AIDS and Behavior

, Volume 23, Issue 6, pp 1431–1451 | Cite as

Unintended Pregnancy in Women Living with HIV in Sub-Saharan Africa: A Systematic Review and Meta-analysis

  • Tesfaye Regassa FeyissaEmail author
  • Melissa L. Harris
  • Alemu Sufa Melka
  • Deborah Loxton
Substantive Review


In 2014, about 1.5 million pregnancies occurred among HIV-positive women in low and middle-income countries. To pool magnitude and factors associated with unintended pregnancy in women living with HIV in sub-Saharan Africa, a systematic search of electronic databases was undertaken in November 2016. Pooling the magnitude of unintended pregnancy reported by 14 studies yielded a crude summary prevalence of 55.9%. The magnitude of unwanted pregnancy and mistimed pregnancy in six studies ranged from 14 to 59 and 9 to 47.2%, respectively. Contraceptive failure was an important factor for many unintended pregnancies. The magnitude of unintended pregnancy was significantly higher in HIV-positive women than for HIV-negative women in three out of six studies. The available evidence suggests that there is a high magnitude of unintended pregnancy in this population. Improving effective contraceptive utilization is thus a priority to address unintended pregnancies and to prevent mother to child transmission of HIV. PROSPERO Number: CRD42016051310.


Unintended pregnancy Unplanned pregnancy Unwanted pregnancy Mistimed pregnancy HIV Women 



Antenatal care


Antiretroviral therapy


Adjusted odds ratio


Adjusted prevalence ratio


Confidence interval


Johanna Briggs Institute


Medical subject headings


Odds ratio


People living with HIV


Prevention of mother to child transmission


Women living with HIV



TRF and ASM are supported by The University of Newcastle International Postgraduate Research Scholarship (UNIPRS) and The University of Newcastle Research Scholarship Central 50:50 (UNRSC 50:50). We are grateful to Hunter Medical Research Institute/Greaves Family Postgraduate Top Up Scholarship (G1701582). We would also like to thank Ryan O’Neill for language edition. Finally, we thank Debbie Booth for supporting in searching.

Author contributions

Contributed to conception and design of the systematic review: TRF, MLH, and DL. Involved in the development of the search strategy, the selection criteria, the strategy for assessment of risk of bias, and data abstraction form: TRF, MLH, and DL. Involved in the screening, assessment of eligibility, selection of studies and critical appraisal as well as data extraction: TRF, MLH, ASM, and DL. Contributed to analysis and interpretation of the data: TRF, MLH, ASM, and DL. Involved in drafting the manuscript and revising it critically: TRF, MLH, ASM, and DL. All authors have given final approval for the manuscript to be published.



Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no competing interests.

Ethical Approval

This article does not contain any studies with human participants performed by any of the authors.

Supplementary material

10461_2018_2346_MOESM1_ESM.docx (97 kb)
Supplementary material 1 (DOCX 97 kb)


