Sterilization regret among U.S. couples

The 1982 US National Survey of Family Growth included questions aimed at measuring sterilization regret. Of the 8583 couples in the survey who were protected from pregnancy by vasectomy or tubal ligation, 26% indicated they would like to have more children and 10% desire sterilization reversal. The proportion of women who want more children despite sterilization is highest (42%) among those aged 20-29 years, then declines with rising age to a low of 13% among women 40-44 years of age. Of all women who assert they want a reversal, 62% are aged 25-34 years. Blacks comprise 11% of contraceptively sterilized couples in the US but 18% of those who want the procedure reversed; similarly, Hispanics make up 6% of contraceptively sterilized couples but 17% of those expressing a desire for reversal. Significantly higher percentages of Medicaid recipients desire sterilization reversal, although this may reflect the fact that poor women are generally younger. Women who were not currently married were significantly more likely than married women to desire reversal (21% versus 8%). Finally, women who were sterilized before the age of 30 years were significantly more likely than those who were older at the time of the procedure to want another child (33% versus 17%) and to desire reversal (14% versus 6%). It is recognized that the responses to this question are not a good indication of the strength of sterilization regret, and they do not provide an accurate measure of need or potential demand for sterilization reversal. However, these findings do reflect a substantial level of dissatisfaction with sterilization as a means of fertility control. Providers of sterilization services should be aware that 10% or more of their patients may later regret their decision. It is possible that if more acceptable methods of reversible contraception were available, fewer women would resort to sterilization at young ages and the level of regret would be reduced.     

Pregnancy and contraception use among urban Rwandan women after HIV testing and counseling.

OBJECTIVES. This study examined hormonal contraceptive use and pregnancy in urban Rwandan women, following human immunodeficiency virus (HIV) antibody testing and counseling. METHODS. A sample of 1458 childbearing urban Rwandan women aged 18 to 35 years was tested and followed for 2 years. RESULTS. At enrollment, 17% of 998 HIV-negative women and 11% of 460 HIV-positive women were pregnant, and 17% vs 23%, respectively, were using hormonal contraceptives. One year later, half of the HIV-positive and one third of the HIV-negative hormonal-contraceptive users had discontinued use. The 2-year incidence of pregnancy was 43% in HIV-positive and 58% in HIV-negative women. HIV-positive women with fewer than four children were more likely to become pregnant than those with four or more; this association persisted in multivariate analyses but was not noted among HIV-negative women. At the end of the study, over 40% of non-users said that they would use hormonal contraception if it was provided at the study clinic, but 40% of HIV-positive women desired more children. CONCLUSIONS. Research is needed to identify the practical and psychosocial obstacles to effective long-term contraception among HIV-positive women. HIV counseling programs must specifically address the issue of childbearing.     

Accelerating India's fertility decline: the role of temporary contraceptive methods

This report summarizes findings from the 1992-93 National Family Health Survey of India, on fertility and contraceptive use. Fertility declined about 2 children/woman during 1972-92. The total fertility rate in 1992-93 was 3.4 children/woman. The average desired number of children among ever married women aged 13-49 years was 2.9 children/woman. Among the 41% of women who used contraception, 76% relied on sterilization. 27% of currently married women of reproductive age were sterilized, and 3% had husbands who were sterilized. 20% of women had an unmet need for family planning. 64% of all women currently using temporary methods wanted no more children. 11% desired more children after an interval of 2 or more years. 9% desired a stop to childbearing. Women not currently using contraception and intending to use in the future preferred sterilization (59%) or a temporary method (36%). Currently, 24% of contraceptive users rely on temporary methods. It is likely that meeting unmet need for temporary methods would substantially increase contraceptive use. Women who were not using any method averaged 2.7 children, while sterilized women had 4.0 children. Women who used traditional methods averaged 2.8 children. Women using temporary methods averaged 2.6 children. It is unlikely that sterilization would further reduce fertility much below levels already reached. Women sterilized before the age of 24 years tended to have modest sized families, but most women were sterilized at older ages. Currently, only 10% of married women use temporary methods, and only 6% use a modern method.     

