Study design and period
An institution-based cross-sectional study was conducted from February 1st to march 30th 2022.
Study setting
This study had conducted in Bahirdar town PMTCT site health facilities northwest Ethiopia. Bahirdar is the capital city of the Amhara Regional state. It is one of the leading tourist destinations in Ethiopia, with a variety of attractions in the nearby Lake Tana and Abay River.
The town is known for its wide avenues lined with palm trees and a variety of colourful flowers. It is located at the exit of the Abbay from Lake Tana at an altitude of 1,820 metres (5,970 ft) above sea level. The city is located approximately 578 km north-northwest of Addis Ababa (the capital city of Ethiopia).Lake Tana region is a UNESCO Biopshere Reserve since 2015. Bahir Dar is home to a number of universities and colleges. The most prominent of all is the Bahir Dar University.
According to Central Statistical Agency of Ethiopia population estimation in 2013, the total population of the town was estimated to be 389,071. Of whom, around 328, 071 were residing the urban area. In the urban part of the town, female at reproductive age (15-49) were about 110,730.Besisdes, there were two public referral hospitals, more than three private hospitals, six public health centres, one primary hospital, and there was more than 8 private higher clinics. Of these, eight of them were PMTCT/ART sites that continuously provides care for more than 14,855 HIV positive peoples at the time of study
Source population
The source population for this study was all pregnant women who utilizes PMTCT services in Bahirdar town public health facilities.
Study population
Those pregnant women, who utilizes PMTCT services and available during the study period were the study population.
Inclusion and Exclusion criteria
Inclusion criteria
Those pregnant women living with HIV in the reproductive age (15-49) and have at least one PMTCT follow-up, registered in PMTCT cohort and who gave an informed consent to participate in the study period were included in the study.
Exclusion criteria
Those who unable to give response at the time of data collection and pregnant women who transferred to other health facility were excluded from the study.
Sample size determination
The sample size for this study was determined by using a single population proportion formula by considering the following assumptions; 40.9% prevalence of unintended pregnancy among HIV positive women (31), 95% level of confidence, and 5% margin of error.\(\text{n}=\frac{(\text{Z}{\alpha }/2{)}^{2}\text{*}\text{p}(1-\text{p})}{{\text{d}}^{2}}\), where n = required sample size, α = level of significance, z = standard normal distribution curve value for 95% confidence level = 1.96, p = proportion d = margin of error.
Therefore, n1=\(\frac{\left(1.96{)}^{2}\text{*}0.409\right(1-0.409)}{\left(0.05\right)2}\)= 372
For the second objective sample size was calculated by using Epi Info version7.1 and by considering different assumptions (Table 1).
Table 1
Summary of sample size for factors associated with unintended pregnancy among HIV positive women in Bahirdar town health facilities 2022 (31) .
Associated factors
|
Confidence interval
|
Power
|
%outcome in un exposed
|
COR
|
Non response rates
|
Total sample size
|
Contraceptive use
|
95%
|
80%
|
56.2%
|
2.651
|
10%
|
192
|
Knowledge status on MTCT and PMTCT
|
95%
|
80%
|
57.8%
|
0.20
|
10%
|
73
|
Discussion with ART provider on RH issues
|
95%
|
80%
|
33.3%
|
0.22
|
10%
|
124
|
Hence the sample size obtained from the first objective was used to determine the final sample size. After considering a 10% contingency for non-response rate, the minimum adequate sample size was 408 .
Sampling technique and procedures
There were eight public health care facilities in Bahir Dar town providing ART/PMTCT service consistently at the time of the study.The six month report of HIV positive women attending ART/PMTCT clinic was obtained from each health facility.Then average monthly performace was calculated,after that the calculated sample size was proportionally allocated to each health facility. Systematic Random Sampling was used to select the study participants. There after,the list of participants were selected according to the average monthly report 654/408 =1.6 so that averagely every 2 women were selected for two consequetive months.from eight health facility.
