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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 33  |  Issue : 3  |  Page : 284-287

Pattern of contraceptive uptake among clients in an HIV clinic


Clinical Sciences Division, Nigerian Institute of Medical Research, Lagos, Nigeria

Date of Web Publication8-Feb-2017

Correspondence Address:
E C Herbertson
Clinical Sciences Division, Nigerian Institute of Medical Research, 6, Edmund Crescent, PMB 2013, Yaba, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-5117.199804

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  Abstract 

Introduction: Contraception use is low in sub-Saharan Africa where women have a high burden of HIV. Most of these women are in their childbearing age and require access to safe and effective contraception. The objectives of this study were to determine the use and pattern of contraceptive uptake among HIV-infected clients registered for antiretroviral therapy (ART) services at an HIV outpatient clinic in South-West Nigeria; factors influencing contraceptive uptake among HIV-infected clients; and the contraceptive failure and/or discontinuation rates among the cohort of clients.
Methods: A database review was conducted on a cohort of clients registered at the family planning (FP) clinic from 2009 to 2013. Data management and descriptive statistics were with IBM SPSS software version 20.
Results: The number of FP clients in the 5 years is 537, constituting 7.7% of the ART population. Most were female, 531 (98.9%); with an average age of 32.3 years. Majority of them were married, i.e., 524 (97.6%) with 322 (60.0%) in serodiscordant marriages. Two hundred and fifty-six clients (45.8%) chose and used injectable contraceptives. One hundred and thirteen (21.0%) clients chose condom only. Dual method of hormonal contraception and consistent condom was accepted and used by 73 (13.6%) clients. Two hundred and seventy-four (51.0%) discontinued their chosen contraceptive method. Reasons for discontinuation include desired conception in 54 (16.6%), menstrual irregularities in 45 (13.8%), and spouse disapproval in 11 clients (2%). Clients referred out for intrauterine contraceptive device and implant were 47 (14.5%). Twenty-one (3.9%) clients reported pregnant within the first 2 months of use.
Conclusion: Contraceptive use is low (7.7%) with 51% discontinuation rate. Several reasons were given for discontinuation. Contraceptive failure rate was 3.9%. There is a need to find reasons for failed contraception and provide interventions to improve contraceptive success.

Keywords: Contraceptive; HIV; pattern.


How to cite this article:
Ohihoin A G, Herbertson E C, Anyansi E, Gbajabiamila T A, Idigbe E I, Ezechi O C, Ujah I. Pattern of contraceptive uptake among clients in an HIV clinic. Trop J Obstet Gynaecol 2016;33:284-7

How to cite this URL:
Ohihoin A G, Herbertson E C, Anyansi E, Gbajabiamila T A, Idigbe E I, Ezechi O C, Ujah I. Pattern of contraceptive uptake among clients in an HIV clinic. Trop J Obstet Gynaecol [serial online] 2016 [cited 2020 Sep 26];33:284-7. Available from: http://www.tjogonline.com/text.asp?2016/33/3/284/199804


  Introduction Top


It is currently estimated that as much as 220 million women in the world have an unmet need for contraception, national survey data indicate 30% in sub-Saharan Africa, excluding the unmet needs of adolescents and unmarried individuals.[1] In 2012, an estimated 222 million women in the developing countries had an unmet need for modern contraception.[1],[2]