Fertility desires and intentions of HIV-positive men and women

CONTEXT: HIV-positive men and women may have fertility desires and may intend to have children. The extent of these desires and intentions and how they may vary by individuals' social and demographic characteristics and health factors is not well understood. METHODS: Interviews were conducted from September through December 1998 with 1,421 HIV-infected adults who were part of the HIV Cost and Services Utilization Study, a nationally representative probability sample of 2,864 HIV-infected adults who were receiving medical care within the contiguous United States in early 1996. RESULTS: Overall, 28-29% of HIV-infected men and women receiving medical care in the United States desire children in the future. Among those desiring children, 69% of women and 59% of men actually expect to have one or more children in the future. The proportion of HIV-infected women desiring a child in the future is somewhat lower than the overall proportion of U.S. women who desire a child. The fertility desires of HIV-infected individuals do not always agree with those of their partners: As many as 20% of HIV-positive men who desire children have a partner who does not Generally, HIV-positive individuals who desire children are younger, have fewer children and report higher ratings of their physical functioning or overall health than their counterparts who do not desire children, yet desire for future childbearing is not related to measures of HIV progression. HIV-positive individuals who expect children are generally younger and less likely to be married than those who do not. Multivariate analyses indicate that black HIlV-positive individuals are more likely to expect children in the future than are others. While HIV-positive women who already have children are significantly less likely than others both to desire and to expect more births, partner's HIV status has mixed effects: Women whose partner's HIVstatus is known are significantly less likely to desire children but are significantly more likely to expect children in the future than are women whose partner's HIV status is unknown. Moreover, personal health status significantly affects women's desire for children in the future but not men's, while health status more strongly influences men's expectations to have children. CONCLUSIONS: The fact that many HIV-infected adults desire and expect to have children has important implications for the prevention of vertical and heterosexual transmission of HIV, the need for counseling to facilitate informed decision-making about childbearing and childrearing, and the future demand for social services for children born to infected parents.     

"Throwing the dice": pregnancy decision-making among HIV-positive women in four U.S. cities

CONTEXT: Although AIDS-related deaths among U.S. women have decreased, the number of HIV-positive women, especially of reproductive age, has increased. A better understanding of the interaction between HIV and family planning is needed, especially as antiretroviral medications allow HIV-positive women to live longer, healthier lives. METHODS: Qualitative methods were used to examine pregnancy decision-making among 56 HIV-positive women in four U.S. cities. Biomedical, individual and sociocultural themes were analyzed in groups of women, categorized by their pregnancy experiences and intentions. RESULTS: Regardless of women's pregnancy experiences or intentions, reproductive decision-making themes included the perceived risk of vertical transmission, which was often overestimated; beliefs about vertical transmission risk reduction strategies; desire for motherhood; stigma; religious values; attitudes of partners and health care providers; and the impact of the mother's health and longevity on the child. Most women who did not want children after their diagnosis cited vertical transmission risk as the reason, and most of these women already had children. Those who became pregnant or desired children after their diagnosis seemed more confident in the efficacy of risk reduction strategies and often did not already have children. CONCLUSIONS: Future studies may help clarify the relationship between factors that influence pregnancy decision-making among HIV-positive women. HIV-positive and at-risk women of childbearing age may benefit from counseling interventions sensitive to factors that influence infected women's pregnancy decisions.     

HIV与输血传播病毒的母婴传播的调查

目的 了解艾滋病高发区HIV与输血传播病毒(TTV)母婴传播情况。方法 对华中地区某艾滋病高发农村228名母亲及其年龄小于15岁的子女180名进行入户流行病学调查，采集静脉血检测抗HIV、抗TTV，回顾性分析2种病毒的母婴传播特点。结果 82例HIV阳性母亲1993年后生的103名儿童中，39例HIV阳性，母婴传播率为37.9％；59例抗TTV阳性母亲所生的76名儿童中，5例抗TTV阳性，母婴传播率为6.6％。结论 HIV与TTV在当地均存在母婴传播；母婴传播是儿童感染HIV的主要途径。未对HIV流行地区高危生育期妇女进行有效的HIV监测与咨询，未及时采取有效干预措施是造成该地区儿童感染HIV的主要原因，亟需制定实施相应的对策，控制HIV进一步蔓延，保护HIV感染高发区妇女及儿童的健康。     

Sterilization acceptance and regret in Thailand

The prevalence of sterilization increased steadily in Thailand from 1969/70 to 1984, but remained unchanged over the period 1984–1987. This paper uses data from the 1987 Thai DHS to examine sterilization acceptance and regret.

