Demographic profile of pregnant HIV-positive women 1
Demographic profile of pregnant HIV-positive women accessing health care services in a public hospital in Postmasburg, South Africa: A short report
K.H. KALONJI AND M.M. MOKGATLE
School of Public Health, Department of Biostatistics, Faculty of Health Science, University of Limpopo- Medunsa Campus, South Africa. Email: or
Abstract
Demographics play an important role in both pregnancy intentions and actual childbearing. Profiling of pregnant HIV-positive women is vital for developing effective policies and interventions aimed at preventing pediatric HIV, decreasing the maternal mortality rates, and reducing spread the of HIV among couples. The aim of this study was to describe the demographic profile of pregnant HIV-positive women attending antenatal care (ANC) in public sector clinics in a rural area—Postmasburg, as well as the circumstances associated with the occurrence of their current pregnancies. A quantitative, descriptive survey design was used to collect data from 41 consecutively pregnant HIV-positive women who attended ANC at three public sector clinics in Postmasburg, from September to December 2010. Respondents were administered a structured pre-tested questionnaire in their home language by same sex trained interviewers. Pregnant HIV-positive women attending ANC in Postmasburg were likely to be young (mean age, 27.71 ± 5.72 years), never married (56.10%), Africans (65.9%) and Setswana language speakers (58.52%) of low socioeconomic status, and 65.85 % with one or no child. The majority of respondents (63.4%) were from a predominantly informal settlement; 78% were unemployed. Most (78.05%) became aware of their HIV-positive diagnosis during their current pregnancy that was unplanned in 73.17% of cases. Low levels of pregnancy intendedness (31.71%), low hormonal contraceptive use (24.9%) and condoms uptake (34.15%), with self-reported high rates of condoms failure were found among users (87.12%). Pregnant HIV-positive women in Postmasburg were predominantly young Africans of low socioeconomic status, often unaware of their HIV-positive status at the time of conception, and whose pregnancies were unplanned in most of the cases.
Keywords: Demographic profiling, HIV-positive pregnancy, unintended pregnancy.
How to cite this article:
Kalonji, K.H. & Mokgatle, M.M. (2014). Demographic profile of pregnant HIV-positive women accessing health care services in a public hospital in Postmasburg, South Africa: A short report
African Journal for Physical, Health Education, Recreation and Dance, September (Supplement 1), 32-47.
Introduction
South Africa is among the world’s leading countries in terms of the number of HIV- positive pregnant women. The 2011 National Antenatal Sentinel HIV and Syphilis Prevalence Survey showed that of the 36,000 women attending 1,445 antenatal clinics across all nine provinces, 29.5% of pregnant women (aged 15-49) were living with HIV (DOH 2011).Although one in three South African pregnant women is HIV-positive, little is, however, known about the demographic profile of these HIV-positive women who fall pregnant and experience parenthood, despite the fact that several socio-demographic characteristics (e.g., young age, being married or cohabiting, small family size, geographic location, lower educational level) may play a role in both pregnancy intentions and actual childbearing (Meyer, 2010; Cooper, Moodley & Zweigenthal, 2009). Addressing the specific reproductive needs of HIV-positive women is important because HIV-positive pregnancies are associated with a potential risk of re-infection with a different strain of HIV and with the risk of transmitting HIV to the offspring and to an uninfected male partner. The risk of HIV transmission is heightened by the fact that many among these women have fallen pregnant unintentionally and have failed to practice protected sex during pregnancy, despite receiving adequate counseling during the antenatal care attendance (Cooper et al., 2009; Peltzer, Chao & Dana, 2009). Cooper and colleagues have reported that unintended pregnancy rates may range from 30% in South African HIV-positive women who are receiving Highly Active Anti-retroviral Therapy (HAART) to 100% in those not receiving this treatment. These high rates of unintended pregnancies suggest the existence of possible sexual risk behaviors, unmet reproductive needs and/or community, contextual and individual factors that may determine and/or make HIV-positive women to fall pregnant.
In South Africa, the odds of maternal mortality amongst HIV-positive pregnant women are ten times more than among the HIV-negative pregnant women. Another challenge is the pediatric HIV epidemic which is associated with the high under-five year’s old mortality rates that has increased relative to 1990. The increasing maternal and child mortality rates are counterproductive to South Africa reaching the Millennium Development Goals (MDGs) 4 and 5 (Chopra et al., 2009; Prendergast et al., 2007).