  1. 1.
    UNAIDS. Global AIDS update 2016. UNIAIDS 2016;1–7.Google Scholar
  2. 2.
    World Health Organization. Progress report: global health sector response to HIV, 2000–2015 focus on innovations in Africa 2015. Accessed 29 Nov 2016.
  3. 3.
    UNAIDS. Progress Report on the global plan towards the elimination of new HIV infections among children and keeping their mothers alive 2015. Accessed 28 Sep 2016.
  4. 4.
    UNAIDS. Africa prepares to eliminate mother-to-child transmission of HIV by 2015 2010. August 2017
  5. 5.
    Katirayi L, Namadingo H, Phiri M, Bobrow EA, Ahimbisibwe A, Berhan AY, et al. HIV-positive pregnant and postpartum women’s perspectives about Option B + in Malawi: a qualitative study. J Int AIDS Soc. 2016;19(1):20919.Google Scholar
  6. 6.
    O’Shea MS, Rosenberg NE, Tang JH, Mukuzunga C, Kaliti S, Mwale M, et al. Reproductive intentions and family planning practices of pregnant HIV-infected Malawian women on antiretroviral therapy. AIDS Care. 2016;28(8):1027–34.Google Scholar
  7. 7.
    Nattabi B, Li J, Thompson SC, Orach CG, Earnest J. A systematic review of factors influencing fertility desires and intentions among people living with HIV/AIDS: implications for policy and service delivery. AIDS Behav. 2009;13(5):949–68.Google Scholar
  8. 8.
    McLaughlin LC. The price of failure of informed consent law: coercive sterilizations of HIV-positive women in South Africa. Law Ineq. 2014;32:69.Google Scholar
  9. 9.
    Bi S, Klusty T. Forced sterilizations of HIV-positive women: a global ethics and policy failure. AMA J Ethics. 2015;17(10):952–7.Google Scholar
  10. 10.
    Mindry D, Maharaj P, Letsoalo T, Munthree C, Crankshaw T. Knowing client rights and meeting their needs: provider knowledge and attitudes toward meeting the reproductive needs and rights of people living with HIV in South Africa. Global perspectives on women’s sexual and reproductive health across the lifecourse. New York: Springer; 2018. p. 141–58.Google Scholar
  11. 11.
    Kawale P, Mindry D, Phoya A, Jansen P, Hoffman RM. Provider attitudes about childbearing and knowledge of safer conception at two HIV clinics in Malawi. Reprod Health. 2015;12(1):17.Google Scholar
  12. 12.
    Padian NS, McCoy SI, Karim SSA, Nina Hasen JK, Bartos M, Katabira E, et al. HIV prevention transformed: the new prevention research agenda. Lancet. 2011;378:269–78.Google Scholar
  13. 13.
    Wilcher R, Cates W. Reproductive choices for women with HIV. Bull World Health Organ. 2009;87(11):833–9.Google Scholar
  14. 14.
    Halperin DT, Stover J, Reynolds HW. Benefits and costs of expanding access to family planning programs to women living with HIV. Aids. 2009;23(Suppl 1):S123–30.Google Scholar
  15. 15.
    Jhangri GS, Heys J, Alibhai A, Rubaale T, Kipp W. Unmet need for effective family planning in HIV-infected individuals: results from a survey in rural Uganda. J Fam Plann Reprod Health Care. 2012;38(1):23–9.Google Scholar
  16. 16.
    Phillips T, Zerbe A, McIntyre J, Petro G, Abrams E, Myer L. Pregnancy intentions among HIV-infected women seeking antenatal care in Cape Town, South Africa. Top Antivir Med. 2014;22:443.Google Scholar
  17. 17.
    King R, Khana K, Nakayiwa S, Katuntu D, Homsy J, Lindkvist P, et al. ‘Pregnancy comes accidentally–like it did with me’: reproductive decisions among women on ART and their partners in rural Uganda. BMC Public Health. 2011;11:530.Google Scholar
  18. 18.
    McCoy SI, Buzdugan R, Ralph LJ, Mushavi A, Mahomva A, Hakobyan A, et al. Unmet need for family planning, contraceptive failure, and unintended pregnancy among HIV-infected and HIV-uninfected women in Zimbabwe. PLoS ONE. 2014;9(8):e105320.Google Scholar
  19. 19.
    Klima CS. Unintended pregnancy. Consequences and solutions for a worldwide problem. J Nurse-Midwifery. 1998;43(6):483–91.Google Scholar
  20. 20.
    Haddad L, Wall KM, Vwalika B, Khu NH, Brill I, Kilembe W, et al. Contraceptive discontinuation and switching among couples receiving integrated HIV and family planning services in Lusaka, Zambia. Aids. 2013;27(Suppl 1):S93–103.Google Scholar