The prevalence of sterilization increases with both the number of children and with the age of the woman. Among women with two or more children, there is a positive association between education and wealth, and tubal ligation, but there is no correlation between education and wealth and the percentage of husbands with a vasectomy.

Women whose last delivery was in hospital were more likely to have been sterilized than were women with a home delivery, and among women with a hospital delivery, those who had a cesarean section were more likely to have been sterilized than were women with a vaginal delivery. Both accessibility to medical facilities and medical problems apparently play a role in affecting who gets sterilized.

The percentage of women who reported that they regretted that either they had gotten sterilized or that their spouses had gotten sterilized was 11% but regret was higher in cases in which the wife had had surgery (12%) than in cases in which the spouse had had a vasectomy (8%). This difference persisted even when other variables were introduced to examine the correlates of regret (number of children at time of sterilization, subsequent death of a child, whether sterilization was done at time of CS, residence of the respondent) using multiple classification analysis. Perhaps when women themselves are sterilized, they attribute subsequent problems in health to the operation, whereas such changes cannot be attributed to the vasectomy of their husband.     

HIV status,fertility intentions,and contraception in the era of expanded access to antiretroviral therapy: A case study of rural Mozambique

Provision of effective contraception to HIV-positive women of reproductive age is critical to effective management of HIV infection and prevention of both vertical and horizontal HIV transmission in developing countries. This exploratory retrospective study examines contraceptive use during the prolonged post-partum period in a sample of 285 HIV-positive and HIV-negative women who gave birth at four rural maternity clinics in a high HIV-prevalence region in Mozambique. Multivariate analyses show no significant variations by HIV status in contraceptive timing (mean time to first contraceptive use of 7.1 months) or prevalence (31% at time of survey) but detect a moderating effect of fertility intentions: while HIV status makes no difference for women wishing to stop childbearing, among women who want to continue having children, or are unsure about their reproductive plans, HIV-positive status is associated with higher likelihood of contraceptive use. Regardless of HIV status, virtually no condom use is reported. These results are situated within the context of a rapidly widening access to post-partum antiretroviral therapy in the study site and similar sub-Saharan settings.     

The Rise of Female Sterilization: A Closer Look at Colombia

Objective In the 1970s, OCPs and IUDs were the most popular contraceptive methods in Colombia. According to data from the most recent Demographic and Health Survey (DHS), sterilization has become the most common form of birth control in Colombia. This study aims to examine the characteristics of Colombian women desiring long-acting contraception. Methods This study uses the 2005 and 2010 Colombian DHS dataset. Women who choose long-acting contraception were divided into those using female sterilization and those using long-acting reversible contraception (LARC). A multivariate logistic regression model was used to compare demographic and social determinants of contraceptive choice among reproductive age women seeking long-acting contraception between the years 2005 and 2010. Results Among women using a long-acting contraceptive method in 2010, compared to 2005, women were significantly more likely to be sterilized (1.14 OR, 95% CI 1.09–1.18) and less likely to use LARC (0.88 OR, 95% CI 0.85–0.92). Of women seeking long-acting contraception, those exposed to a family planning provider were less likely to undergo sterilization (0.54 OR, 95% CI 0.51–0.58) and more likely to use LARC (1.84 OR, 95% CI 1.73–1.96). When compared to all contraceptive users, younger women and women with less than two children were more likely to use LARC than sterilization. Conclusion Between 2005 and 2010, an increase in the proportion of contracepting women being sterilized in Colombia occurred. Our findings suggest that exposure to a family planning provider and appropriate contraceptive counseling appears to be key determinants of long-acting contraceptive choice. To improve use of long-acting, effective contraception, efforts should be made to increase access to family planning providers.     

