Without Strong Integration of Family Planning into PMTCT
Services in Rwanda, Clients Remain with a High Unmet
Need for Effective Family Planning
Jennifer A Leslie*1, Emmanuel Munyambanza1,
Susan E Adamchak2, Barbara Janowitz2,
Thomas W Grey3 and Kyampof Kirota4
2FHI/North Carolina; 3Carolina
Population Center of the University of North Carolina,
Chapel Hill, NC; 4National AIDS Control
Commission of Rwanda
African Journal of Reproductive Health,
December 2010; 14:
2008, about 33.4 million people were estimated to be
living with HIV worldwide, including about 15.7 million
women and 2.1 million children under the age of 15.1
The majority of new infections in children occur as a
result of vertical transmission, either in the course of
pregnancy, during labour, or through breastfeeding. The
risk of mother to child transmission can be reduced from
15-45 percent to less than 2 percent with highly active
antiretroviral therapy which, along with the practice of
delivering babies of HIV-positive mothers by elective
Caesarean section and bottle feeding, has effectively
eliminated vertical transmission in high-income
Prevention of unintended pregnancies and adequate birth
spacing among HIV-positive women have been shown to be
cost-effective and essential components of a
comprehensive approach to prevention of mother to child
transmission (PMTCT).5-7 However, low-income
countries that have implemented PMTCT programs have
tended to focus almost entirely on delivery of
antiretrovirals, and have neglected measures to reduce
the rate of unintended pregnancies among HIV-positive
women. This practice has been attributed to factors such
as funding exigencies created by spending limitations
placed on the purchase of contraceptives, lack of clear
policy and operational guidance on how prevention of
unintended pregnancies should be implemented in the
context of PMTCT and within the framework of national
HIV prevention programs, as well as stigma directed
towards HIV-positive clients seeking reproductive health
Rwanda, along with a continuing need for FP services,
there is a generalised HIV epidemic, with 3 percent
prevalence in the general population and 4.3 percent
prevalence among pregnant women. Recognising the
importance of the role of FP in the HIV response, the
government initiated family planning-HIV (FP-HIV)
integration in 2007, linking FP to PMTCT services. At
the request of Rwanda’s National Committee for the Fight
against AIDS and the Ministry of Health, a situation
analysis of family planning-PMTCT (FP-PMTCT) integration
was conducted in 2008 with the goal of providing
information to improve integrated services and to
optimise the potential for scale-up.9 This
brief provides a report on two of the study objectives,
focusing on HIV-positive women and their service
providers: (1) to determine the need for family planning
services among PMTCT clients after birth and (2) to
describe the readiness of antenatal and postnatal
service providers to offer FP.
comprehensive database of PMTCT sites maintained by TRAC
for Treatment on Research on AIDS, Malaria, Tuberculosis
and other Epidemics),
was used to purposively select eligible health
facilities based on daily client volume in PMTCT
services; number of HIV-infected women enrolled in PMTCT
services; geographic distribution; and whether they were
public or faith-based facilities. Thirty health
facilities with integrated services in 15 administrative
districts were selected, representing approximately 10
percent of the total number of health facilities with
PMTCT services in the country. Within each facility, all
managers and providers of antenatal care (ANC) and
postnatal care (PNC), as well as female clients aged
18-45 years who came to receive ANC/PNC, agreed to
participate. In all, 34 health professionals, 84 ANC
clients, and 120 PNC clients agreed to participate.
Interviews were conducted by trained research assistants
using a pre-tested, structured questionnaire
administered in the local language, Kinyarwanda. Data
collection was carried out in November 2008. The need
for family planning among PMTCT clients after birth was
calculated by considering current contraceptive use,
desire for pregnancy, self-report of fecundity (return
of menses) and resumed sexual activity post-pregnancy.
