Unwanted Fertility Experience, HIV Status and Post-partum Contraceptive Use in a PMTCT Population in Durban, South Africa

The HIV prevalence in South Africa is 17.1% and a majority of HIV infected adults are women. One of the government's strategies to avert new HIV infections is the prevention of unwanted pregnancies in HIV positive women through contraceptive use. Therefore, understanding how unwanted fertility and HIV status affect contraceptive use is important to meeting this goal. The purpose of this mixed methods dissertation is to understand how unwanted fertility experience, HIV status and health facility factors affect women's contraceptive use in the post-partum period. The specific aims are: Aim 1: To examine whether knowledge of HIV status affects women's modern contraceptive use post-partum, Aim 2: To determine whether unwanted fertility and HIV status affect post-partum modern contraceptive use and intent and Aim 3: To explore health facility factors including client-provider interactions around contraception, counselor's knowledge about contraceptive methods, client waiting times and other health facility factors affecting modern contraceptive use post-partum. Quantitative methods were used for Aims 1 and 2 using a sample of sexually active post-partum women from an urban township outside of Durban, South Africa. Several multivariate logistic regression models were used to examine intent to use contraceptives at baseline and unwanted fertility experience, HIV status and post-partum contraceptive use at 14 weeks. Qualitative methods were used for Aim 3. In-depth interviews were conducted with clients and providers to identify health facility factors influencing in post-partum contraceptive use. Results from the quantitative paper demonstrate that intent did not predict post-partum contraceptive use, HIV status had a direct, but not moderating, effect on post-partum contraceptive use and that women experiencing unwanted fertility were less likely to use contraceptives post-partum. The measure of unwanted fertility likely underestimated unwanted fertility experience in this population. Findings from the qualitative paper indicate areas where clinic contraceptive programs can improve post-partum contraceptive use. Educating nurses about contraceptive initiation and more permanent methods, such as sterilization, could improve post-partum contraceptive use and reduce costs and patient overload. Creating opportunities for nurses and clients to have more in-depth discussions about contraceptive methods, side effects, condoms and STIs would improve post-partum contraceptive use