Worldwide, as many as one-third of the 357,000 annual maternal deaths are attributable to unintended pregnancies, the majority of these mortalities occur in low- and middle-income countries.[3],[4],[5] Recent estimates of the maternal mortality burden by the Federal Ministry of Health put maternal mortality ratio at an unacceptably high figure of 800/100,000 live births, even by the standard of a developing country in Africa.[6] In addition to substantial risks of dying from pregnancy complications,[7] an estimated 15.4 million women are infected with HIV worldwide.[8] The burden is higher among sub-Saharan African women.[9] Most are in their childbearing years and need access to safe and effective contraception.[10] Estimates show the number of people living with HIV/AIDS in Nigeria in 2003 to be between 3.2 and 3.8 million.[11] Epidemic estimates according to the USAID (2008) reveal that adults in Nigeria aged between 15 and 49 years have a prevalence rate of between 2.3% and 3.8%, while the age group of 20–24 years has the highest national prevalence (5.6%).[12] Providing safe, effective contraception to HIV-infected women who desire it has also been identified by the World Health Organization as a primary strategy for the prevention of pediatric infections.[3] In 2006, as many as 1 million prenatal HIV infections were prevented through provision of effective contraception in settings where HIV infection is highly endemic.[13] Effective family planning (FP) services are central to initiatives to reduce unintended pregnancies, slow population growth, promote economic development, and improve the health of women and children worldwide.[14] FP services' integration within all HIV clinics and opened to patients during the clinic hours improve access to FP.[15] A woman who has already spent much of her morning in an antiretroviral therapy (ART) clinic is less likely to return to spend another half day in a FP clinic. Periodic stock-outs of reproductive health commodities may also limit women's access to FP services. In addition, most messages in the community promote condom use over the use of more effective modern contraception or dual method use. Providers' attitudes toward sexual and reproductive health care for HIV-infected patients [16] and misconceptions regarding the safety of hormonal contraceptive methods among women on ART may also play a role in limiting HIV-infected women's access to FP.[17] This study, therefore, was to determine the pattern of contraceptive uptake among clients attending an outpatient HIV clinic.

Study setting

This study was conducted in an outpatient HIV clinic which provides care and treatment for almost 20,000 people living with HIV from different parts of Lagos and beyond. Almost half of these people are on ART. Over 64% of the ART clients are women (aged 15–49 years). Within 2009–2013, 7000 clients were on ART. In 2009, FP service was integrated into the clinic with the aim of providing more effective contraceptive methods (hormonal contraceptives) promptly during clinic visits. Proper counseling on the different types of contraceptives and possible effects were given to clients by trained FP providers. Referrals were given to patients after FP counseling for other contraceptives not offered in the clinic (IUCD [intrauterine contraceptive device], implants, and bilateral tubal ligation [BTL]).

Objectives of the study

  • To determine the use and pattern of contraceptive uptake among HIV-infected clients registered for the prevention of mother-to-child transmission of HIV services at the outpatient HIV clinic
  • To determine the factors that influence contraceptive uptake among HIV-infected clients
  • To determine the contraceptive failure and/or discontinuation rate among the cohort of clients.


Ethical consideration

Ethical approval was obtained from the Institutional Ethics Review Board. Informed consent was obtained from the study participants, participation was by free will and no client was denied access to contraceptives because they refused to participate in the study. All data were de-identified to ensure confidentiality. All complaints of side effect were referred to the physician for care.


  Methods Top


This was a database review of a cohort of clients, who were registered at the FP clinic within the HIV outpatients' clinic from 2009 to 2013. Data management and descriptive statistics were with IBM SPSS software version 20 (Armonk, NY: IBM Corp).


  Results Top


Seven thousand clients were on ART within 2009–2013, of which 537 clients registered for FP, constituting 7.7% of the ART population. The number of female clients who registered for FP was 531 (98.9%). The age range was 19–48 years (average age: 32.3); most were married, i.e., 524 (97.6%); 322 (60.0%) were in serodiscordant relationship. Four hundred and sixty-three (86.2%) of them completed at least secondary education [Table 1]. Most clients were Christians, 451 (84.0%). Among the women, nine (1.7%) had zero parity, ninety (17.0%) were of parity one; and two (0.4%) were of parity eight, the highest number of female clients had either two or three children, 162 (30.5%) and 167 (31.5%), respectively.
Table 1: Sociodemographic distribution of the clients (n=537)

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Few of the clients, i.e., nine (1.7%) desired to space childbearing for 6 months; ninety (16.8%) desired to space for 12 months or more; 167 (31.1%) desired to space for 24 months or more, and 109 (20.3%) had no more desire for conception. Almost half of the clients, i.e., 246 (45.8%) chose and used injectable (depot-medroxyprogesterone acetate and depo-norethisterone acetate). The choice and use of condoms only was in 113 clients (21.0%) (female and male condoms). Dual method of hormonal and consistent condom use was accepted and used by 73 clients (13.6%). Some clients, i.e., 44 (8.3%) were referred for methods not offered in the clinic (BTL, IUCD, and implants) [Table 2].
Table 2: The pattern of contraceptive use among the clients

