Contraceptive Use and Factors Associated With Postpartum Surgical Sterilization Among HIV-Infected Women in Pune, India
Suryavanshi N, Mave V, Gupte N, Bhosale R, Sambarey P, Patil S, Sastry J, Bollinger R, Gupta A, Shankar A & The SWEN India Study Team.
The authors desire to better understand contraceptive practices and factors associated with surgical tubal ligation (STL) among HIV-infected women. Secondary data were obtained from HIV-infected women enrolled in a National Institutes of Health–funded clinical trial assessing the efficacy of extended-dose nevirapine given to breastfed infants at a government hospital in Pune, India, and were analyzed. The most common contraceptive methods adopted were abstinence (55%), followed by STL (34%). Having a living male child and being multigravida were directly associated with acceptance of STL. Thorough contraceptive counseling services are needed for HIV-infected women so that STL is not perceived to be protective against sexually transmitted diseases and HIV transmission.
contraceptive, counseling, HIV, STD, surgical tubal ligation, women
India has an estimated fertility rate (FR) of 2.7 children per woman, with women usually achieving their desired fertility by 25 years of age. At that point, they frequently adopt a permanent method of contraception (NFHS-3 National Family Health Survey [NFHS-3], 2007). Rates of surgical tubal ligation (STL) have continued to increase in India, rising from 27% (1992–1993) to 34% and 37.3%, respectively in 2001 and 2008 (NFHS-1 National Family Health Survey [NFHS-1], 1995; NFHS-2 National Family Health Survey [NFHS-2], 2001; NFHS-3, 2007). In India, currently 2.3 million adults are infected with HIV, of whom 39% are women of reproductive age (National AIDS Control Organisation, 2010). There are little data on contraceptive choices for HIV-infected Indian women in the literature.
Globally, contraceptive choices for HIV-infected women vary considerably by region. Reports from Rwanda and Uganda (Elul et al., 2009) have noted that condoms were the most commonly used methods by HIV-infected women, while in Tanzania (Keogh, Urassa, Kumogola, Mngara, & Zaba, 2009) reports that injectable hormonal contraception was most popular. These studies also report that HIV-infected women were less likely to want additional children than are their HIV-negative counterparts. A study from two regions in Brazil showed that HIV-infected women from both areas desired permanent contraception, but there were dramatic differences in the prevalence of STL, due primarily to the lack of available STL services in one region (Mitchell & Stephens, 2004).
STL is highly effective and widely used (Trussell, Hatcher, Cates, Stewart, & Kost, 1990) in India and has the highest user-satisfaction rate of any currently available method (Rosenfeld, Zahorik, Saint, & Murphy, 1993). However, in populations, such as HIV-infected populations, where prevention of sexually transmitted diseases (STDs) is an important health concern, the use of barrier methods is required. Our main objective is to describe the contraceptive practices. In addition, we compare the characteristics of postpartum HIV-infected women who underwent STL after delivery with those of women who did not to identify factors that influence the use of STL among HIV-infected women postpartum. Given the high rates of STL in the general population, we also explored the reasons for choice of STL among HIV-infected women in India.
Our study population included HIV-infected women enrolled in a prevention of HIV mother-to-child transmission trial, the 6-week extended nevirapine (SWEN India) trial (Six Week Extended-Dose Nevirapine [SWEN] Study Team et al., 2008). This study, funded by the U.S. National Institutes of Health, was conducted at a government of Maharashtra urban public teaching hospital, Byramjee Jeejeebhoy Medical College & Sassoon General Hospital (BJMC & SGH) in Pune, India, between 2002 and 2007 and was approved by the Pune, India, and Johns Hopkins University (Baltimore, Maryland, USA) institutional review boards and the BJMC Ethics Committee.
The methods and results of the primary objective of this study have been previously described (SWEN Study Team et al., 2008). In brief, HIV-infected pregnant women aged 18 years and older who intended to breastfeed their infants were recruited from the antenatal clinic, delivery ward, or postpartum ward within 72 hours of delivery. Women were counseled by counselors and health care providers about various methods of family planning, including STL, and were informed about known risks and benefits of each method at enrollment and during scheduled follow-up visits up to 12 months' postpartum. Discussion of postpartum sterilization via STL was included but was never the sole recommendation. All those who underwent postpartum STL were encouraged to use condoms to prevent further transmission of HIV and transmission or acquisition of STDs. In this study, a nuclear family is defined as a family unit comprising husband, wife, and their biological/adopted living children. Abstinence as a method of contraception is defined as abstaining from sexual activity during any specified time period during 12 months postpartum due to any reason.
Materials and Procedures
Participants were asked about contraceptive use at each of 11 scheduled postpartum follow-up visits using standardized follow-up case report forms. Case report forms were pilot tested before finalization. Interviewers were members of the SWEN study team and trained in data collection methods. Questions were asked mainly about acceptance of contraceptive method, contraceptive use since last visit, and type of contraception used. Type of contraceptive used could vary over the 12-month period, and we characterized the predominant contraceptive use patterns in the group. Predominant contraceptive use is defined as type of contraception reported to be used in majority of the 11 visits by each woman. Free condoms were offered at all follow-up visits by family planning staff of BJMC. STDs were defined as per World Health Organization guidelines (WHO, 2011) for individual and syndrome diagnosis and were assessed by the study physician through a speculum examination to identify clinical signs of STDs. At enrollment and every follow-up visit, history, clinical examination and laboratory reports were used to categorize STDs.
We performed descriptive statistical analyses; categorical variables were compared using the χ2 test, and continuous variables were evaluated using the Student t-test. Univariate and multivariate logistic regression analyses were performed to examine the factors associated with postpartum STL using STATA (Version 10, College Station, Texas).
Of 725 women included in the study, the median age was 23 years, all were reported married, 79% were Hindu, 48% belonged to nuclear families, 98% had a living spouse, and 81% were housewives (Table 1). CD4 counts and HIV viral loads were determined at baseline and baseline visit was at delivery. Median CD4 counts and viral loads were measured for the study participants at baseline. The median CD4 count was 459 cells/mm3, and median HIV viral load was 4 log copies/mL. The majority of women (76%) reported some type of contraceptive choice (Table 2), while the remaining 24% engaged in sexual activity but used no contraception. Contraceptive choice varied over the 12 months of reporting. Of those reporting contraceptive choice (n = 550), more than half (55%) reported abstaining from sexual activity during the 12 months postpartum. The next most common contraceptive choice was STL (34%), followed by oral contraceptive pills (OCP) (8%). Only 3% of women reported only using intrauterine devices (IUDs). Of 189 women who underwent STL, a majority reported using condoms (65%) as well. It is important to note that 103 (54%) had an STL within 8 days post delivery, of which 20% were post cesarean section. Of those using OCP, 70% used it alone, whereas the remaining also used other methods such as condoms.
Journal of HIV/AIDS & Social Services. 2015;14(3). 21 Aug [Epub ahead of print] DOI:10.1080/15381501.2014.946548