In view of the important role that demographics play in both pregnancy intentions and actual childbearing, it is necessary to investigate the demographic profile of pregnant HIV-positive women for developing effective policies and interventions aimed at preventing pediatric HIV, decreasing the maternal mortality rates, and preventing the spread of HIV among sero-discordant couples. National registries developed within specific surveillance programmes as well as multisite longitudinal studies have significantly contributed to the knowledge of the typical picture of pregnant HIV-positive women in developed countries (Townsend, Cortina-Borja, Peckham & Tookey, 2008; Byrant, 2007). Evidence from South Africa is still lacking because such a national registry has not been developed yet, but also because most of the studies conducted in this country have focused either on HIV-positive pregnancy outcomes or on fertility desires and intention (Cooper et al., 2009; Rollin, Coovadia & Bland, 2007).The aim of this study was therefore to describe the demographic profile of pregnant HIV-positive women who were attending antenatal care in Postmasburg, a rural area located in the Northern Cape Province of South Africa. The study had three objectives. The first objective was to describe the demographic profile of pregnant HIV-positive women attending ANC at the selected public sector clinics. The second objective was to determine the proportion of these pregnant HIV-infected women who were aware of their HIV-positive status prior to the occurrence of their current pregnancy. Lastly, the third objective was to describe the circumstances of the occurrence of the HIV-positive pregnancies among the participants.
Methodology
Study design
A descriptive quantitative design involving different groups of pregnant HIV-positive women attending ANC in three public sector clinics in Postmasburg was used.
Study settings
Postmasburg is a sub-district located in rural Northern Cape Province which lies mid-way between Kimberley and Upington. There are three townships in Postmasburg, namelyBoichoko, a predominantly formal township; Newtown, a predominantly informal township and Postedene, a predominantly formal township. The catchment area of Postmasburg clinic is Newtown.
Sample population
The study sample comprised 41 consecutive pregnant HIV-positive women who attended ANC at the selected clinics between September and December 2010. Eligible respondents were recruited during their routinely scheduled clinical appointments. No sampling was done as all potential respondents were approached and requested to participate in the study. Eligibility criteria for inclusion in the study were as follows: (a) Being a pregnant HIV-positive woman at the time of recruitment; (b) being an attendee of ANC in a public sector clinic in Boichoko, Newtown or Postedene townships; (c) being able to give informed consent. Eligible respondents unable to give informed consent and those who were unwilling to give consent were excluded from the study.
Data collection
Data were collected using a 31-item piloted and pre-tested interviewer-administered structured questionnaire. The questionnaire was aligned with the study’s objectives and was thus purposefully divided into three components.
Eligible respondents were approached by the nurse doing ANC during their routinely scheduled ANC appointment. Those who showed their interest to participate in the study met the investigators in a separate room and were then scheduled for the interview during their subsequent routine ANC appointment. Respondents were enrolled after they have signed the informed consent form and underwent interview in a private room allocated by each clinic. Interviewers were trained assistant nurses who administered the structured questionnaire in the respondents’ home language. Ethics approval was obtained from the Research Ethical Committee of the University of Limpopo/Medunsa Campus.
Data were captured coded in a Microsoft Excel Spreadsheet and then imported to Stata version 10.0 software for analysis.
Results
A total of 41 consecutive pregnant HIV-positive women were approached during the period of data collection for participating in the study. All of them accepted to sign the informed consent form and completed the structured questionnaire. They comprised 26 respondents from Postmasburg clinic, 12 from Boichoko clinic and 3 from Postedene clinic. An overall response rate of 100 was achieved. All items were answered by respondents as applicable. There were no missing data. The findings are presented based on the research questions.
The demographic profile of respondents
The respondents’ ages ranged from 15 to 39 years (mean 27.71± 5.72 years), and 23 women in the sample were under the age of 30 years. Of the 41 pregnant women, 27 were Africans, 24 Setswana speaking and 15 Afrikaans speaking. More than half of the respondents (n=23) were single and 17 were cohabiting. A large proportion of them were unemployed (n=32) and only six were working. Even though most women were unemployed some of them relied on social support and/or disability grants for themselves or their children. The general monthly income was less than a thousand rand (R1000.00 or approximately $100 as at the time of the study), while 16 women had no income. Out of 41 respondents, 35 respondents had secondary education. Most women (n=53) were in current relationships with the median duration of relationships being 24 months and the mean age of the partners who fathered the pregnancy was 32.05 (SD=6.75). The average age difference between partners was 4.35 years. Thirteen out of 41 respondents stated that the partner who fathered the pregnancy was five years or older than them with four out of five respondents aged 15-19 years being involved in different sexual relationships. The majority (63.41%) of respondents were living in an informal settlement. About 49% of the respondents were living with one or both parents before conception and 43.90% were living with the partner. Overall, 92.68% of the respondents did not change their place of residence after conception.