Ethical approval to conduct the study was granted by the
Protection of Human Subjects Committee of Family Health
International (FHI) and the Rwanda National Ethics
Committee. Participating providers and managers gave
informed oral consent, while clients gave informed
were entered into EpiInfo 6.04d, and analysed with SAS
version 9.1. Descriptive statistics were calculated.
Providers and managers were merged into a single group
because of small numbers.
Unmet need for FP among PNC clients was 12 percent; 20
percent of women were identified as having no current
need based on calculations described above and 68
percent as currently using FP. Of FP users, 43 percent
said they were using male condoms as their contraceptive
method, but use was inconsistent. Nearly all ANC clients
(90 percent) expressed a desire not to have children in
the future, with 49 percent indicating a preference for
sterilization and 35 percent a preference for implant
postpartum. Among the PNC clients using FP, only 5
percent were using long-acting or permanent methods. A
majority (69 percent) of PNC clients and 48 percent of
ANC clients reported that their most recent pregnancy
was either mistimed or unwanted. Women who were found to
have no current need for FP gave the following reasons:
husband away or deceased; pregnancy-related; or against
providers (80 percent) reported that they raised the
topic of FP with their clients and referred those who
expressed a need to the FP clinic. However, only a few
clients reported that their providers discussed their
desire for children in the future (30 percent ANC, 15
percent PNC), referred them for FP services (5 percent
ANC, 12 percent PNC), or gave them a FP method (7
percent ANC, 12 percent PNC). Analysis of provider
attitudes regarding FP and HIV revealed that while
providers were opposed to an HIV-negative woman being
sterilised if she had no living children (88 percent),
they were in favour of an HIV-positive woman undergoing
tubal ligation (91 percent).
many women, pregnancy and child care constitute the two
main reasons they come into contact with the health
system. This contact provides an excellent opportunity
for delivering PMTCT interventions and engaging women in
a comprehensive continuum of HIV prevention, care, and
treatment services during pregnancy, the puerperium, and
reasons given by women in PNC for not needing
contraception do not suggest abstinence, and thus, such
women may be engaging in unprotected intercourse and be
vulnerable to unwanted pregnancies and sexually
transmitted infections. When calculating the need for
family planning among PMTCT clients after birth,
questions about the age of the child or the
breastfeeding status of women were not included, which
may have contributed to an underestimate of unmet need.
Supporting this idea is the fact that many women in ANC
and PNC reported mistimed or unwanted pregnancies.
discrepancy between the number of providers who said
they discuss FP with their clients and client reports
that providers seldom raise the issue of FP is striking
and suggests that providers might benefit from further
training in communication skills and FP.
Provider attitudes indicate that the reason they favour
FP is not to help HIV-infected women make informed
choices about birth spacing and limiting but simply to
encourage them not to have children at all. This
attitude seems to reflect a tension between prioritising
public health, which emphasises prevention of
pregnancies, and protecting women’s reproductive rights,
which advocates for a woman’s right to choose her future
reproduction, as described in Rutenberg and Baek’s
analysis of varied field experiences integrating FP into
PMTCT programs.10 They observed that in the
Dominican Republic, India, and Thailand, HIV-positive
women are routinely offered sterilisation, and most
suggest that a balance between these two perspectives
could be achieved through a service that has better
linkages between FP and maternal health services, as
well as better linkages between ANC and PNC. We envisage
a situation where a woman seeks medical advice prior to
her next conception so that provider and client could
work together towards her optimal health (reduced viral
load, increased CD4 count, no opportunistic infections).
For those women who do not wish to become pregnant,
providers must be able to discuss feasible, safe, and
effective contraceptive options. As in traditional FP
programmes, informed-choice counselling must be the
cornerstone of contraceptive services in HIV-service
delivery settings. Care must be taken to ensure that
HIV-infected women are not coerced into a particular
reproductive decision as they, like all women, have the
right to make informed reproductive choices for
UNAIDS/WHO. AIDS epidemic update, December 2009.
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