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Utilization of modern contraception and determinants among HIV positive women in Ethiopia: a systematic review and meta-analysis

BMC Women's Health volume 24, Article number: 616 (2024) Cite this article

Abstract

Background

The burden of pediatric HIV/AIDS, mother-to-child transmission rate, and unintended pregnancy among HIV-positive women remain high in sub-Saharan Africa, including Ethiopia. Provision of contraceptives is an undeniable strategy to overcome the risks. However, pooled data to provide informed decisions on modern contraceptive use among HIV-positive women attending ART clinics in Ethiopia are meager. Hence, this review aimed to estimate the magnitude of modern contraception, and revisable long act contraceptives methods (RLCM) use and associated factors among HIV positive ART clinic attending women.

Methods

A systematic review and meta-analysis was conducted using PubMed, Google, Cochrane library, Web of Science, Google Scholar, and Scopus database. A funnel plot and Egger’s regression test were used to assess publication bias. Heterogeneity of studies was assessed using I-square statistics and the Joanna Briggs Institute (JBI) quality assessment tool was applied to ensure the quality of the included articles. We employed a random-effect model to pool the national utilization of modern contraceptives and the effect size of associated factors. We conducted sub-group analysis by regions to control heterogeneity and to detect variation.

Results

A total of 21 studies were included in the meta-analysis. The magnitude of pooled utilization of modern contraceptive and RLCM was 60% [95% CI: 52–68] and 11%, [95% CI: 8–14], respectively. In the random effect model, young women [OR = 2.36, 95% CI: 1.78–3.13], attending secondary school and above [AOR = 1.34, 95% CI: 1.06–1.69], having two or more live children [AOR = 1.84, 95% CI: 1.46–2.34], discussion with a husband [AOR = 2.92, 95% CI: 2.39–3.57], CD4 > 250cells/mm3 [AOR = 1.59, 95% CI: 1.08–2.33], and using HAART [AOR = 1.71, 95% CI: 1.35–2.15] increased odds of modern contraceptive methods utilization.

Conclusion

Overall the utilization of RLCM among modern contraceptive users HIV positive women is low. Therefore, to improve the uptake of RLCM among modern contraceptive users HIV positive women, policymakers and program designers need to take into account age and educational levels of women and programs which enhance reproductive health consultation habit between couples. Moreover, integration of family planning services to ART clinics needs to be strengthened.

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Introduction

HIV/AIDS remains a significant global health challenge. Since the start of the epidemic, 36.7 million people have been living with HIV/AIDS and 35.0 million people have died from AIDS-related illnesses in worldwide. In 2016, around 53% of all people living with HIV had access to treatment and 160,000 children acquired new HIV infections. Sub-Saharan Africa (SSA) accounted for 76% of the total new HIV infections and 75% of the total HIV/AIDS deaths [1]. Globally, 4,700 AIDS-related indirect maternal deaths were reported in 2015, and sub-Saharan African countries accounted for 85% of these deaths [2]. A high proportion of global child (80%) and HIV positive pregnant women (86%) live in focus countries. In Ethiopia, estimated 690,000 people live with HIV/AIDS, 11,000 AIDS related deaths, and 2,700 new HIV infections in children were reported in 2018 [3, 4].

Family planning is one of the most vital prevention measure, mothers to child transmission (PMTCT) of HIV. Family planning also plays paramount role to delaying first births, extending birth intervals, preventing unintended pregnancies, reducing the high risk of dying from HIV/AIDS and pregnancy-related complication, and reducing the number of HIV positive births [5]. Family planning include both modern and non-modern methods of contraception. In Ethiopia currently women use sterilization, reversible long-acting contraception (Intrauterine devices, subdermal implants), oral contraceptives, condom, and injectables modern contraception methods [6].