Operational definitions and definition of terms
Unintended pregnancy: - is current pregnancy, which is either mistimed or unwanted at the time of conception (25).
Mistimed: - Pregnancy, which has occurred without the wish of the woman at the specific time of occurrence of the pregnancy, but she has a desire to be pregnant and have a child or children sometimes in the future (25).
Unwanted: - Pregnancy that has occurred to the women when no children or no more children were desired (25).
Dual method:- is the use of family planning methods which will prevent both unwanted pregnancy and HIV/STD infections during sexual intercourse. through the use of a barrier method such as a male or female condom together with another contraceptive method (18).
Adequate knowledge of MTCT: based on the questions designed to assess women’s knowledge of MTCT, if the women answers more than 50% or above, she was considered as knowledgeable (21).
Adequate knowledge of PMTCT: based on the questions prepared to assess women’s knowledge of PMTCT, women able to score above the mean was considered as knowledgeable (21).
Husband involvement: Measured using five variables with yes/no response. Score given as 1 for (yes) and 0 for (no). The involvement score for each respondent could range from 0 = no involvement to 5 = involved in all 5 activities. A total score of 3-5 will considered as a 'high' male involvement score and 0-2 as 'low' relative to this particular population (26).
Household decision making power: women were considered to participate in the house hold decisions if they make decisions alone or jointly with their husband in all the seven questions (26).
Media exposure: Respondents were asked how often they listened to the radio, or watched television. Those who responded at least once a week are considered to be regularly exposed to that form of media (26).
Variables of the study
Dependent variable
Unintended pregnancy among women who used PMTCT service (Yes/No)
Independent variable
Socio-demographic variables: Age, women’s educational status, Residence, Marital status, women’s occupation, husband educational status, husband occupation, Estimated time to walk to the nearest health facility, Number of children (family size), Household income, and media exposure.
Reproductive and maternity health service related factors: Parity,Gravidity,Partner desire for child,Ideal number of children,History of abortion.
Contraceptive related factors: Type of contraceptive used,use of dual method ,health care provider counseling ,discussion on family planning with partner ,get family planning and ARVs from the same facility,cost of family planning services.
HIV and related factors: Duration of HIV diagnosis,ART duration,ART regimen,Knowledge of partner status,partner status,Partner ART status,knowledge of HIV transmission,viral load,CD4 count Partner ART status,knowledge of methods of HIV transmission,Viral load,CD4 count.
Health Service-Related:Type of health facility,distance to health facility ,(STI) prevention counseling by a health care professional.
Data collection tool,instruments & procedures
The data collection tool was developed by reviewing related literature and were collected using a structured questionnaire through face-to-face interviews and chart review.The questionnaire contains socio-demographic characteristics, reproductive and maternity health service related characterstics, HIV and ART releted, contraceptive related, PMTCT knowledge and unitended pregnancy related characterstics. Four Diploma and two BSc degree holder midwifes were recruited for data collection and supervision respectively.
Data quality control
To ensure consistentcy and easily undestandability,the questionnaire was first prepared in English and translated to the local Amharic language and back to English.
Before the actual data collection, the pretest has done on 21 HIV positive women at Debremarkos referal hospital which is not be included in the data analysis.From the pretest finding language,clarity skiping pattern and measurement issues were corrected. Before data collection, a one day training was given for the data collectors and supervisors. During data collection, the questionnaire was checked for Completeness weekly by the supervisors.
Data processing and analysis
Data completeness has checked, coded,and entered into Epi data version 4.6 and then exported to SPSS version 23 for cleaning and data analysis. Descriptive statistics proportions, frequency, mean, median, standard deviation, tables, and graphs were used to present the characteristics of study participants. Bivariable logistic regression model was fitted to identify independent factros and variables having a p-value of less than 0.2 was included in the multivariable logistic regression to handle possible confounders. In the multivariable logistic regression, a p-value of ≤ 0.05 with a 95% CI for the adjusted odds ratio was used to affirm the statistical association.