“We never thought of a vasectomy”: a qualitative study of men and women's counseling around sterilization

Background

Sterilization is the most commonly used method of contraception in the United States; however, little is known about how providers counsel about these procedures or the information patients desire. In this study, we explore male and female experiences of sterilization counseling and their perspectives on ideal sterilization counseling.

Study design

In-depth individual and group interviews were conducted with 37 heterosexual couples between the ages of 25 and 55 years. Each couple had reached their desired family size. Interviews were recorded and transcribed using NVivo software and analyzed using modified grounded theory.

Results

Men and women differed in their experiences of sterilization counseling. Women commonly received counseling on female sterilization but not vasectomy, while men rarely discussed either form of sterilization with their providers. Both men and women desired more information about sterilization.

Conclusions

Contraceptive counseling of couples who have completed childbearing does not routinely include men or the option of vasectomy, despite the advantages of this method with respect to safety, efficacy and cost. Family planning and primary care providers have an important role in ensuring that couples are aware of all their options and can make an informed decision about their contraception.     

Contraceptive method and self-reported HIV status among women in Malawi

ObjectivesWe aimed to describe contraceptive methods used by women in Malawi and determine whether contraceptive use differed by self-reported HIV status. Effective contraception is a primary method of preventing mother-to-child transmission of HIV.Study designAnalysis is based on 12,658 nonpregnant, sexually debuted women ages 15–49 years in the 2010 Malawi Demographic and Health Survey. Analysis was restricted to respondents with contraceptive need (i.e., fecund and did not want a child in the next 12 months) who reported their last HIV test result. We accounted for the two-stage cluster sampling design by applying cluster, stratum and sample weights. We assessed differences in contraceptive method use by HIV status with χ² tests and multivariable logistic regression.ResultsA total of 893 (7.0%) of respondents reported being HIV positive. Use of long-acting reversible contraception (LARC) was low and did not differ between HIV-positive (1.4%) and HIV-negative (1.9%) women [adjusted odds ratio (aOR)=0.7, 95% confidence interval (CI), 0.4–1.4]. HIV-positive women (15.6%) were less likely than HIV-negative women (30.4%) to use progestin-only injectable contraception (aOR, 0.7; 95% CI, 0.5–0.8). Prevalence of female sterilization was higher among HIV-positive women (17.9%) compared to HIV-negative women (9.2%; aOR=1.7; 95% CI, 1.2–2.3).ConclusionsLARC use was low among adult women with contraceptive need in Malawi. HIV-positive women were less likely to report progestin-only injectable use but more likely to report having undergone female sterilization compared to their HIV-negative counterparts. Noncoercive interventions that provide highly effective methods of contraception to HIV-positive women with contraceptive need are valuable methods of vertical transmission prevention in Malawi.ImplicationsContraceptive use differed by self-reported HIV status among adult women with contraceptive need in Malawi. Female sterilization was significantly higher, and use of progestin-only injectables was significantly lower, among HIV-positive women compared to their HIV-negative counterparts. Use of long-acting reversible contraception was low among both HIV-positive and HIV-negative women.     

Fertility Desires Among HIV-Infected Men and Women in Los Angeles County: Client Needs and Provider Perspectives

Combination antiretroviral therapy for persons living with HIV/AIDS (PLHA) has extended life expectancy, and enabled PLHA to live productive lives that can include having children. Despite calls to address childbearing for PLHA there has been limited attention to developing safe conception programs. This research sought to assess the childbearing desires of PLHA and the experiences of health care providers serving this population. Research entailed a brief cross-sectional client survey given to HIV-infected men and women over age 18 at two Los Angeles County clinics administered over an 8-week period. Focus group discussions were conducted with providers at each clinic site. Although 39 % of the 93 clients surveyed reported a desire to have children, two-thirds of clients had not discussed their desires, or methods of safe conception, with providers. Providers reported challenges in providing safe conception services in resource poor settings where clients cannot afford assisted fertility services and in the absence of national, state, or county guidelines for safe conception. They noted complex and varied client circumstances and a critical need for provider training in safe conception. Guidelines that focus on safe conception and harm reduction strategies as well as the legal ramifications of counseling on these practices are needed. HIV providers need training and patients need educational tools and workshops informing them of the risks, challenges, and options available to them and their partners to safely conceive and bear an HIV-negative child.     