Although family planning is the primary strategy to prevent unwanted pregnancies among HIV-infected women. Empirical evidence shows the unmet need for contraception among HIV positive women resulted in approximately 6 million unintended births and 61,000 children with HIV in 2015 alone [5]. A recent systematic review and meta-analysis of sub-Saharan African countries found that the prevalence of unintended pregnancy among women living with HIV ranged from 32.4% to 55.9% [7]. In Ethiopia, the unmet need for family planning among HIV-positive women is high. One in four reproductive age women living with HIV had unmet need family planning. Factors such as age, marital status, educational status, place of residence, and knowledge of maternal-to-child transmission have been identified as significant predictors of unmet need for contraception [8]. The impact of unmet need for family planning such as unintended pregnancies and HIV-related child mortality, are substantial. As recent evidences showed in Ethiopia, almost half (46.1%) of women living with HIV have had unintended pregnancies, and 8.3% of live births ended with deaths [9, 10].

To address the high burden of unintended pregnancy and reduce the number of HIV-infected children born to women living with HIV, as well as to achieve the goal of an HIV-free generation, the government of Ethiopia and non-governmental organizations have been invested and implemented various programs. These programs include Prevention of Mother-to-Child Transmission (PMTCT) services, the expansion of access to effective HIV diagnosis, treatment, and care, and the integration of family planning services with ART services [3, 11]. However, there is a lack of specific national data regarding the utilization of modern contraceptives and the integration of family planning services with ART at service delivery points. While evidence shows that modern contraceptive uptake among HIV-positive women in Ethiopia ranges from 30 to 88%, the determinants of contraception use have been investigated inconsistently, which make it difficult for decision-makers to have a complete picture of the country [12,13,14,15,16,17]. Therefore, this review aimed to estimate the magnitude of modern contraception, and RLCM use and associated factors among HIV positive ART clinic attending women.

Methods

Reporting

The finding of this systematic and meta-analysis was reported based on the Preferred Reporting Items for Systematic Review and Meta-Analysis statement (PRISMA) guideline (Table S1) [18].

Searching strategy and information sources

We searched the literature via PubMed, Web of Science, Scopus, and the Cochrane Library electronic bibliographic databases: likewise, Google, and Google Scholar were used to search grey literature. The principal search terms and phrases were “reversible long-acting family planning”, reversible long-acting contraception “, “utilization of family planning”, “utilization of contraception”, “HAART”, “ART Women”, “HIV positive women”, “HIV chronic care”, “Ethiopia”. The search strategies were developed using different Boolean operators. To fit the advanced PubMed database, the following search strategy was performed and updated by MMB and TG in between March 23 – 30, 2023: [(((Reversible long act family planning) OR reversible long act family planning [MeSH Terms]) OR reversible long act contraception) OR Reversible long act contraception [MeSH Terms]) OR utilization of family planning) OR utilization of family planning [MeSH Terms]) OR utilization of contraception) OR utilization of contraception [MeSH Terms])) AND (Highly Active Antiretroviral Therapy) OR Highly Active Antiretroviral Therapy [MeSH Terms]) OR Antiretroviral Therapy) OR ART women [MeSH Terms]) OR HIV positive women) OR HIV positive women [MeSH Terms]) OR HIV chronic care) OR HIV chronic care [MeSH Terms])) AND (Ethiopia). From PubMed (n = 388), Cochrane library (n = 31), Google and google scholar (n = 89), Web of Science (n = 15), and Scopus (n = 8) articles were retrieved. This review is registered in the Prospero database: registration number is CRD42019127259, available from https://www.crd.york.ac.uk/PROSPERO.

Study selection

Initially, all sought articles were exported into Endnote version 8 software program and checked for duplication. The duplicated articles were removed. Three independent authors, MMB and ABG, and MK have reviewed the title and abstract. Three authors; MMB, AA and ABG have scanned the abstracts and full document. The disagreement was handled based on established article selection criteria.

Inclusion and exclusion criteria

All cross-sectional studies were included. Those studies reported at least the prevalence of modern contraception and associated factors and published in English, unpublished and grey literature were considered. The study cited without abstract or full-text, editorials, studies which included both sexes, and women who did not attend ART clinics were excluded from the analysis by two independent authors MMB, and ABG. This review included studies that conducted from January 1, 2011, to March 30, 2023. In this review, studies conducted after initiation of ART program in Ethiopia (2011), and family planning service integration with ART clinic has been started since 2013.