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For the length of use of chosen contraceptive method, 1 month was the minimum (18 [3.4%]) and 48 months was the maximum (8 [1.5%]). One hundred and sixty-seven clients (31.1%) used their chosen method for ≤6 months while 87 clients (16.2%) stopped at 2–3 months of use. Use of chosen method for 7–9 months was by 43 clients (8.0%), 40 clients (7.4%) used the chosen method for 12 months, and 91 clients (17.0%) used the chosen method for 13–48 months. Some clients, i.e., 21 (3.9%) reported pregnancy, 1–2 months of use of method (Duration of use for all methods put together not for individual methods; many of the clients still have ongoing usage for the methods).


  Discussion Top


The uptake of contraceptives is low in this setting (7.7%) of clients registered for ART. This is within the range of 7% to 15% reported by Cleland et al., 2011, who reviewed progress toward adoption of contraception among married or cohabiting women in West and East Africa between 1991 and 2004 by examining subjective need, approval, access, and use.[18]

Condom use was low (21.0%), despite that 59.96% of the clients were in serodiscordant marriages. Condom use rate in this study is far below the rate of 59.3% reported by Salaudeen et al., 2013, in a study among HIV-serodiscordant couples in North-Central Nigeria.[19] The low rate of utilization of condom in this study is of great significance, particularly against the background that close to 60% of the respondents are married in a serodiscordant setting. The poor utilization of barrier contraception will ultimately increase the risk of seroconversion in the negative partner. Another significant fallout of this low rate of condom utilization is the increased risk of developing resistance in clients who are married in seroconcordant settings. Use of barrier contraception is a useful practice in the management of individuals living with HIV.

The default rate was high (51%). Nearly 17.13% of them stopped the use of contraceptive method (hormonal) mostly within the first 2 months of use, giving no reason for discontinuation. About 3.2% of clients stopped the use of hormonal contraceptive method due to spouse disapproval and marital problems; this supports the need for men's involvement in FP and spousal communication as recommended by Feyisetan, 2000, in his work among Yoruba-speaking tribe of Nigeria. Other reasons for default rate were linked to the development of perceived side effects during the use of the methods.

Women who still desire more children prefer short-acting contraceptives unlike those who have no more desire for children. This agrees with the work by Creanga et al., 2011, who documented an increase in the use of short-term contraceptives in five African countries. The increased use as reported by Creanga et al. was among women who desire to space childbearing rather than stop childbearing.[20]

Fear of effect of contraceptives on the body, delay in conception after use, increase in weight, proximity to care, hypertension, and abdominal pain were some of the reasons that influenced the use of contraceptives in this study.


  Conclusion Top


Contraceptive use among these HIV-positive patients is low. Use of shorter contraceptive methods was more. There is a need for men's participation in FP counseling to increase the acceptance of contraceptive methods since husband's disapproval was a contributory factor to discontinuation of contraceptive use. The low rate of usage of barrier contraception and the relatively high rate of default is of concern, hence counseling effort for contraception during care of HIV patients should be encouraged to target these gaps. Provision of safe and effective FP methods within the clinic is very important to reduce referrals.

Acknowledgment

The following people are hereby acknowledged for their role during the study:

  • Mrs. S. M. Dasen (Registered Nurse) – Contraceptive administration and data collection
  • Mrs. D. Oladipo (Matron) – Contraceptive administration and data
  • Mrs. E. Amadi (Chief Nursing Officer) – Supervision of nurses.


