High rate of unplanned pregnancy in the context of integrated family planning and HIV care services in South Africa

The majority of HIV-infected women are within the reproductive age group [1, 2]. Even though the availability of antiretroviral therapy has significantly reduced the risk of mother-to-child transmission of HIV and made prevention of mother to child transmission (PMTCT) possible, many women infected with HIV want to avoid pregnancy [3–7]. The reasons why many HIV-infected women prefer to avoid pregnancy are well documented. Among these reasons are the desire to stop bearing children, fear of premature death, financial constraints, having previously infected baby, and concerns about transmitting HIV to partners and children [6, 8, 9]. However, many of these women experience an unplanned pregnancy, which remains a major public health concern globally. In other words, the rate of unplanned pregnancies is alarmingly high in both developed and developing countries [6, 10–15].

South Africa, a country with a heavy burden of HIV [1], has made remarkable progress in the PMTCT of HIV. High rate of unplanned pregnancy in women infected with HIV remains a major concern [12, 16–18]. In 2012, a South African study showed that 62% of pregnancies among women with HIV were unplanned, with about half ending in abortion [12]. A high rate of unplanned pregnancy (68% to 85%) was also reported among HIV-infected women in the United States [14, 19]. Worryingly, a disproportionately higher rate of unplanned pregnancy was reported among adolescent women infected with HIV [15]. A high rate of unplanned pregnancy is commonly reported in the general population irrespective of women’s HIV status. A study has shown that there is no significant difference in the rate of unplanned pregnancy and contraceptive use between HIV sero-negative and sero-positive women [20]. In other words, sexual behaviours of HIV positive- and negative women are not dissimilar.

The question to ask is, “Why is unplanned pregnancy so high despite the availability of family planning services at the health facility level?”. As shown in the literature, contraceptive failure, incorrect and inconsistent condom use, and lack of knowledge of emergency contraception are among the reasons for high prevalence of unplanned pregnancy [21–23]. Absent father—a common phenomenon in South Africa context—has been linked to increased risk for early sexual activities and adolescent unplanned pregnancy [24]. In addition, younger age, never married status, experience of contraceptive failure, unemployment, early sexual debut, smoking, drug use, and lower education are among the factors associated with unplanned pregnancy [11, 13, 25–27]. The links between sexual risk taking and alcohol and substance use are well established and explain, in part, why unplanned pregnancy is prevalent globally [28–31].

The consequences of unplanned pregnancy are deleterious; among which are partner violence, depression, suicidal ideation, anxiety, and even death [13, 26, 27]. A Canadian study shows that unplanned pregnancy is associated with being unhappy [11]. The effect of unplanned pregnancy is not limited to women only; there is evidence that fathers facing unplanned pregnancies endure significantly more stress and often express a feeling of powerlessness in adapting to the arrival of a new infant [32]. Women with an unplanned pregnancy face an increased risk of abortion-related mortality, especially in countries with restrictive abortion laws [27]. Even in countries with permissive abortion laws, people often do not seek care due to abortion-related stigmas [33, 34], which are more prolific than HIV-related stigma [5].

Unplanned pregnancy is also an important indication of possible horizontal transmission of HIV. Some studies in the United States [13] and South Africa [11, 16] reveal that one-third of HIV-infected pregnant women partake in unprotected sex with a male partner with either negative or unknown status. Unplanned pregnancy, unprotected sex and transmission of HIV are intertwined and are often exacerbated through the transactional nature of sex [16, 35]. The complex nature of the link between transactional sex, poverty and unemployment makes it difficult to tackle the problem of unplanned pregnancy. Young adolescents are faced with increased risk of HIV infection and unplanned pregnancy as a result of intergenerational sex [17]. Vulnerable women, especially adolescents, tend to focus on tackling the more urgent risks in their lives: poverty, homelessness, and the frequent disruption of socio-economic support systems [36].

There is consensus among scholars that the integration of family planning services into HIV care, and PMTCT could potentially reduce the high rate of unplanned pregnancy, therefore, paving the way for a more cost-effective strategy to eliminate mother-to-child transmission of HIV [7, 15, 37–39]. A study has shown that averting unplanned pregnancy through the use of family planning messages and provision of contraception is a more cost-effective strategy than HIV counselling, testing and HAART provision in preventing perinatal HIV transmission [39]. However, a cluster randomised control trial study did not find any effect of service integration on the rate of unplanned pregnancy [38]. Nevertheless, service integration was associated with increased uptake of more effective contraceptive methods and condom use [38].