Quality assessment

All the articles included were critically appraised using the cross-sectional JBI quality assessment tool [19]. Two independent authors (TG and MK) assessed the quality of the study, methodological fitness, and finding validity. Specifically, the focus was the inclusion criteria, the study subjects and settings, the validity and reliability of the exposure and outcome measurement, the objective and appropriate statistical analysis used. Any uncertainties or discrepancies were resolved through joint discussions within the team. For a study to be included in the review, it had to meet a minimum score of 6 out of 8 on the JBI criteria, indicating good quality. The most common reason for not meeting the minimum score requirement was the lack of clear or adequately explained inclusion and exclusion criteria for study subjects (Table S2).

Finally, publication bias was investigated by the construction of funnel plot, and Egger’s tests. P-values < 0.05 on test indicate potential publication bias [20]. Based on the symmetrical distribution of studies in a funnel plot and the non-significant p-values for Egger’s test (0.156), we did not detect publication bias (Figs. 1 and 2).

Fig. 1
figure 1

Eggers’ regression test result for publication bias

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Fig. 2
figure 2

Funnel plot for publication bias, represented in the x-axis and standard error of log proportion in the y-axis

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Data extraction

Excel sheet form was prepared by two independent reviewers (MMB and AA) and used to extract data from the studies included for assessment of study quality. The abstracted data were included in the study setting, study year and proportion of modern or reversible long-acting contraception utilization, associated variables with odd ratio and 95% confidence interval. During the data extraction, no article reported missing and incomplete data. Two independent reviewer’s (MMB and AA) discrepancies were identified and resolved through face-to-face discussion.

Statistical analysis

The meta-analysis was done using STATA version 14 statistical software. The pooled estimate, with a 95% confidence interval, was reported for both the main outcome variable (prevalence) and associated factors with adjusted odd ratio. Each eligible study was briefly described using a summary table. The summary table mainly described the characteristics of the studies included and the main findings. Forest plots were used to present the meta-analysis results graphically. To examine publication bias, funnel plot and Egger’s regression test were used. The presence of statistical heterogeneity was checked using the Chi-square test (Cochran Q test) at a p-value of ≤ 0.05. Heterogeneity between the studies was checked using I2 statistics, and we considered an I2 75% and above as significant heterogeneity [21].

Results

Studies included

A total of 531 articles were extracted from a different electronics database, and all articles were imported into Endnote for duplication screening and full document review. Of the total 531 articles, 469 articles abstracts, and titles not matched with review, HIV positive women not attending ART clinics article (n = 1), men included studies (n = 2), publication without abstract or full text or editorials (n = 7) and duplicated articles (n = 28) were removed. After the title, abstract and full-text review 24 articles were remained. Finally, 21 studies remained after quality assessment (Fig. 3).

Fig. 3
figure 3

Schematic presentation of the PRISMA flow diagram to select and include studies

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As presented in Table 1, from a total of 21 studies, ten (46.7%) were from Amhara [12, 13, 17, 22,23,24,25,26,27,28], four (19.1%) Oromia [14, 29,30,31], three (14.2%) South Nation Nationalities and People [32,33,34], and four (19.1%) from Tigray and Addis Ababa regions [15, 16, 35, 36] were included. Based on the year of study, all studies were conducted in the year between 2011 and 2020. Twenty studies were conducted between 2012 to 2020, whereas the remaining one was conducted before 2012 [33]. All the finally selected articles were cross-sectional by their design and studied in the health facility setting. Of the included studies, 19 reported on the prevalence of reversible long-acting contraception utilization [12,13,14,15,16,17, 23,24,25,26,27,28,29,30,31, 33,34,35,36], and 17 reported on associated factors [12,13,14,15,16,17, 23,24,25,26,27, 29, 30, 33,34,35, 36]. Fifteen articles reported on socio-demographic factors such as age, marital status, education status, residence, employment, and income [12, 14,15,16,17, 25,26,27,28,29,30,31, 33], while six articles focused on HIV/AIDS-related factors [12, 13, 15, 17, 30, 36], and eight articles on reproductive health-related factors [12,13,14, 17, 25, 30, 33, 36]. In addition, eight articles were reported other factors, such as husband and contraception counseling [13,14,15,16, 25, 28, 30, 36].