Financial support and sponsorship

This work was funded by the researchers, FP commodities were provided by the Ministry of Health.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Duru MU, Aluyi HS, Anukam KC. Rapid screening for co-infection of HIV and HCV in pregnant women in Benin City, Edo State, Nigeria. Afr Health Sci 2009;9:137-42.  Back to cited text no. 1
    
2.
Singh S, Darroch JE. Adding it Up: Costs and Benefits of Contraceptive Services. New York: Guttmacher Institute, UNFPA. 2012.  Back to cited text no. 2
    
3.
World Health Organization, PSV. PMTCT Strategic Vision 2010-2012. Geneva, Switzerland: World Health Organization; 2010.  Back to cited text no. 3
    
4.
Sonfield A, Kost K. Public Costs from Unintended Pregnancies and the Role of Public Insurance Programs in Paying for Pregnancy and Infant Care: Estimates for 2008. New York: Guttmacher Institute; 2013.  Back to cited text no. 4
    
5.
Hubacher D, Mavranezouli I, McGinn E. Unintended pregnancy in Sub-Saharan Africa: Magnitude of the problem and potential role of contraceptive implants to alleviate it. Contraception 2008;78:73-8.  Back to cited text no. 5
    
6.
Federal Ministry of Health (FMOH) Nigeria/WHO. Reduce Maternal and Newborn Deaths in Nigeria: Make Pregnancy Safer. Abuja: Federal Ministry of Health (FMOH) Nigeria; 2011.  Back to cited text no. 6
    
7.
Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980-2008: A systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010;375:1609-23.  Back to cited text no. 7
    
8.
O'Connor P, Earnest J. Introduction. Voices of Resilience. NY: Springer; 2011. p. 1-9.  Back to cited text no. 8
    
9.
Mah TL, Halperin DT. Concurrent sexual partnerships and the HIV epidemics in Africa: Evidence to move forward. AIDS Behav 2010;14:11-6.  Back to cited text no. 9
    
10.
Shah IH, Say L. Maternal mortality and maternity care from 1990 to 2005: Uneven but important gains. Reprod Health Matters 2007;15:17-27.  Back to cited text no. 10
    
11.
Ebeniro CD. Knowledge and beliefs about HIV/AIDS among male and female students of Nigerian Universities. J Comp Res Anthropol Sociol 2010;1:121-31.  Back to cited text no. 11
    
12.
UNAIDS W. Report on the Global AIDS Epidemic. Global Summary; 2008.  Back to cited text no. 12
    
13.
Stringer EM, Giganti M, Carter RJ, El-Sadr W, Abrams EJ, Stringer JS; MTCT-Plus Initiative. Hormonal contraception and HIV disease progression: A multicountry cohort analysis of the MTCT-Plus Initiative. AIDS 2009;23 Suppl 1:S69-77.  Back to cited text no. 13
    
14.
Singh S, Sedgh G, Hussain R. Unintended pregnancy: Worldwide levels, trends, and outcomes. Stud Fam Plann 2010;41:241-50.  Back to cited text no. 14
    
15.
Grossman D, Onono M, Newmann SJ, Blat C, Bukusi EA, Shade SB, et al. Integration of family planning services into HIV care and treatment in Kenya: A cluster-randomized trial. AIDS 2013;27 Suppl 1:S77-85.  Back to cited text no. 15
    
16.
Hayford SR, Agadjanian V. Providers' views concerning family planning service delivery to HIV-positive women in Mozambique. Stud Fam Plann 2010;41:291-300.  Back to cited text no. 16
    
17.
Adamchak S, Janowitz B, Liku J, Munyambanza E, Grey T, Keyes E. Study of Family Planning and HIV Integrated Services in Five Countries. Family Health International, Research Triangle Park, NC, USA; 2010.  Back to cited text no. 17
    
18.
Cleland JG, Ndugwa RP, Zulu EM. Family planning in Sub-Saharan Africa: Progress or stagnation? Bull World Health Organ 2011;89:137-43.  Back to cited text no. 18
    
19.
Salaudeen AG, Durowade KA, Musa OI, Yusuf AS, Saka MJ. Condom use among HIV sero-concordant couples attending a secondary health facility in North-Central Nigeria. Niger J Basic Clin Sci 2013;10:51-6.  Back to cited text no. 19
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20.
Creanga AA, Gillespie D, Karklins S, Tsui AO. Low use of contraception among poor women in Africa: An equity issue. Bull World Health Organ 2011;89:258-66.  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2]


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