Family planning helps prevent HIV from spreading: why are many Nigerians not using contraception?

Unintended pregnancies are more common in sub-Saharan Africa than the world average: up to 91 out of 1,000 pregnancies compared to 64 in 1,000. Unintended pregnancy is common among women living with HIV too. In a South African study, for example, more of the women living with HIV reported unintended pregnancies (55% of them) than those not living with HIV (33%). Preventing unintended pregnancies among women living with HIV is a critical strategy for the prevention of mother-to-child HIV transmission. Family planning is an effective way to prevent new HIV infections. This is particularly important in a country like Nigeria, which has one of the highest rates of mother-to-child HIV transmission globally. According to the country’s National Agency for the Control of Aids, about 22,000 new cases of mother-to-child HIV transmission are recorded annually in Nigeria. In fact, one in seven children born with HIV globally is born in Nigeria. We are a team of researchers with expertise in sexual and reproductive health, family planning, HIV/Aids, health-related stigma, mental health and implementation science. To better understand unintended pregnancy and the factors that may explain it among women living with HIV, we conducted research in Cross River State, southern Nigeria. This state was chosen because it has the highest unmet need for family planning (35%) among women of reproductive age (15-49 years) in Nigeria. Also, its HIV prevalence of 1.8% is higher than the national average of 1.4%. Our research found that about 61% of the women were on modern contraceptives, mainly male condoms. The rate of unintended pregnancy was 49.2%. It was more common among those with higher religiosity, those who had not engaged in transactional sex in the past year, and those without a history of miscarriage. These findings matter for the prevention of mother-to-child HIV transmission and maternal deaths, of which Nigeria has one of the highest rates globally. Unintended pregnancy rates are highest in Africa: a look at the complex reasons

Our research We interviewed 893 women living with HIV using a tablet-based survey. The average age among the women we interviewed was 34 years. We asked if they had ever been pregnant when they did not want to. We found that nearly half (49.2%) of the women living with HIV had experienced unintended pregnancy. Also, only 61% were using modern contraceptives, particularly male condoms (37.6%). Addressing unintended pregnancies among women living with HIV could reduce mother-to-child HIV transmission and other pregnancy complications. The most effective way to reduce unintended pregnancy is to make low-cost or free modern contraceptive methods available for those who need them, particularly women of reproductive age, irrespective of their HIV status. Nigerian women and contraceptives: study finds big gaps between the haves and the have-nots

What women had to say A number of factors appeared to play a role in unintended pregnancy among our respondents. Firstly, most of these women were likely to engage in religious activities. In follow-up in-depth interviews by our team, women explained that religious leaders preached against modern contraceptives, and they followed their teachings. This increases the chances of unintended pregnancies. A 38-year-old single mother with three children had this to say about the impact of religion on contraceptives uptake: The church has said people should not do family planning that God has given them children to born here in the world. If they (religious leaders) hear that you have done it, they will give you suspension in the church. Pastor normally stop members. Also, a 36-year-old married woman with two children said she used contraceptives without the knowledge of her husband and church: For me I put it (contraceptives), my husband does not know that I have it. For the church, they will tell you that God is in charge. Like me pastor has told me that I should stop taking the drugs that I will get health issues … They go around deceiving people that they should not take drugs that they will receive healing by faith. Second, we found that women living with HIV who’d had a previous miscarriage or stillbirth reported fewer unintended pregnancies than those without such a history. We presume that women with this history might need to recover biologically and mentally, and therefore delay their next pregnancy through family planning. Also, this experience may encourage future family planning to reduce unintended pregnancy. Third, women living with HIV whose households had a good income reported fewer unintended pregnancies than those with lower income. A recent systematic review of studies in east Africa about unintended pregnancy among women living with HIV found that unemployed women or women with minimal income were three times more likely to experience unintended pregnancies than those with higher income. Women often have to pay for modern contraceptives themselves in health facilities in Nigeria. Fourth, women living with HIV who had not exchanged sex for gifts or money in the past 12 months reported more unintended pregnancy than those who did. We found that 59% of women who were cohabiting and 35% of married women engaged in transactional sex. This shows that women who exchanged sex for money or gifts were more conscious of the need to use contraceptives to avoid pregnancy. HIV and high blood pressure in pregnancy: we’re tracing the connections

What needs to be done Preventing unintended pregnancies in women living with HIV is not only a cost-effective approach to preventing mother-to-child HIV transmission. It also has the potential to reduce maternal deaths in Nigeria. This is because pregnant women living with HIV may experience pregnancy complications such as miscarriage or stillbirth, opportunistic infections like toxoplasmosis and tuberculosis, and life threatening infections such as maternal sepsis. We conclude from our findings that the following steps should be taken: There should be adequate access to modern contraceptives. This could reduce unintended pregnancies among women living with HIV.

It’s important to train religious leaders on the importance of family planning. They should also be encouraged to advocate for modern contraceptives use among their congregants, especially women of reproductive age.

Governmental and non-governmental organisations should empower women with low income living with HIV and make modern contraceptive methods available for free or at a very low cost.

Oluwafemi Atanda Adeagbo receives funding from the National Institutes of Health Oluwaseun Abdulganiyu Badru does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.