Table 1 Description of the study characteristics included in the review and meta-analysis on modern contraceptives use
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Pooled proportion of contraception users among HIV positive women

The overall pooled estimate of modern contraceptive utilization among HIV-positive women attending ART clinics in Ethiopia was 60% (95% CI: 52–68), with an I2 value of 98.77 and a p-value = 0.00 (Fig. 4). Subgroup analysis was conducted to examine regional and yearly variations. The highest pooled proportion of modern contraception use was observed in the Oromia region (74%), while the lowest was observed in the Tigray region (45%) Fig. 5.

Fig. 4
figure 4

Forest plot for the pooled proportion of modern contraception utilization among HIV positive women attending ART clinics in Ethiopia

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Fig. 5
figure 5

Forest plot for the pooled proportion of modern contraception utilization among HIV positive women by region

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Furthermore, pooled estimate of reversible long-acting contraception methods (RLCM) utilization among women living with HIV/AIDS was 11% (95% CI: 8–14), with an I2 = 97.16 and p-value = 0.00 (Fig. 6). RLCM use variations were observed among regions and study years. The highest pooled estimate of RLCM use was found in the Amhara region (15%), while the lowest was observed in the Tigray region (2%) Table 2.

Fig. 6
figure 6

Forest plot for the proportion of revisable long-acting modern contraceptive use among HIV positive women attending in Ethiopia ART clinics

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Table 2 Pooled proportion of revisable long-act contraception among modern contraception users; 95% CI and heterogeneity estimate with a p-value for the subgroup analysis
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Factors associated with modern contraception utilization among HIV positive women

The utilization of modern contraception among HIV-positive women attending ART clinics in Ethiopia significantly associated with socio-demographic factors, HIV-AIDS related factors, reproductive health-related, and other factors.

Socio-demographic variables such as being young women (15–24 years), married marital status, urban residence, secondary school, and above educational status were reported in different articles as significant determinants of modern contraception utilization in Ethiopia [12,13,14,15,16,17, 25,26,27, 30,31,32,33, 36].

In the pooled estimate, women 15–24 years, married, and secondary school or above were significantly associated with modern contraception use. Accordingly, HIV positive women at the young age group were 2.46 times more likely used modern contraception compared to the old age group [AOR = 2.46, 95% CI: 1.90–3.19], and HIV positive women who attended secondary or higher education were 1.34 times more likely used contraception than women without formal education [AOR = 1.34 95% CI: 1.06–1.69]. The odds of contraceptive use among married women were 1.79 times higher than single women [AOR = 2.79 95% CI: 1.79–2.68] (Fig. 7).

Fig. 7
figure 7

Forest plot for socioeconomic factors associated with modern contraception utilization among HIV positive women attended ART clinics of Ethiopia

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Regarding HIV-related factors, CD4 cells count and using HAART were showed significantly associated with utilization of modern contraception. Women who had CD4 cells count greater than 250 cell/mm3 and using HAART were more like used contraception as compared with their counterpart [AOR = 1.59, 95%CI: 1.08–2.33], [AOR = 1.71, 95%CI: 1.35–2.15] (Fig. 8).

Fig. 8
figure 8

Forest plot for HIV related associated factors with modern contraception utilization among HIV positive women attended ART clinics of Ethiopia

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Reproductive health-related variables such as fertility desire, number of live children, having contraception information and previous history of using contraception were reported as significant determinants of utilization of modern contraception among women attending ART clinics in Ethiopia. In the pooled estimate, having two or more live children were associated with the utilization of contraception. HIV-positive women who had two or more living children were 1.84 times more likely used contraception compared to HIV-positive women who had no surviving children [AOR = 1.84, 95% CI: 1.24–1.74]. However, fertility desire and previous use of contraception were (Fig. 9).

Fig. 9
figure 9

Forest plot for reproductive health-related factors associated with modern contraception utilization among HIV positive women attended ART clinics of Ethiopia

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In this review other factors like discussion with a husband and provision of contraception counselling during chronic care follow up were reported to increase the utilization of modern contraception in different articles [12,13,14, 17, 25, 30, 33, 36]. In the pooled estimate, HIV positive women who had discussion with husband 2.65 times more likely used contraception compared to who did not [AOR = 2.65, 95% CI: 2.21–3.17] (Fig. 10).

