Factors associated with childbearing intention of women on Antiretroviral Therapy in Northwest Ethiopia: A cross sectional study

Background: Though, childbearing intention is normal, it is imperative in Human Immune Virus positive women and identifying their intention has signicant in reducing mother to child transmission. This study was intended to assess childbearing intention and associated factors among women on antiretroviral therapy in South Gondar Hospitals, Northwest Ethiopia. Methods: Institution based cross sectional study was employed. The sample for each Hospitals was allocated proportionally. Systematic random sampling method was used to select the study participants. Data were coded and entered into epidata 4.2 software and exported to statistical package for social sciences version 25 for analysis. Binary logistic regression was used to saw the association between each independent variable and dependent variable. All variables with P-value < 0.25 during bi-variable analyses were considered for multivariable logistic regression analyses. Odds ratio along with 95%CI were estimated to measure the strength of the association. Level of statistical signicance was declared at p value less or equal to 0.05. Results: - A total of 418 women on antiretroviral therapy participated in the study. Child bearing intention was 42.6%. History of pregnancy after HIV diagnosis [Adjusted Odd Ratio (AOR) =5.19, 95% CI: (1.83, 14.7)], Partners fertility desire [AOR=10.99, 95% CI: (4.34, 27.86)], having alive children [AOR=0.23, 95% CI: 0.23(0.81, 0.63)] were signicantly associated with childbearing intention.

Worldwide, less than one-third of women of childbearing age visit the health institutions and speak with a health care provider prior to pregnancy about their health status and its potential impact on pregnancy outcome (3). Research has documented high fertility intentions among HIV-positive women and live births have increased among women living with HIV since the availability of antiretroviral therapy (ART) (4)(5)(6). A majority of pregnancies, however, remained unintended with subsequent risks for poor maternal outcomes (7)(8)(9)(10)(11).
Furthermore, up to 50% of People living with human immune virus (PLWH) are in ongoing relationships with an HIV-negative partner (12). Such data underscore the importance of providing services through preconception care that reduce the risk of transmission. There is a need to optimize women's immunologic status and address common comorbidities (e.g., depression, diabetes, tuberculosis malaria, and anemia that affect maternal health and contribute to adverse pregnancy and perinatal outcomes (e.g., fetal growth restriction, birth defects) (13)(14)(15)(16).
Preconception care is client education, evaluation, and management aimed to prevent unplanned pregnancies, decrease the risk of adverse health effects for the woman, fetus, and neonate by optimizing the woman's health and knowledge before planning and conceiving a pregnancy (17).
In the past two decades, signi cant breakthroughs have occurred in the area of HIV and pregnancy, largely centered on the prevention of vertical transmission. However, there are other important factors to consider for an HIV-positive woman wanting to become pregnant, including the prevention of horizontal transmission between partners, the optimization of antiretroviral therapy (ART), including the discontinuation of potentially teratogenicity drugs, and the promotion of a healthy pre-conception lifestyle to reduce maternal and fetal complications (18,19).
In spite of understanding HIV-infected women experiences and perceptions of reproductive counseling in the health care context is critical to inform design of effective pharmaco behavioral interventions that minimize preconception HIV risks, realize their fertility goals and maximize maternal and child outcomes (20), the previous efforts done on improving maternal and child health with special emphasis on preconception care among HIV positive women were not felt across the country. Therefore; this study was intended to assess childbearing intention and its associated factors among HIV positive women attending highly active anti retro viral therapy (HAART) South Gondar Hospitals, Amhara region.

Methods
Study design, setting, period and population An institution based cross sectional study was conducted in south Gondar Hospitals from January to The desire of the client to have child in the future and measured as a dichotomous variable (Yes/No).

Data Quality Control
Pretest was done on 5% of the sample size. One day training was given for data collectors and supervisors on data collection tools and data collection procedure. Data collectors had been supervised closely by the supervisors and the principal investigator. Completeness of each data collection tools had been checked by the principal investigator and the supervisors in a daily base. The questionnaire was prepared in English and translated to "Amharic". 'Forward and backward translation' was done. Double data entry was done by two data clerks and consistency of the entered data was cross-checked.

