Repeat Pregnancy in HIV Positive Indian Women Nishi Suryavanshi 1 Ashwini Erande 1, Hemlata Pisal 1, Anita V. Shankar 2, Robert C. Bollinger 3, Mrudula Phadke 4, Jayagowri Sastry 1 MIT study staff 1 1 Ed Search, Pune, India; 2 Johns Hopkins University, School of Public Health, Baltimore, United States; 3 Johns Hopkins University, School of Medicine, Baltimore, United States; 4 Maharashtra University Of Health Sciences, Nasik, India. Abstract No: WEAX0303

Background Developed Setting Sowell (2002): Intent to get pregnant to traditional gender roles Wilson (1999): contraceptive use HIV positive women Local norms about fertility control Acceptability of contraception Developing Setting Ganatra (2002): Greater reproductive decision making role. Older women proved their fertility Better economic means and mobility Barge et al (2003): Difference of opinion, it is usually the wishes of the husband that prevail.

Background Social norms and familial obligations influence reproductive choices of married HIV positive women Reproductive decision making is a challenging gender issue in India. Having HIV adds critical component to these challenges. Understanding these factors will guide interventions and counseling strategies to better inform and support HIV positive women.

Research Questions and Hypothesis RESEARCH QUESTIONS : 1.What are the socio-cultural factors associated with repeat pregnancies among HIV positive and HIV negative women? 2. For HIV-positive women, what socio-cultural characteristics are different between women who become pregnant and those who are currently not pregnant?

Research Questions and Hypothesis HYPOTHESES: 1.Majority of repeat pregnancies among HIV positive women are unplanned 2. Family pressure, child death, disclosure of positive HIV status to no one, contraceptive usage etc. are some of the characteristics that may lead to repeat pregnancies.

METHODS PARTICIPANTS: Sub sample of women participated/participating in a clinical trial. HIV positive pregnant (n=63). HIV positive women non pregnant within 9 to 12 months of their most recent pregnancy (n=63). HIV negative pregnant (n=63). DEFINITION OF REPEAT PREGNANCY: For the purpose of this study, we define a repeat pregnancy as one in which a woman who has been previously screened for HIV, has completed at least one pregnancy and is pregnant again – with in 2 years of the last pregnancy DATA COLLECTION PERIOD: Sept to March 2006 DATA COLLECTION TOOL: Semi structured interviews. ANALYSIS: Data were entered and analysed in SPSS computer software.Chi square was done to compare demographic variables and simple logistic regression, was done to compare socio cultural variables among HIV positive pregnant, HIV negative pregnant and HIV positive non- pregnant women.

Results Socio-demographic characteristics of HIV positive and HIV negative women HIV positive Pregnant N (%) N=63 HIV negative Pregnant N (%) N=63 HIV positive Non- pregnant N (%) N=63 Mean Age (yrs) Education. Secondary + above 43 (68)52 (81)38 (60) Occupation. House wife49 (78)56 (87)50 (79) Family Type Joint36 (57)49 (77 )*37 (59) * p=0.02

Results Knowledge & Practice:Contraception HIV positive Pregnant. N (%) N=63 HIV Negative Pregnant N (%) N=63 HIV positive Non- Pregnant. N (%) N=63 Discussed Contraception with Husband 38 (60)30 (47)43 (68) Used some type of contraception 46 (73)29 (45)54 (86) Used condom 37 (80)16 (55)48 (89) Provided condom 28 (76)08 (50)44 (92) Received information on contraception 37 (80)19 (66)53 (98)

Narratives (unplanned pregnancies ) “I can not help as my husband does not know about my HIV status and he wants baby. Even the financial condition at my natal home is very poor. I have no support from anyone. He wants this child so I had to accept and continue (pregnancy).(21 years old housewife) I have 2 kids so I came for FP operation and I had taken date for operation but my mother in law did not allow. She does not know my HIV status. I have two daughters and she wants male child” She said “I have one son so you should also have one to support when you get older" Anyway her son does not look after her but who is going to tell her.” (27years.housewife)

Results Fig. 1:Socio-cultural factors associated with repeat pregnancies among HIV positive and HIV negative women

Results Fig 2: Socio –cultural factors affecting reproductive decision making among Pregnant and non pregnant HIV positive women.

Conclusion These data appear to indicate that desire of family, having lost a child affect reproductive decision of HIV positive women irrespective of their positive status. Face greater challenges and are more likely not to have planned their most recent pregnancy. Despite being pregnant they are concerned about their pregnancy (mostly because of the risk of HIV transmission)

Implications Appropriate counseling techniques for HIV positive pregnant women need to include reproductive counseling. If possible, with woman’s consent involve husband and other key family members who influence reproductive choices of couple. Life skill interventions will be important in reducing Number of unplanned high risk pregnancies.

Implications Need to understand gender dynamics along with social and cultural norms while counseling about reproductive choices in the context of HIV/AIDS epidemic. The determinants of contraceptive use, barriers to contraceptive use, and factors that contribute to effective contraceptive use in this population must be understood to reduce the risk of unplanned pregnancies. It is also important to know how health care providers address the issues related to unintended pregnancies among HIV positive women.

Acknowledgement This study is supported by a grant from National Institutes of Health (NIH, NIAID) (R01 AI45 462) and This presentation has been supported, in part, by a fellowship/grant from the Fogarty International Center/USNIH: Grant # 2 D 43 TW AITRP The authors would like to thank the participants, as well as all BJ Medical College-Johns Hopkins University-MTCT project staff (Pune) for their help with this study.