Fig. 10
figure 10

Forest plot for other associated factors with modern contraception utilization among HIV positive women attended ART clinics of Ethiopia

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Discussion

This review aimed to estimate the overall utilization of modern contraception, reversible long-acting contraception methods, and associated factors from the finally reviewed 21 articles. Accordingly, 60% and 11% of HIV positive ART using women were used modern contraception and RLCM, respectively. In the meta-analysis, young age women, married, secondary school or above, having two or more live children, discussion with husband, CD4 cells count and using HAART were significantly associated with utilization of modern contraceptive methods.

This study revealed that 60% (95% CI: 52–68) of HIV positive ART using women utilized modern contraception to prevent unintended pregnancy. This finding was consistent with survey finding obtained from Zambia (64.4%) [37]. However, our pooled estimate is higher than findings from Malawi Demographic and Health Survey (DHS) (53.9%) [38], 2016 Ethiopian Demographic and Health Survey (EDHS) report (35%) [39], Ghana (21.7%) [40], and Uganda 30.3% [40]. The possible explanation for these discrepancies might be women with HIV positive women frequent contact with health care providers and obtain information and counselling on contraception than the general population which might be provides a better opportunity for contraception uptake. This finding is also higher than the global survey on sexual and reproductive health rights of women living with HIV study (40%) [41]. In contrast, results of the current review lower than findings obtained from Kenya (91%), Namibia (93%), Tanzania (83%) [42] and South Africa (86%) [43]. The reseason for this discrepancy might be due to different accessibility of contraceptives commodity, socio-demographic characteristic of study participants, and reproductive health policy of countries. In fact, cultural traits and attitudes also different among African regions, including the value of children, these can have a big impact on contraceptive use.

This review also revealed that 11% of clients used RLCM. This finding agree with the national DHS report (8%) [39]. In contrast, the finding is lower than study results obtained from Ethiopia (16.6%) [44], Uganda (49%) [40], and Zambia 38% [37]. Moreover, huge variation of contraception use identified among regions. Tigray region (2%) had lowest modern contraception use compared to other regions. For low utilization of RLCM, variations in sociodemographic characteristics of participants like low education status, lack of women’s decision-making power and lack of discussion with partners, and gender-related factors were reported as the major barriers [22, 45].

Our meta-analysis revealed that the odds of modern contraception utilization were higher among young (15–24 years) women compared to old, aged women. This result in line with study result obtained from Togo [46]. However, it contradicts with the 2011 EDHS report [47]. In fact, most older women in the menopausal stage less likely utilize contraception because of decreased sexual desire and low fecundability. Moreover, low utilization of contraception among old age (35–49 years) women might be relate with physiological cessation of menses.

In this review, higher odds of contraception utilization were observed among women who had secondary or above education compared to women without formal education. This finding was also supported by studies obtained from Malawi and Tanzania [48]. The possible suggestions may be due to the fact that education might boost women’s level of knowledge about the use of contraceptive methods, improves information and communication of women, and increases confidence in decision making towards the uptake of modern contraceptive methods. Our finding showed significant difference in contraception use between unmarried and married HIV positive women. This finding is supported by study conducted in Ethiopia, which indicated that single women more likely experience an abortion or an unwanted pregnancy compared to married women [49]. It also suggests the poor access of modern contraception to sexually active unmarried women.

Mothers who had two or more living children were more likely use contraceptive compared to women who had no surviving children. This finding is supported by studies conducted in Malawi [38] and Uganda [40]. Women with no child have more desire to having a child and not use contraception because the social status of women often described by the presence or absence of children in most African countries. However, this finding was in disagreement with the EDHS report, in which mothers who had 1 to 2 children highly used contraceptive [47].

In our pooled analyses, women’s communication with their partners was associated with modern contraception use. Women who had discussed with their husbands were more likely to use modern contraceptive than who did not discuss. A study in Tanzania [48], supported this finding. Moreover, HIV AIDS related factors such as CD4 counts and using HAART significantly associated with contraception use. Women who had CD4 count > 250cells/mm3 more likely using contraceptive than lesser CD4 counts. This finding in line with study conducted from Zambia [50]. This suggests ART and ongoing secondary prevention messaging may have an effect on the usage of contraception.