Engaging HIV Care Providers in Conversations With Their Reproductive-Age Patients About Fertility Desires and Intentions: A Historical Review of the HIV Epidemic in the United States

Provider-initiated conversations with people living with HIV about reproductive plans are lacking. Providers must know whether their patients want to bear children to tailor treatment and refer for HIV preconception counseling to help achieve patients’ reproductive goals while minimizing transmission to partners and children. The early focus on men who have sex with men largely excluded consideration of the epidemic’s impact on reproductive health. We used a historical review of the US epidemic to describe the problem’s scope and understand if this legacy underlies the current neglect of reproductive planning. Drawing on peer-reviewed literature, we discuss key themes relevant to assessing and understanding attention to desires for children among HIV-positive people. We conclude with recommendations for addressing persistent stigma and enhancing patient–provider communication about reproductive intentions.We reviewed the literature on childbearing desires among people living with HIV to understand to what extent and why such desires have not been appropriately addressed in the public health response to HIV. We briefly explain why appropriate attention to fertility desires among people living with HIV should be a public health priority. We then present the results of a historical review of the HIV epidemic in the United States focused on reproductive desires for biological children. From the early epidemic up to the current context, we document a critical unmet need for reproductive planning, including research on this topic. We present evidence that (1) reproductive desires among people living with HIV have been largely ignored historically, (2) HIV-positive women and men desire to have biological children, and (3) despite recent attention to fertility intentions in research, patient–provider communication about safer childbearing remains limited according to the few published studies available.Drawing on this history, we discuss 3 key reasons for the lack of attention spanning across the 3 decades of the epidemic: (1) the initial focus on men who have sex with men (MSM) because of the early epidemiology of the epidemic, (2) subsequent focus on infants and sexual partners because of legitimate concerns about vertical and horizontal transmission before the development of antiretroviral therapy (ART) and HIV preconception strategies, and (3) a legacy of stigma that persists despite medical advances that make childbearing among people living with HIV much safer. We recommend a series of strategies for addressing this unmet need.Roughly three quarters of more than 1 million people living with HIV in the United States are of reproductive age.1,2 Similar to persons who are not infected with HIV, research suggests that people living with HIV have desires and intentions to have biological children that warrant adequate attention and available high-quality reproductive health care from HIV providers. In a seminal study published in 2001, Chen et al. reported that among 1421 HIV-positive women and men from a nationally representative sample of adults in the United States receiving medical care, 29% of women and 28% of men desired children in the future.3 More recently, a study of HIV-positive women in a Baltimore, Maryland, clinic (mean age = 32 years) documented that 59% desired to bear future children.4 Despite these desires, a few recent studies suggest that reproductive counseling has yet to become a standard component of routine HIV clinical care in the United States.5–7Why is this a concern? For one, providers must know whether their HIV-positive patients want to bear children to tailor treatment options and refer patients for HIV preconception counseling to meet their childbearing desires while preventing HIV transmission to partners (horizontal transmission) and children (vertical transmission). In addition, there is the need to ensure that services adequately respond to the sexual and reproductive rights of people living with HIV.8,9Although there has been recent recognition that the reproductive intentions of people living with HIV have been largely neglected with consequences for public health and human rights, there has not been a historical review to explore the past and current scope of this problem or discuss why this need remains unmet in the United States. To enhance provider communication with HIV-positive patients of reproductive age about their reproductive desires and intentions, these gaps must be addressed. Therefore, we explored 3 aims. First, we turned to the history of the epidemic in the United States to understand the scope of the need for reproductive planning for people living with HIV. Second, using this historical context, we explored the reasons underlying the current challenge. Third, we considered strategies for meeting this need.Our analysis focuses specifically on desires to have biological children among people living with HIV. However, nearly half of all pregnancies in the United States in 2006 were unintended,10 indicating that the need for routine reproductive planning certainly extends beyond people living with HIV. Several of the concluding recommendations can apply to the general population more broadly. The review and recommendations also focus on women and men who have sex with women as having biological children is a more relevant reproductive health concern for these populations than for MSM. Much of this article presents data on HIV-positive women because of the very limited research on childbearing desires among HIV-positive men and HIV-negative women in relationships with HIV-positive men. We recognize, however, the importance of this issue for these populations and highlight the need for future research. Finally, to ensure focus, we have limited the review to the desire for biological children and childbearing; thus, pregnancy prevention is not discussed. It is likely, however, that many of the conclusions and recommendations will apply to pregnancy prevention or spacing—the more commonly emphasized dimensions of family planning.We also focused on the US epidemic for several reasons. Increasingly, research on the fertility intentions of people living with HIV occurs in low-resource country contexts and rightfully so because of the magnitude of the epidemics in these settings.11,12 Much of the historical literature, however, discusses the epidemic in the United States, and even in this high-resource setting, HIV persists as a public health challenge. According to the Centers for Disease Control and Prevention (CDC), there were an estimated 47 500 new HIV infections in 2010. Of these, 63% stemmed from male-to-male sex and 25% occurred via heterosexual transmission.13 Women constituted an estimated 20% of the newly infected persons in 2010, 64% of whom were Black women13 who must not only contend with HIV-related stigma but also with marginalization in the form of sexism and racism.14 With this epidemiology and its implications, the lack of attention to the epidemic’s impact on women, men who have sex with women, and reproduction must be addressed.     

