PEPFAR

Unplanned pregnancy in the 2011 Botswana Antenatal Clinic Sentinel

Surveillance A.C. Voetsch, M.G. Anderson, E. Machakaire, S. Bodika, W.

Jimbo, B.P. Yadav, M. Schann, T. Madidimalo, R. Lebelonyane

AIDS 2012 - Turning the Tide Together

Outline

• Background– Reproductive health in Botswana– Botswana PMTCT program

• 2011 Botswana Antenatal Clinic Survey• Unplanned pregnancy question analysis• Recommendations/Next steps

• Population = 2.1 million

• Middle income country

• Per capita GDP = $16,300

• Adult HIV prevalence = 25%

• 300,000 PLWH

Background

Reproductive health in Botswana

• Fertility rate 3.2• Annual birth rate 22 births/1,000 • Antenatal care visits 95%

• Skilled antenatal clinic provider 94%

• Delivery in a health care facility 94%

• Skilled provider at delivery 95%

• Outcomes• Maternal mortality 190/100,000 live births

• Infant mortality 57/1,000 live births

Botswana PMTCT program 2011

• Pregnant women 43,828 • Tested for HIV and knew result 97%

• Tested HIV positive 30.6%

• Received ARVs to prevent MTCT 93%

• HIV-exposed infants • Tested for HIV 91%

• Tested positive for HIV <4%

Four prong approach

1. Primary prevention

2. Prevent unintended pregnancies

3. Prevent vertical transmission

4. Link to care, treatment, follow-up

Knowledge and current use of contraceptives

Contraceptive method Knowledge Current use

Condom 96.5% 41.7%

Pill 87.8% 6.1%

Injection 87.1% 6.8%

IUD 75.0% 0.8%

Female sterilization 61.5% 2.1%

Periodic abstinence 55.2% 1.8%

Male sterilization 52.7% 0.1%

Withdrawal 52.4% 0.6%

Diaphragm 51.7% 0.6%

Other 4.1% 0.2%

ANC Sentinel Surveillance

• August 1 through October 28, 2011• 262 selected antenatal clinics• All 24 health districts • Pregnant women aged 15–49 years • First presentation • One-page surveillance form

• Demographic information • Gravidity • HIV testing history • Planned pregnancy (“Was this pregnancy planned?”)

Results

• 7209 eligible women

• 6745 (94%) women surveyed and tested

• Adjusted national HIV prevalence = 30.4%

• Prevalence varied by district and age

Age-specific HIV prevalence

Age group (years)

HIV prevalence by district

Results

• 6667 (99%) answered planned pregnancy question• 3383 (51%) current pregnancy was unplanned • Highest among women

• 15-19 years (68%) and 40-49 years (67%)

• 4 or more pregnancies (67%)

• Divorced, widowed, separated (60%)

• Primary school education (61%)

• HIV-positive (56%)

Unplanned pregnancy by age and HIV status

0

20

40

60

80

100

15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49

Unp

lann

ed p

regn

ancy

(%)

Age (years)

HIV positive HIV negative

Multivariable model

Characteristic Adjusted odds ratio 95% confidence interval

Unmarried 2.17 1.81–2.60

Two or more previous pregnancies 1.83 1.60–2.10

HIV-positive 1.73 1.51–1.99

Unemployed 1.29 1.15–1.44

Logistic regression model adjusted for linear and quadratic effects of age and for health district

Conclusions

• Gap between contraceptive knowledge and use

• Half of women in ANC survey reported unplanned pregnancy

• Both HIV-positive and HIV-negative women

• Younger/older, less educated, unmarried

Recommendations

• Strengthen HIV/Sexual Reproductive Health linkages

• Dual protection

• Guidance for women who want to become pregnant

• Target family planning services

• Improve supply chain for contraceptives

Next steps

• European Union grant

• UNFPA national coordinator

• Pilot co-location in 3 districts

• PEPFAR

• Education materials/flip charts

• Male/youth friendly services

• Supply chain

Acknowledgments

• Staff from the 262 clinics who collected the data • 6745 pregnant women in the 2011 ANC survey• This research has been supported by the President’s

Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention under the terms of grant number 5U62PS025095-05.

Ke a leboga (Thank you)

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.