In this study, we made efforts to include all relevant and potential databases during the search process, which enhances the validity of our findings. However, it is important to acknowledge the presence of certain limitations in our study.

One notable limitation is the substantial heterogeneity observed in the pooled estimate. Although we conducted subgroup analyses to explore potential sources of heterogeneity, the inherent variability among the included studies may still introduce uncertainty in the overall summary measure. Therefore, caution should be considered when interpreting the pooled estimate, and further investigation is necessary to gain a better understanding of the underlying factors contributing to the observed heterogeneity.

Additionally, the representativeness of our results is limited due to the absence of published articles from certain regions of Ethiopia, including Benishangul Gumuz, Afar, Gambella, Somalia, Dire Dawa, and Harare regions. This restriction in regional representation may impact the generalizability of our findings to the entire population of Ethiopia.

Moreover, it is important to note that our review focused on studies conducted in an ART setting and English language published articles. This selection criterion may introduce a potential selection bias and limit the inclusiveness of studies conducted in non-healthcare settings or published in languages other than English.

Conclusions

Overall, the utilization of modern contraceptive methods among ART user women was higher, considering in the general population. However, RLCM utilization among modern contraceptive users low when compared with general population. Regional variation was detected on modern contraceptive utilization among ART user women. Being young age (15–24 years), Educational status (secondary school or above), having live children (two and more), discussion with husband, CD4 cells count and using HAART were identified as independent predictors to use a modern contraceptive.

For the achievement of new pediatrics HIV/AIDS infection elimination goal, the stakeholders, government, and policymakers need to focus on old, uneducated reproductive age women, reversible long-acting contraception during program designing and implementation activities. Program designers also need to consider couple-communication-enhancing activities to HIV positive reproductive-age women.

Data availability

All the relevant data are provided in the manuscript and can be made available from corresponding author on a reasonable request.

Abbreviations

AIDS:

Acquired Immunodeficiency Syndrome

ART:

Antiretroviral therapy

CD4:

Cluster of differentiation 4

CI:

Confidence Interval

DHS:

Demographic and Health Survey

EDHS:

Ethiopian Demographic and Health Survey

HAART:

Highly Active Antiretroviral Therapy

HIV:

Human Immunodeficiency Virus

JBI:

Joanna Briggs Institute

PMTCT:

Prevention of Mother-To-Child Transmission

RLCM:

Reversible Long-acting Contraception Methods

SSA:

Sub-Saharan Africa

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Acknowledgements

The authors would like to acknowledge the University of Gondar Institute of Public Health staff who provided us technical advice and support during the review and analysis processes.

Funding

This research received no specific grant from any funding agency in public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Department of Reproductive Health, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, P. O. Box: 196, Gondar, Ethiopia

    Moges Muluneh Boke & Alehegn Bishaw Geremew

  2. Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

    Asmamaw Atnafu & Tsegaye Gebremedhin Haile

  3. Department of Nursing, College of Health Science, Woldia University, Woldia, Ethiopia

    Mesfin Wudu Kassaw

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  1. Moges Muluneh Boke
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  5. Tsegaye Gebremedhin Haile
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Contributions

MMB conceived and designed the study, coordinated review, drafted the manuscript, and carried out the statistical analysis. MWK and ABG participated in the design of the study, extracted data, involved in data analysis and drafted the manuscript. TG and MWK extracted data, drafted and reviewed the manuscript. AA and TG: Involved in data extraction, analysis, drafted and reviewed the manuscript, and corresponding author. All authors read and approved the final manuscript and participated in data extraction, tool preparation and reviewing articles.

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Correspondence to Moges Muluneh Boke.

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Boke, M.M., Geremew, A.B., Atnafu, A. et al. Utilization of modern contraception and determinants among HIV positive women in Ethiopia: a systematic review and meta-analysis. BMC Women's Health 24, 616 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12905-024-03454-9

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BMC Women's Health

ISSN: 1472-6874

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