Table 1: Socio-demographic characteristics of the pregnant HIV-positive women attending ANC at public sector clinics in Postmasburg, South Africa (n=41).
Sample Characteristic / n/N / %Mean age (yrs.) [SD] / 27.71 [5.72]
Age group (yrs.):
- 15 – 19
- 20 – 24
- 25 – 29
- 30 – 34
- 35 – 39
8
10
13
5 / 12.20
19.52
24.39
31.71
12.20
Enrolment site:
- Boichoko clinic
- Postedene clinic
- Postmasburg clinic
3
26 / 29.27
7.32
63.41
Living in predominantly informal settlement / 26 / 63.41
Place of living before conception:
- Living alone
- Living with partner
- Living with one or both parents
18
20 / 7.32
43.90
48.78
Race:
- African
- Colored
14 / 65.90
34.10
Language:
Afrikaans
- Setswana
- Isixhosa
- Sesotho
24
1
1 / 36.60
58.52
2.44
2.44
Number of living children:
- 0
- 1
- 2
- 3 or more
18
8
6 / 21.95
43.90
19.51
14.64
Marital status:
- Married or cohabiting
- Single
- Separated
23
1 / 41.46
56.10
2.44
Currently in relationship / 36 / 87.80
Mean age of partner who fathered respondent [SD] / 32.05[6.75]
Mean age difference to partner (yrs.)
Sex mixing (age difference to partner ≥ 5 years)
- among the 20-49 years old
- among the 15-19 years old
13
9
4 / 31.75
25.00
80.00
Monthly income in South African Rand:
- 0
- 1 – 500
- 501 – 1000
- 1001 – 2000
9
6
10 / 39.02
21.95
14.63
24.39
Source of income:
- No source of income
- Disability grant (for self or child)
- Partner
- Salary
12
7
6 / 39.02
29.27
17.07
14.64
Employment status:
- Presently full-time employed
- Presently part-time employed
- Presently unemployed
- Student
2
32
1 / 14.63
4.88
78.05
2.44
Education:
- Primary school
- Secondary school
35 / 14.63
85.37
Number of living children:
0
1
2
3
4 / 9
18
8
5
1 / 21.95%
43.90%
19.51%
12.20%
2.44%
Thirty-two respondents out of 41 had at least one living child at the time of interview. Nine respondents did not have any child. Table 2 shows that 9 respondents had one child, eight had two children, and there were 9 nulliparous respondents.
HIV status and pregnancy context of respondents
Table 2 indicates the context of HIV status of the respondents. Of the 41 respondents, nine were diagnosed before their current pregnancy and 32 during their current pregnancy. Of the nine respondents who were diagnosed HIV-positive before the occurrence of their current pregnancy, eight said they disclosed their HIV-positive status to the partner who fathered their child. The median duration of respondents’ HIV-positive status was 3 years (range 1 to 12 years).
Table 2 shows that 18 of the respondents who were diagnosed HIV-positive before their current pregnancy knew their diagnosis for at least 1 to 2 years. A similar percentage was found for those who were HIV-infected for 5 years or more. Five of nine HIV-positive women had been aware of their HIV infection for less than 5 years.