Data processing and analysis
Data were entered, coded, cleaned and checked by EpiData statistical software version 4.2.0.0 and analysis was done by using SPSS Version 25 statistical software. Descriptive statistics such as proportions, percentages, ratios, frequency distributions and appropriate graphic presentations were used for describing the data. Binary logistic regression was used to saw the association between each independent variable with dependent Variable. All variables with a p-value ≤ 0.25 in the bivariate analysis was entered into the nal model for multivariable analysis. Variables with p values ≤ 0.05 in multivariable logistic regression model analysis were considered as statistically signi cant.

Ethical Considerations
Ethical clearance was obtained from Debretabor University, College of Health Sciences, Institutional Health Research Ethics Review Committee (IHRERC).Then O cial letter had been written to each Hospitals for permission and support. Permission letter was obtained from the selected hospitals'. Oral consent was taken from each participants. Data collected was used for the study purpose only and con dentiality was assured.

Results
Socio-demographic characteristics of the study participants In this study, a total of 418 Women living with Human immune virus (WLHIV) were participated making a response rate of 99%. The mean age of the participants was 34.4 years (SD ± 6.5).Majority, 354(84.7%) were from urban( Table 1). Reasons not to desire children and reasons not to use contraceptives Being unmarried (20.6%) is the leading cause not to desire children in the future (Fig. 1).
Among the eligible participants, 28.7% used contraceptives either for spacing or limiting. Being unmarried (32.1%) and infertile (16.3%) are the major reasons for those who didn't use contraceptives (Fig. 2).

Child Bearing Intention
A total of 418 women on HAART were participated in the study. The nding showed that overall childbearing intention was 42.6%.
Factor associated with childbearing intention A binary logistic regression was done to identify the association between fertility desire and independent variables. In bivariable logistic regression marital status, pregnancy after HIV diagnosis, current pregnancy status, partner fertility desire, year of HIV diagnosis, have alive child and contraceptive use were met the criteria to be tted into a multivariable analysis ( value ≤ 0.25).But, in multivariable analysis history of pregnancy after HIV diagnosis, partner fertility desire and having alive child were found to be signi cantly associated with childbearing intention.
In this study, childbearing intention of women on antiretroviral therapy was associated by different factors such as pregnancy after HIV diagnosis, partner fertility desire and having alive child.
The study revealed that those who have history of pregnancy after HIV diagnosis were more likely to have childbearing intention than their counterparts. This study is in contrast with study conducted in Jamaica (34). This could be difference in sample size, study setting, study participant selection. The other reason might be ART use increase incidence of pregnancy an fertility desire (35,36).
Those women whose partners have fertility desire were more likiliy to have childbearing intention than women whose partners had no fertility intention. The study is agreed on studies conducted in Malawi (26),India (37) .This could be due to discussion with spouse decision-making in relation to the cost ,PMTCT and utility of children.
Women who have alive children were less likiliy to have childbearing intention than women who have no alive child .This nding is agreed with previous ndings from Finoteselam Hospital (28),Addis Ababa (38),South west Ethiopia (39), Ethiopia(40), South Africa (33), Malawi (26),Tanzania (21) .This could be discrimative attitude face by the mother i.e. 48% of women thought that children living with HIV should not be able to attend school with children who are HIV negative (41),fear of stigma and discrimination (42). The other reason could be fear of mother to child transmission, care of alive child.
Limitation of the study The study participants were only women on ART

Conclusions
Though a signi cant number of participants discussed an important preconception care practices with their care providers, much is needed to improve and hasten their discussion. Pregnancy after their HIV diagnosis, partner fertility desire and having alive child were factors associated with child bearing intention.

Declarations
Ethical approval and consent to participate: Ethical clearance was obtained from Debretabor University, College of Health Sciences, and Institutional Health Research Ethics Review Committee (IHRERC).

Consent to publication: Not applicable
Availability of data and materials: Data will be available upon request from the corresponding author.
Competing interests: The authors declare that they have no competing interests.

Funding: Not applicable
Authors' Contribution: AS worked on designing the study, training the data collectors, supervising the data collectors, interpreting the result. BM, DM analyzed the result and wrote the manuscript. All authors involved starting from design, data interpretation, to critically review the manuscript.

Figure 1
Reasons not to desire children in the future among women on ART care in the hospitals of South Gondar Zone, Ethiopia, 2019