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Table 3 Healthcare providers’ perception regarding facilitators and barriers to fertility plan discussions with women living with HIV in western Ethiopia

From: “They haven’t asked me. I haven’t told them either”: fertility plan discussions between women living with HIV and healthcare providers in western Ethiopia

Themes

Quote Code

Quote

Facilitators to discussing reproductive plans

 

14

We prepare a plan and send to the mum-to-mum group [s]. Mum-to-mum group [s] give them a support when they [women] need to get pregnant, follow them and find them even if they missed during follow-up (HCP#1).

15

The mother support carers are working with an NGO [non-governmental organization named ICAP-The International Center for AIDS Care and Treatment Programs]. At this center, they are providing close counselling for pregnant women. In addition to medical consultation, they prepare coffee and tea ceremony. The mother support carers provide advice for pregnant women related to care during pregnancy, post-delivery care for children, medical examination, DBS [Dry Blood Sample] for children, and virological test [s]. Hence, the two women [mum-to-mum] are shouldering those duties … Furthermore, they are arranging education service program [s] (HCP#2).

16

We spend 30 min with a single patient, then adherence supporters counsel them [HIV-positive women] (HCP#3).

17

We refer them for family planning service [to family planning clinics], particularly for long-acting [contraception] … By the way, we are providing health education to enhance awareness during every morning on different topics (HCP#4).

Barriers to discussions

 High client load and insufficient staffing

18

Human power has also its own impact as ART guideline recommends 20 patients per day, but we have about 45, 40, or 35 [per day]...The shortage of human resource [s] is creating a challenge to the implementation of policy. The room at which we are providing a service for HIV-positive people often gets busy (HCP#3).

 A poor referral system

19

Moreover, we refer them to family planning clinic... During referral time, there are some dropouts (HCP#4).

Barriers to good quality discussions

 Lack of recognizing women’s fertility needs

20

Not many, they are about 5–10 person out of 100 (HCP#1).

21

If they insist on having a child, we discuss with them on the possible opportunities [strategies] (HCP#4).

 A lack of time and being overworked

22

There is high client load … So, this makes [it] difficult to provide a complete service because it takes time. A lot of patients are waiting for me [waiting time] while I’m discussing with a single client for some time...It is hardly possible for one worker to serve [all] customers. There are also additional duties as workers provide services in an integrated approach. [There is] duty of registration, a worker is doing throughout a day like a report writer (HCP#3).

 Mismatched fertility desires among couples

23

He [man] wants to see his offspring before death and force woman to have a child. Less frequently, a woman also wants to have a child because she does not have a child before (HCP#2).

24

They [couple] are opposing each other. She didn’t need to have a child, because he drank alcohol, and didn’t believe her, he is [HIV] positive and she is [HIV] negative (HCP#1).

 Nondisclosure of HIV-status to a partner

25

Another challenge is about disclosure. It is difficult to disclose the status of the patients, particularly beyond the existing ethics and regulation and their interests. In some cases, a husband knows; in other case [s], a woman knows ... Some women do not want their personal health status to be revealed to their husbands being fear of the possible consequences such as separation in which they may face difficulty in [future] living condition and their lives … She might be pregnant during this time (HCP#4).

 Poor partner involvement

26

Women [some] who are tested positive through our clinic do not tell their husband. But there are cases where we invite the husband and he gets tested. In some cases, he refuses to come. On the other side, there is a situation in which husbands bring their wives to the clinic for a test [HIV] … Therefore, their husbands have to receive advice at our center to use condoms properly. Those [women] who have husbands want their consensus for contraceptive use (HCP#2).

27

For instance, if a woman is HIV-negative and a man is HIV-positive, you advise the use of condoms. In practice, there is a situation he has sex without condoms. He says, ‘let me live then let die’. Thus, he has sex without condoms. On the other hand, if a woman is HIV positive and a husband is HIV negative, there is a condition in which the husband leaves her or gets separated (HCP#2).

28

In fact, most of the time, they were required to receive close advice at the center. But, a husband sometimes says, ‘I am free and but it is up to you’ (for discussion) (HCP#2).

29

There are people who have two or three children while being discordant... We tell the HIV-negative person, there is the possibility to acquire HIV when having sex without condoms (HCP#3).

30

In the process, we observe the discordant converting to positive. Some of them [wrongly] believe that they could not be infected because of their blood type (HCP#3).

31

Sometimes they [couple] come together, other time [s] the woman alone (HCP#1).

 Fear of repercussions of disclosing fertility desires to a HCP

32

There are people who desire to have a child, but fear to disclose (HCP#1).

33

We have been advising her not to get pregnant. She may fear to inform us since she gets pregnant against our counselling … First, if a child gets HIV-infected, it is a burden to a family. Secondly, a child born with HIV suffers a lot throughout his life including taking drugs. So, we advise couples [family] not to have a child (HCP#2).

34

Most of the time, those women who lack or have one child only come with their partner and discuss with us. Those having 3 or more children do not disclose [intention to have a child] for the matter they may lack permission (HCP#3).

35

She said ‘I feared them [HCPs] since I told them I have neither a husband nor [boy] a friend’. Secondly, the reason for this case was the short contact time with the provider (HCP#3).

36

Seldom, there is a possibility of getting pregnant while we are counselling them not to have a child. When we ask them ‘why they do like that; why you don’t tell us?’ Their response is that ‘you advised us to delay pregnancies and you may not accept but we wanted to have a child’. The decision behind at large was due to their fear of pressure from providers (HCP#4).

 HCPs fear of seroconversion

37

In fact, we strongly promote practice of safe sex with condoms to all our patients, in particular for discordant in our institution. You [HCP] need to avoid any complaint against us if they get seroconverted (HCP#3).