Fertility desires and family planning demand among HIV-positive clients in follow-up care at antiretroviral treatment unit in Gondar university hospital,Ethiopia

Despite the growing importance of fertility issues for HIV-infected persons, little is known about their actual fertility desires and intentions. This study was, therefore, aimed at assessing fertility desires and demand for family planning in HIV-positive clients in follow-up care at antiretroviral treatment (ART) unit in Gondar University Hospital, Ethiopia. A cross sectional quantitative study on 389 study subjects (56% females and 44% males living with HIV/AIDS in follow-up care) supplemented by in-depth interview was conducted between November 2007 and January 2008. Eighty-five (49.71%) of the male and seventy-nine (36.3%) of the female participants expressed the desire for children, giving a total of 164 (42.16%) of all participants. Study subjects who had no children and whose partners wants children were more likely to have children desire. During the survey period, 100 (25.7%) of the clients were using different forms of family planning devices and 124 (42.9%) wants to use family planning in the future. The extent of fertility desire and family planning needs of these people has implication for vertical and heterosexual transmission of HIV, the needs for fertility-related counselling, and/or contraception, and advice regarding childbirth.     

Changes in family structure and regret following tubal sterilization

Tubal sterilization is one of the contraceptive methods whose use has increased the most in Brazil, but a growing number of women have expressed regret after the procedure. A case-control study was conducted at the Centro Integrado de Saúde Amaury de Medeiros (CISAM), Recife, Pernambuco, Brazil, in 1997 to investigate the association between changes in family structure and request for or submittal to surgical reversal of tubal sterilization, comparing 304 sterilized women who had requested or submitted to reversal of tubal sterilization and 304 women who were also sterilized but had not requested, had not submitted to, and who did not wish to submit to reversal. The simple and adjusted odds ratios were estimated using logistic regression. The results of the current study showed that death of children, partners without children prior to the current union, and partner change after tubal sterilization were associated with the request for or submittal to reversal of tubal sterilization. More strict criteria are suggested in the indication of tubal sterilization, including an in-depth profile of the woman requesting tubal sterilization and identification of risk factors for future regret.     