  21. 21.
    Hofmeyr GJ, Singata-Madliki M, Lawrie TA, Bergel E, Temmerman M. Effects of the copper intrauterine device versus injectable progestin contraception on pregnancy rates and method discontinuation among women attending termination of pregnancy services in South Africa: a pragmatic randomized controlled trial. Reprod Health. 2016;13:42.Google Scholar
  22. 22.
    Pallitto CC, Garcia-Moreno C, Jansen HA, Heise L, Ellsberg M, Watts C. Intimate partner violence, abortion, and unintended pregnancy: results from the WHO Multi-country Study on Women’s Health and Domestic Violence. Int J Gynaecol Obstet. 2013;120(1):3–9.Google Scholar
  23. 23.
    Gomez AM. Sexual violence as a predictor of unintended pregnancy, contraceptive use, and unmet need among female youth in Colombia. J Womens Health (Larchmt). 2011;20(9):1349–56.Google Scholar
  24. 24.
    Feyissa TR, Melka AS. Demand for modern family planning among married women living with HIV in western Ethiopia. PLoS ONE. 2014;9(11):e113008.Google Scholar
  25. 25.
    Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol. 2012;120(6):1291–7.Google Scholar
  26. 26.
    WHO. Rapid advice: use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants. Geneva: WHO; 2010.Google Scholar
  27. 27.
    Segurado AC, Paiva V. Rights of HIV positive people to sexual and reproductive health: parenthood. Reprod Health Matters. 2007;15(29):27–45.Google Scholar
  28. 28.
    Organization WH. Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples: recommendations for a public health approach. 2012.Google Scholar
  29. 29.
    Mugo NR, Heffron R, Donnell D, Wald A, Were EO, Rees H, et al. Increased risk of HIV-1 transmission in pregnancy: a prospective study among African HIV-1 serodiscordant couples. AIDS (Lond, Engl). 2011;25(15):1887.Google Scholar
  30. 30.
    Beyeza-Kashesya J, Kaharuza F, Mirembe F, Neema S, Ekstrom AM, Kulane A. The dilemma of safe sex and having children: challenges facing HIV sero-discordant couples in Uganda. Afr Health Sci. 2009;9(1):2–12.Google Scholar
  31. 31.
    Yeatman S, Eaton JW, Beckles Z, Benton L, Gregson S, Zaba B. Impact of ART on the fertility of HIV-positive women in sub-Saharan Africa. Trop Med Int Health. 2016;21(9):1071–85.Google Scholar
  32. 32.
    Myer L, Carter RJ, Katyal M, Toro P, El-Sadr WM, Abrams EJ. Impact of antiretroviral therapy on incidence of pregnancy among HIV-infected women in Sub-Saharan Africa: a cohort study. PLoS Med. 2010;7(2):e1000229.Google Scholar
  33. 33.
    Kaida A, Andia I, Maier M, Strathdee SA, Bangsberg DR, Spiegel J, et al. The potential impact of antiretroviral therapy on fertility in sub-Saharan Africa. Curr HIV/AIDS Rep. 2006;3(4):187–94.Google Scholar
  34. 34.
    Kumar S, Gruskin S, Khosla R, Narasimhan M. Human rights and the sexual and reproductive health of women living with HIV–a literature review. J Int AIDS Soc. 2015;18:20290.Google Scholar
  35. 35.
    Crankshaw TL, Voce A, King RL, Giddy J, Sheon NM, Butler LM. Double disclosure bind: complexities of communicating an HIV diagnosis in the context of unintended pregnancy in Durban, South Africa. AIDS Behav. 2014;18(Suppl 1):S53–9.Google Scholar
  36. 36.
    Grilo SA, Catallozzi M, Heck CJ, Mathur S, Nakyanjo N, Santelli JS. Couple perspectives on unintended pregnancy in an area with high HIV prevalence: a qualitative analysis in Rakai, Uganda. Global Public Health 2018;1–12.Google Scholar
  37. 37.
    Mindry DL, Crankshaw TL, Maharaj P, Munthree C, Letsoalo T, Milford C, et al. “We have to try and have this child before it is too late”: missed opportunities in client-provider communication on reproductive intentions of people living with HIV. AIDS Care. 2015;27(1):25–30.Google Scholar
  38. 38.
    Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264–9.Google Scholar
  39. 39.
    Todd J, Slaymaker E, Zaba B, Mahy M, Byass P. Measuring HIV-related mortality in the first decade of anti-retroviral therapy in sub-Saharan Africa. Global Health Action. 2014;7:24787.Google Scholar
  40. 40.