For over a decade, family planning services have been integrated into HIV services in South Africa with the aim of ensuring that all pregnancies are planned, and to prevent mother to child transmission of HIV. Women seeking reproductive health services are counselled on HIV and use of family planning. Also, contraceptives are freely given to women in all public health facilities. A good measure of the impact of service integration would be a measure of the rate of unplanned pregnancy in HIV-infected women in care. The reported rate of unplanned pregnancy would be important to track progress and address challenges. With a view to providing data for planning, monitoring and addressing the problem of unplanned pregnancy among women infected with HIV, this paper describes the prevalence and correlates of unplanned pregnancy in HIV-infected women attending maternal services in three large hospitals in the Eastern Cape, South Africa. Also, the study critically examines the impact of service integration by comparing the rate of unplanned pregnancy between women already engaged in HIV care and those who were newly diagnosed at the index pregnancy.

This study determines the prevalence of unplanned pregnancy and also, examines its correlates with a view to assessing the impact of the integrated services of family planning, HIV care and PMTCT. Our study shows that despite services integration, unplanned pregnancy is still very high and disproportionately high among women aged below 21 years, who have undergone three to five abortions, who have five to seven children, who are unaware of their HIV status at booking and single. The prevalence of unplanned pregnancy found in this study is higher than those reported by Schwartz et al., [12] in South Africa, Loutfy et al., [11] in Canada and Yanikkerem [27] in Turkey. However, a higher rate of unplanned pregnancy was reported by Sutton et al., [14]. The present study further shows that the majority of pregnancies in HIV-infected women are unplanned, despite family planning counselling and free access to contraceptives at HIV clinics in the region.

Plausible explanations for the high rate of unwanted pregnancies in our study include a high rate of unprotected sex irrespective of HIV serostatus among younger age group; discontinuation or irregular use of contraceptives; underutilization of emergency contraceptives and abortion services in the region [12, 18, 22, 23, 41]. In the South African communities, abortion-related stigma which is even worse than HIV-related stigma [5], could perhaps be among the reasons why many of these women decided to carry these pregnancies to term.

Our study shows that the rate of unplanned pregnancy is lower among women with a prior diagnosis of HIV in comparison with those who were diagnosed in the index pregnancy. This suggests a possible impact of services’ integration on reduction of unplanned pregnancy rate, contrary to Grossman et al., [38]. It is possible that the rate of unplanned pregnancy has declined in previously diagnosed women receiving care. There is evidence that the rate of unplanned pregnancy declined for the first time in the United States, which is a possible indication of the effectiveness of HIV care and family planning services’ integration [42].

The very high rate of unplanned pregnancy among adolescents and young women is not surprising, and is consistent with previous studies [15, 43]. Women below the age of 21 years are more than thrice likely to report an unplanned pregnancy compared to women aged 21 and above. The disproportionately high rate of unplanned pregnancy among adolescents and young women is perhaps due to the vulnerability of this age cohort. Older men often prey on vulnerable girls for transactional sex [17]. In Worth’s study [36], vulnerable women, especially adolescents, tend to focus on tackling the more urgent risks in their lives: poverty, homelessness and the frequent disruption of socio-economic support systems. Another plausible explanation is that adolescents and young women are more likely to engage in risky sexual behaviours including intergenerational sex [44–46].

Another important finding of this study is unmarried women being four times more likely to report an unplanned pregnancy compared to married women. This finding is consistent with previous studies [11, 47] and is not surprising, considering that conversations about pregnancy are more plausible in a marital relationship. The current study also reveals that late booking and peri-partum immunosuppression are associated with unplanned pregnancy. Low CD4 counts and late booking (after 27 weeks) could potentially have catastrophic implications for such women’s health. The finding stresses the need to ensure all pregnancies are planned. Innovative strategies to improve consistent use of contraception among women infected with HIV are needed in the study setting. Even though all the parturient women received peri-partum contraceptives prior to discharge, there is a need for continued engagement of these women in family planning services in order to prevent future unplanned pregnancies.

For over a decade, family planning services have been integrated into HIV services in South Africa as a core strategy to prevent mother-to-child transmission of HIV. Women seeking reproductive health services are counselled on HIV and use of family planning. Also, contraceptives are freely given to women in all public health facilities. The current study indicates a gap in the HIV services and reproductive health services’ integration. Our study also emphasises that while service integration is important, it is insufficient to address the problem of unplanned pregnancy in women infected with HIV. There is a need for constant monitoring of unplanned pregnancy rates in order to track progress and address challenges. Our study would serve as a baseline for future comparison and tracking of progress in the reduction of unplanned pregnancy rates in the region.

Unplanned pregnancy remains high overall among parturient women living with HIV in the region, however, with significant reduction among those who were exposed to integrated services. Our study confirms that integration of HIV care and family planning services is an important strategy to reduced unplanned pregnancy among women living with HIV. The study’s findings have significant implications for the elimination of mother-to-child transmission of HIV in South Africa. Innovative interventions are needed to further consolidate and maximise the benefits of integrating family planning services with HIV care.