Provision of female sterilization in Ribeirao Preto, Sao Paulo, Brazil

Forty percent of Brazilian married women from 15 to 49 years of age have undergone surgical sterilization. The 1988 Brazilian Constitution states that all scientifically proven contraceptive methods should be available to all citizens, but it was only in 1997 that specific family planning legislation was approved. This study examines physicians' perceptions and attitudes towards the current provision of female sterilization and its legal implications, as well as women's experience with obtaining and undergoing sterilization. The study design included: (1) an investigation of the hospitals and health professionals and (2) a survey of women sterilized in combination with cesarean delivery in 1998. The survey showed they had a median of 3 living children, 60.0% had been sterilized between 30 and 39 years of age, and 61.0% had paid for the procedure. Many women reported previous method failure and adverse effects with hormonal contraceptives. Women with less schooling and lower socioeconomic status had more children and had begun childbearing and had been sterilized at younger ages than women with more schooling and higher socioeconomic status. Inequalities related to reproduction were strongly associated with teenage pregnancy and inadequate knowledge about contraceptives.     

The impact of health care providers on female sterilization among HIV-positive women in Brazil

This paper explores the reproductive preferences and outcomes of HIV-positive women in two cities in Brazil. We used three types of data, all drawn from women who delivered in public sector hospitals: (1) clinical records of 427 HIV-positive women; (2) pre- and postpartum in-depth interviews with 60 HIV-positive women; and (3) a prospective survey carried out among 363 women drawn from the general population. The HIV-positive samples were collected on women who had prenatal care between July 1999 and June 2000, and the general population survey was conducted with women who started prenatal care between April 1998 and June 1999. Among the women in the clinic sample, we found dramatic differences in the proportion sterilized postpartum: 51% in Sao Paulo vs. 4% in Porto Alegre, compared to 3.4% and 1.1%, respectively, of women in the general population. Our qualitative data suggest that HIV-positive women in this study had strong preferences to have no more future children and that female sterilization was the preferred way to achieve this end. Therefore, we conclude that the large difference in rates is mainly due to HIV-positive women's differential access to sterilization in the two settings. In-depth interviews revealed that women in Sao Paulo were often encouraged by clinic staff to be sterilized postpartum. In contrast, HIV-positive women in Porto Alegre clinics were not offered sterilization as an option and those who requested it were repeatedly put off. The striking difference found in the frequency with which doctors provide postpartum sterilization to seropositive women in our study sites deserves attention and discussion in the respective medical communities. At the higher level of national policy on reproductive rights, there may be grounds for reopening discussion about the norms regarding postpartum procedures, and for devoting far more resources to expanding contraceptive options.     

Factors associated with reproductive options in HIV-infected women

A cross-sectional study was conducted in Campinas, Brazil, in HIV-infected women to evaluate factors associated with reproductive practices. A total of 112 HIV-infected women, 13 to 45 years old, with previous sexual experience were included in the study. Three groups were compared: pregnant women aware of their infection before current pregnancy, sterilized women who had made their reproductive choice after serodiagnosis and women using any reversible contraceptive method. Fisher's Exact Test and multivariate correspondence analysis were used in the statistical analysis. Among women interviewed, 23% were pregnant, 18% had been sterilized and 59% were using a reversible contraceptive method. Being younger was associated with reproductive practices that preserved the possibility of having a child. Reversible contraceptive users had fewer pregnancies and more often reported a desire to have children compared to the other groups. Partner's desire for parenthood was associated with pregnant and sterilized women. The clinical condition of the women and their partners, the serologic status of partner nor counseling about contraceptive choices influenced reproductive practices.     

HIV infection and fertility preferences in rural Malawi

Although HIV-prevalence and fertility rates in sub-Saharan Africa are among the highest in the world, little is known about how HIV infection affects the fertility preferences of men and women in the region. A quasi-experimental design and in-depth interviews conducted in rural Malawi are employed to examine how and through what pathways learning that one is HIV positive alters a person's childbearing desires. Among rural Malawians, particularly men, the desire to have more children decreases after receiving a positive HIV-test result. The motivations underlying this effect are greatly influenced by gender: women fear the physical health consequences of HIV-positive pregnancies and childbearing, whereas men see childbearing as futile because they anticipate their own early death and the deaths of their future children. Considerable ambivalence remains, nevertheless, particularly among women who strategize to live normal lives in spite of their infection, but whose definitions of "normal" vary.