarding the index pregnancy. To diminish this bias, we used the validated LMUP scale, which is specifically designed to assess pregnancy intentions retrospectively. Another potential limitation of this observational study could be unexpected and unmeasured predictors of pregnancy intention. Given the small sample size, we may have lacked power to definitively rule out certain associations with unplanned or ambivalent pregnancies.
This study supports previously published research describing limited discussion of preconception issues by HIV care providers based on reports from HIV-infected women in the United States. A survey of 181 women attending an HIV clinic in Baltimore demonstrated that only 67% women had a general discussion about pregnancy; 31% had a personalized discussion, and the majority of all discussions were patient initiated. A comparison study between practices in the United States and Brazil also demonstrated lack of communication on the part of providers regarding pregnancy intentions in both locations. A strength of our study is that we report a modifiable variable associated with unplanned/ambivalent pregnancy and that this finding should motivate providers to discuss these topics.
Our study showed that having had a prior birth since HIV diagnosis was associated with a decreased risk unplanned pregnancy. We can speculate that this may be related to increased knowledge regarding low risk of transmission of HIV during pregnancy from past experience and, therefore, less ambivalence or fear regarding planning for a future pregnancy. Indeed, although the risk of perinatal HIV transmission is low, there is still significant stigma that women perceive related to child bearing, including fears of negative consequences toward themselves or their children related to HIV serostatus disclosure. A survey of 700 HIV-infected women geographically distributed across the United States reported that only 57% of the 159 pregnant women had a discussion regarding appropriate HIV treatment regimens before conception. Of the total women surveyed, 59% believed that society urged them not to have children.
Data reported in our study also supports previous research described from a Houston prenatal care clinic in which 34% HIV-infected pregnant women did not know the HIV status of their partner and 40% reported that their partner was HIV uninfected. In our study, 46% of the participants did not know the HIV status of their male partner and 28% presumed their partners were HIV uninfected. Most women reported disclosure of HIV status to their partners, but 26% participants reported that some or none other their partners knew their HIV status. Although we do not know whether women in this cohort used safer sex practices to conceive, it seems that a significant proportion of women were in serodifferent relationships with potential for sexual HIV transmission. Screening and prevention education for uninfected male partners is also integral to preconception counseling of HIV-infected women.
Our findings suggest that family planning—including discussions of effective contraception, pregnancy intentions, and safer conception methods—alongside with HIV-prevention education—is needed in this population both postpartum and in the primary HIV care setting. Enhanced screening for HIV to diagnose individuals with unknown serostatus and then maintaining all HIV-infected individuals on ARVs, if clinically indicated, are also key prevention measures. This type of comprehensive care can be achieved through a multidisciplinary (infectious disease, obstetrics and gynecology, primary care, social work, and nursing) awareness of the unique health needs of women with HIV. In our study, respondents were commonly seen by multiple types of providers (eg, primary care, HIV specialist, and obstetrics/gynecology) in the year before pregnancy, limiting our ability to determine which provider types were most likely to deliver family planning and prevention messages. Future studies further elucidating patient–provider communication of family planning and prevention messages could help inform this multidisciplinary delivery of care.
Based on data from this US cohort, discussion of pregnancy intentions with a healthcare provider was associated with a decreased risk of unplanned or ambivalent pregnancy. Given HIV is a chronic medical illness requiring preconception management and there are risks of sexual and perinatal HIV transmission during conception and pregnancy, our goal should be to maximize the number of planned pregnancies. Our data also suggest that a significant number of women in serodifferent relationships are conceiving without knowledge of their partner's HIV serostatus and may need additional advice to promote safer conception. Outcomes related to unintended pregnancy are similar to HIV transmission: increased risk of morbidity and mortality, adverse health outcomes for children, and poor family health. Organizations such as the Centers for Disease Control and Prevention and Infectious Diseases Society of America already endorse discussion of pregnancy intentions and contraception as part of primary medical care of HIV-infected women. Interventions that increase the provision of preconception counseling and ART use may increase the likelihood of planned pregnancy among HIV-infected women in the United States and promote options to decrease risk of HIV transmission among serodifferent couples.
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