    Floyd S, Marston M, Baisley K, Wringe A, Herbst K, Chihana M, et al. The effect of antiretroviral therapy provision on all-cause, AIDS and non-AIDS mortality at the population level–a comparative analysis of data from four settings in Southern and East Africa. Trop Med Int Health. 2012;17(8):e84–93.Google Scholar
  41. 41.
    Hugonnet S, Mosha F, Todd J, Mugeye K, Klokke A, Ndeki L, et al. Incidence of HIV infection in stable sexual partnerships: a retrospective cohort study of 1802 couples in Mwanza Region, Tanzania. J Acquir Immune Defic Syndr (1999). 2002;30(1):73–80.Google Scholar
  42. 42.
    Munn Z, Moola S, Lisy K, Riitano D, Tufanaru C. Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data. Int J Evid Based Healthc. 2015;13(3):147–53.Google Scholar
  43. 43.
    Bankole A, Keogh S, Akinyemi O, Dzekedzeke K, Awolude O, Adewole I. Differences in unintended pregnancy, contraceptive use and abortion by HIV status among women in Nigeria and Zambia. Int Perspect Sex Reprod Health. 2014;40(1):28–38.Google Scholar
  44. 44.
    Ezugwu E, Iyoke C, Nkwo P, Ezegwui H, Akabueze J, Agu P. Unintended pregnancy among hiv positive pregnant women in Enugu, South East Nigeria. Int J Gynecol Obstet. 2015;131:E388.Google Scholar
  45. 45.
    Akelo V, Girde S, Borkowf CB, Angira F, Achola K, Lando R, et al. Attitudes toward family planning among HIV-positive pregnant women enrolled in a prevention of mother-to-child transmission study in Kisumu, Kenya. PLoS ONE. 2013;8(8):e66593.Google Scholar
  46. 46.
    Gutin SA, Namusoke F, Shade SLB, Mirembe F. Fertility desires and intentions among HIV-positive women during the post-natal period in Uganda. Afr J Reprod Health. 2014;18(3):67–77.Google Scholar
  47. 47.
    Crede S, Hoke T, Constant D, Green MS, Moodley J, Harries J. Factors impacting knowledge and use of long acting and permanent contraceptive methods by postpartum HIV positive and negative women in Cape Town, South Africa: a cross-sectional study. BMC Public Health. 2012;12:197.Google Scholar
  48. 48.
    O’Shea MS, Rosenberg NE, Hosseinipour MC, Stuart GS, Miller WC, Kaliti SM, et al. Effect of HIV status on fertility desire and knowledge of long-acting reversible contraception of postpartum Malawian women. AIDS Care. 2015;27(4):489–98.Google Scholar
  49. 49.
    Warren CE, Abuya T, Askew I. Family planning practices and pregnancy intentions among HIV-positive and HIV-negative postpartum women in Swaziland: a cross sectional survey. BMC Pregnancy Childbirth. 2013;13:150.Google Scholar
  50. 50.
    Haddad LB, Feldacker C, Jamieson DJ, Tweya H, Cwiak C, Chaweza T, et al. Pregnancy prevention and condom use practices among HIV-infected women on antiretroviral therapy seeking family planning in Lilongwe, Malawi. PLoS ONE. 2015;10(3):e0121039.Google Scholar
  51. 51.
    Mayondi GK, Wirth K, Morroni C, Moyo S, Ajibola G, Diseko M, et al. Unintended pregnancy, contraceptive use, and childbearing desires among HIV-infected and HIV-uninfected women in Botswana: across-sectional study. BMC Public Health. 2016;16:44.Google Scholar
  52. 52.
    Wanyenze RK, Matovu JK, Kamya MR, Tumwesigye NM, Nannyonga M, Wagner GJ. Fertility desires and unmet need for family planning among HIV infected individuals in two HIV clinics with differing models of family planning service delivery. BMC Womens Health. 2015;15:5.Google Scholar
  53. 53.
    Wanyenze RK, Tumwesigye NM, Kindyomunda R, Beyeza-Kashesya J, Atuyambe L, Kansiime A, et al. Uptake of family planning methods and unplanned pregnancies among HIV-infected individuals: a cross-sectional survey among clients at HIV clinics in Uganda. J Int AIDS Soc. 2011;14:35.Google Scholar
  54. 54.
    Kikuchi K, Wakasugi N, Poudel KC, Sakisaka K, Jimba M. High rate of unintended pregnancies after knowing of HIV infection among HIV positive women under antiretroviral treatment in Kigali, Rwanda. Biosci Trends. 2011;5(6):255–63.Google Scholar
  55. 55.
    Schwartz SR, Rees H, Mehta S, Venter WD, Taha TE, Black V. High incidence of unplanned pregnancy after antiretroviral therapy initiation: findings from a prospective cohort study in South Africa. PLoS ONE. 2012;7(4):e36039.Google Scholar
