HIV-positive women's and men's fertility preferences: Case studies of Zambia and Nigeria Ann M. Moore, Olutosin Awulode, Akinrinola Bankole, Adesina Oladokun, Namuunda Mutombo, and Megan Kavanaugh October 15, 2010

The social context of reproduction among the HIV-positive HIV-positive individuals have higher unmet demand for contraception and higher unwanted fertility than the HIV-negative Understanding social context of reproduction is complicated by whether or not individuals have disclosed HIV status to partners Social stigma against continued childbearing among HIV-positive individuals

Why Nigeria and Zambia? Nigeria (2008) –Moderate HIV rate (4.6%) –Low contraceptive prevalence (15% among married women) –High desired family size (6.1 for women vs. 7.2 for men) –Unmet demand: 20% Zambia (2007) –High HIV rate (14.3%) –High contraceptive prevalence (40% among married women) –Moderate desired family size (4.6 for women vs. 4.9 for men) –Unmet demand: 14%

Nigeria and Zambia: Women aged & Men Community-based interviews –~2600 w/ men and women –~400 matched couples Facility-based interviews –~300 w/men and women all HIV-positive –~100 with providers Follow-up in-depth interviews with outliers –~48 w/ men and women community & facility

HIV-positive survey respondents NigeriaZambia WomenMenWomenMen N=202N=162N=151N=147

Research questions How do gender-specific fertility preferences impact contraceptive use? For those not wanting another child and not using contraception, what are their reasons? What are HIV+ women’s and men’s reasons for wanting a(nother) child? How likely do individuals think they will be in achieving their goals?

Would you like to have a/nother child or would you prefer not to have any (more) children? Zambia Nigeria

Percent who say they do not want another child + not using contraception + perceived partner preference X 2 =7.395 p=0.025 X 2 =9.844 P=0.007 Percent not using contraception

Reasons for not using contraception among those who do not want another child

Reasons for wanting more children: Nigeria Women (n=124) Men (n=101)

Reasons for wanting more children: Zambia Women (n=56) Men (n=61)

Nigeria: How likely do you think you will be in achieving your goal? Want another child Do not want another child Not likely at all Somewhat likely Very likely

Zambia: How likely do you think you will be in achieving your goal? Want another child Do not want another child Not likely at all Somewhat likely Very likely

Conclusions (1) HIV-positive men and women are not that different in their desire to have/not have a(nother) child Primary reasons for not using contraception were fear of side effects (women) and infrequent sex (all) Reasons for wanting more children are similar for men and women: to lead a normal life and to reach desired family size

Conclusions (2) Men and women in Nigeria believe they will be more successful at having a(nother) children than at avoiding having a(nother) Men and women in Zambia believe they will be more successful at avoiding another child than they will be at having children

The role of gender In both Nigeria and Zambia, for those who did not want another child, the percent not using contraception was significantly higher if it was the man’s preference not to have another child or the woman perceived the man did not want a(nother) child compared to when the woman did not want Men and women did not differ significantly on whether they believed they would be successful at achieving their fertility pref. re: having a(nother) child

Policy implications HIV-positive women who do not want a(nother) child require greater support in using FP Couples communication re: fertility desires should be encouraged as a proportion of women did not know whether their husband desired another child Nigerian men and women require further support to avoid unwanted pregnancy while Zambian men and women require support to complete their desired family size

We would like to thank our funders: NIH, the Consortium for Research on Unsafe Abortion in Africa, the Netherlands government, the Ellertson post-doctoral fellowship Guttmacher Institute, New York, USA University of Ibadan, Ibadan, Nigeria Independent Consultant/University of Zambia, Lusaka, Zambia