Table 2: Context of HIV status and pregnancy of respondents
HIV Diagnosis / Frequency / PercentageDiagnosed before pregnancy / 9 / 21.95%
Diagnosed during pregnancy / 32 / 78.05%
Duration of diagnosis in years
1-2 / 4 / 44.44%
3-4 / 1 / 11.11%
5-6 / 1 / 11.11%
7-8 / 2 / 22.22%
≥ 9 / 1 / 11.11%
Disclosed to the partner (n=9) / Frequency / Percentage
Yes / 8 / 88.89%
No / 1 / 11.11%
Knowledge of partner’s HIV status (n=41) / Frequency / Percentage
HIV-negative / 7 / 17.07%
HIV-positive / 6 / 14.63%
Don’t know / 29 / 70.73%
Intended to fall pregnant / Frequency / Percentage
Yes / 13 / 31.71%
No / 28 / 68.29%
Agreement with partner (n=15)
Yes / 14 / 93.33%
No / 1 / 6.67%
Pregnancy occurred because (n=14)
Stopped use for falling pregnant / 0 / 0.00%
Condom was torn during sexual intercourse / 9 / 64.29%
Partner did not have condom / 2 / 14.29%
Was not using condom regularly / 3 / 21.43%
Pregnancy occurred because (n=10)
Stopped use because of side effects / 5 / 50.00%
Missed injection of contraceptive / 2 / 20.00%
Stopped use for falling pregnant / 2 / 20.00%
Other (no specific reasons were given) / 1 / 10.00%
All HIV-positive respondents were asked whether they had disclosed their HIV-positive status to the male partner who made them pregnant and eight out of nine respondents reported to have disclosed. Majority (n=29) of the respondents did not know their partners HIV status. Of the 41 respondents, 13 intended to fall pregnant and 28 did not have pregnancy intentions. Fifteen respondents discussed their pregnancy intentions with the male partner prior their current pregnancy, while 26 of them did not. Out of 19 of the pregnant HIV-positive women 12 respondents never discussed their pregnancy intentions with the partner.
Out of 41 respondents 27 reported that they did not use condoms while 14 did. The reasons for unplanned pregnancies were reported as condom got torn during sexual intercourse (n=9), partner did not use condom (n=2) and, inconsistent use of condoms (n=3).
Contraceptives failure and pregnancy
The ten respondents who were using contraceptives were asked to give the reasons for contraceptive failure with regard to the occurrence of their current pregnancy. Table2 shows that 5 of the respondents who regularly used contraceptives during the previous three months prior to their pregnancy stopped using them due to side effects, two missed their injectable contraceptive, and consequently stopped using contraception.
Discussion
The demographic profile of respondents
This study found that pregnant HIV-positive women in Postmasburg were predominantly Africans, especially, speakers of Setswana language. The majority of them were younger than 30 years. Respondents were also predominantly never married though being married or cohabiting was fairly common among them. Most of the pregnant women had previously experienced parenthood.
Respondents were also likely to be in a relationship at the time of the interviews and the partner was commonly older. A large age gap was more common among the 15-19 year olds. Overall, respondents were more likely to be living with the partner or with one or both parents at the time of conception and thereafter, than staying alone.
These findings are consistent with observed pattern in the local context that shows that HIV infection predominantly affects young adult African whose HIV prevalence in 2005 (19.9%) was more than six times higher than that of Coloured (3.2%) and other racial groups aged 15-49 years (Shisana et al., 2005). Similarly, sex mixing, whose prevalence among South African women aged 15-19 years was 27.6% in 2008 (Shisana et al, 2008) has been reported as a major risk factor for unprotected sex and HIV transmission in this region (Shisana et al., 2008; Gregson et al., 2002). Its main driver is poverty, being commonly motivated by material gains, marriage expectations, and sometimes parents’ pressure as a means of earning money, household necessities or getting married and bringing the ‘lobola’ (bride price) for the family (Gregson et al., 2002).
Young age has been consistently reported as being associated with incident HIV-positive pregnancy in several studies of incident HIV-positive pregnancy conducted in developing and developed countries (Myer et al., 2010; Suryavanshi et al., 2008; Bryant et al., 2007; Blair et al., 2004; Allen et al., 1993). Our findings are also consistent with data from Barbados (Kumar & Bent, 2003), where pregnant HIV-positive women were young (median age, 24 years), predominantly never married (89.0%), living with the male partners (39.7%) or with own parents (48.6%) and likely to be in relationship with older male partners (Kumar & Bent, 2003). However, unlike our respondents who were predominantly (65.85%) childless or had only one child, most of the pregnant HIV-positive women in Barbados (81.3%) were multiparous (Kumar & Bent, 2003). Conflicting results between parity and incident HIV-positive pregnancy have been reported in various prospective studies from sub-Saharan Africa, Europe and USA (Myer et al., 2010; Homsy et al., 2009; Bryant et al., 2007).
Our findings also contradict those reported in most of the studies conducted in sub-Saharan Africa that indicate that pregnant HIV-positive women are predominantly married/cohabiting (Myer et al., 2010; Homsy et al., 2009; Allen et al., 1993). However, data from the USA have also yielded conflicting results in terms of the association between marital status and subsequent pregnancy (Bryant et al., 2007; Bedimo-Rung et al., 2005).