  56. 56.
    Yotebieng M, Norris A, Chalachala JL, Matumona Y, Ramadhani HO, Behets F. Fertility desires, unmet need for family planning, and unwanted pregnancies among HIV-infected women in care in Kinshasa, DR Congo. Pan Afr Med J. 2015;20:235.Google Scholar
  57. 57.
    Obare F, van der Kwaak A, Birungi H. Factors associated with unintended pregnancy, poor birth outcomes and post-partum contraceptive use among HIV-positive female adolescents in Kenya. BMC Womens Health. 2012;12:34.Google Scholar
  58. 58.
    Guttamacher Institute. Abortion in Africa New York: Guttamacher Institute; 2018. Accessed 1 June 2018
  59. 59.
    Sedgh G, Bearak J, Singh S, Bankole A, Popinchalk A, Ganatra B, et al. Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends. Lancet. 2016;388(10041):258–67.Google Scholar
  60. 60.
    Roxby AC, Matemo D, Drake AL, Kinuthia J, John-Stewart GC, Ongecha-Owuor F, et al. Pregnant women and disclosure to sexual partners after testing HIV-1-seropositive during antenatal care. AIDS Patient Care STDS. 2013;27(1):33–7.Google Scholar
  61. 61.
    Larsson EC, Thorson A, Pariyo G, Conrad P, Arinaitwe M, Kemigisa M, et al. Opt-out HIV testing during antenatal care: experiences of pregnant women in rural Uganda. Health Policy Plan. 2012;27(1):69–75.Google Scholar
  62. 62.
    Yeatman S, Trinitapoli J. “I will give birth but not too much”: HIV-positive childbearing in rural Malawi. Women, motherhood and living with HIV/AIDS. New York: Springer; 2013. p. 93–109.Google Scholar
  63. 63.
    Cuca YP, Rose CD. Social stigma and childbearing for women living With HIV/AIDS. Qual Health Res. 2016;26(11):1508–18.Google Scholar
  64. 64.
    Fledderjohann JJ. ‘Zero is not good for me’: implications of infertility in Ghana. Hum Reprod. 2012;27(5):1383–90.Google Scholar
  65. 65.
    Scarsi KK, Darin KM, Chappell CA, Nitz SM, Lamorde M. Drug-drug interactions, effectiveness, and safety of hormonal contraceptives in women living with HIV. Drug Saf. 2016;39(11):1053–72.Google Scholar
  66. 66.
    Moodley J, Naidoo S, Wand H, et al. Contraception use and impact on pregnancy prevention in women participating in an HIV prevention trial in South Africa. J Fam Plan Reprod Health Care. 2016;42(1):5–11.Google Scholar
  67. 67.
    Ndayizigiye M, Fawzi MC, Lively CT, Ware NC. Understanding low uptake of contraceptives in resource-limited settings: a mixed-methods study in rural Burundi. BMC Health Serv Res. 2017;17(1):209.Google Scholar
  68. 68.
    Church K, Wringe A, Fakudze P, Kikuvi J, Nhlabatsi Z, Masuku R, et al. Reliance on condoms for contraceptive protection among HIV care and treatment clients: a mixed methods study on contraceptive choice and motivation within a generalised epidemic. Sex Transm Infect. 2014;90(5):394–400.Google Scholar
  69. 69.
    Liu H, Morisky DE, Lin X, Ma E, Jiang B, Yin Y. Bias in self-reported condom use: association between over-reported condom use and syphilis in a three-site study in China. AIDS Behav. 2016;20(6):1343–52.Google Scholar
  70. 70.
    Taulo F, Berry M, Tsui A, Makanani B, Kafulafula G, Li Q, et al. Fertility intentions of HIV-1 infected and uninfected women in Malawi: a longitudinal study. AIDS Behav. 2009;13(Suppl 1):20–7.Google Scholar
  71. 71.
    Cooper D, Moore E, Mantell JE. Renegotiating intimate relationships with men: how HIV shapes attitudes and experiences of marriage for South African women living with HIV: ‘Now in my life, everything I do, looking at my health’. Acta Jurid (Cape Town, South Africa). 2013;2013:218–38.Google Scholar
  72. 72.
    EDHS. Ethiopian Mini demographic and health suvery Addis Ababa: CSA; 2015.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Tesfaye Regassa Feyissa
    • 1
    • 2
    Email author
  • Melissa L. Harris
    • 2
  • Alemu Sufa Melka
    • 1
    • 2
  • Deborah Loxton
    • 2
  1. 1.College of Health ScienceWollega UniversityNekemteEthiopia
  2. 2.Research Centre for Generational Health and Ageing, Faculty of Health and MedicineThe University of NewcastleNewcastleAustralia

Personalised recommendations