Post-partum sexual abstinence in West Africa: implications for AIDS-control and family planning programmes

Predictors of early resumption of post-partum sexual intercourse among post-partum period women in Ethiopia: A multilevel analysis based on Ethiopian demographic and health survey 2016

Background

Early resumption of post-partum sexual intercourse has an adverse outcome on the health of women and indirectly unintended pregnancy might happen and affects both the health of women and the delivered baby. There is limited evidence that shows predictors at the individual and community level from the Ethiopian demographic and health survey. Therefore, the aim of this study was to assess predictors of early resumption of post-partum sexual intercourse among post-partum period women in Ethiopia: a multilevel analysis based on Ethiopian demographic and health survey 2016.

Methods

This study used an in-depth secondary data analysis of the survey using the 2016 main EDHS. A total weighted sample of 6447 post-partum women who have children aged 0 to 36 months (about 3 years) was included for the analysis. Multilevel binary logistic regression analysis was conducted considering the hierarchical nature of the EDHS data. Intra-class Correlation Coefficient (ICC), and deviance [-2 Log-Likelihood Ratio (LRR)] were used for model comparison and for assessing model fitness. In a multivariable analysis adjusted OR with a 95% CI (Confidence Interval) was reported with a p-value <0.05 was used to declare a significant association between the explanatory and the outcome variables.

Results

The proportion of early resumption of post-partum sexual intercourse was found to be 60.41% [95% CI 59.19–61.63]. Women with age group of 25–28 (AOR = 0.8; 95% CI 0.67–0.96), 29–32 (AOR = 0.79; 95% CI 0.63–0.98), and 33–49 (AOR = 0.67; 95% CI 0.53–0.85), women with sex of child female (AOR = 0.82; 95% CI 0.73–0.92), women whose child is alive (AOR = 0.52; 95% CI 0.38–0.69), women who delivered by cesarean section(AOR = 0.34; 95% CI 0.23–0.49), women with primary educational level (AOR = 1.27; 95% CI 1.09–1.48), women with secondary educational level (AOR = 1.61; 95% CI 1.19–2.17) and women with higher educational level (AOR = 1.6; 95% CI 1.05–2.45), Para 3–4 women (AOR = 1.45; 95% CI 1.21–1.73) and women with grand multi parity (AOR = 1.61; 95% CI 1.29–2), women with fertility desire wanted latter (AOR = 0.81; 95% CI 0.69–0.94), women with fertility desire wanted no more (AOR = 0.81; 95% CI 0.66–1.01), women who are on family planning use (AOR = 1.2; 95% CI 1.05–1.38) and participant with currently on working (AOR = 0.79; 95% CI 0.69–0.91) were significantly associated with early resumption of post-partum sexual intercourse.

Conclusions

The magnitude of early resumption of post-partum sexual intercourse was found to be high. Giving emphasis to the age groups of 25–28, 29–32, and 33–49 women, women with the sex of child female, women who delivered by cesarean section, currently working, the child is live, fertility desire wanted later and no more were suggested to reduce early resumption of post-partum sexual intercourse. On the other hand, improved educational attainments of women, women with parity 3–4, and >5, and family planning use were variables to increase early resumption of post-partum sexual intercourse. Therefore, the health care providers and program managers should act on early resumption of post-partum sexual intercourse through health education and promotion considering the significant factors.

HIV acquisition in pregnancy: implications for mother-to-child transmission at the population level in sub-Saharan Africa

Introduction

A recent sero‐discordant couple study showed an elevated risk of HIV‐acquisition during the pregnancy/postpartum period per‐condomless‐coital‐act. This, along with previous studies, has led to concern over possible increased risk of mother‐to‐child (vertical) transmission, due to the initial high viral load in the first months after seroconversion, in a time when the woman and health services may be unaware of her status. This study looks at whether behavioural differences during the pregnant/postpartum period could reduce the impact of elevated risk of HIV acquisition per‐condomless‐coital‐act at the population level.

Methods

We used data from 60 demographic and health surveys from 32 sub‐Saharan African countries. Using the HIV status of couples, we estimated differences in serodiscordancy between HIV‐negative women who were pregnant/postpartum compared to those who were not pregnant/postpartum. We compare the risk of sexual activity over the pregnant/postpartum period to those not pregnant/postpartum. Using these risks of serodiscordancy and sexual activity along with estimates of increased HIV risk in the pregnancy/postpartum period per‐condomless‐coital‐act, we estimated a population‐level risk of HIV acquisition and acute infection, during pregnancy/postpartum compared to those not pregnant/postpartum.

Results

Sexual activity during pregnancy/postpartum varies considerably. In general, sexual activity is high in the first trimester of pregnancy, then declines to levels lower than among women not pregnant/postpartum, and is at its lowest in the first months postpartum. Adjusted for age and survey, pooled results show HIV‐negative pregnant women are less likely to have an HIV‐positive partner compared to those not pregnant/postpartum (risk ratio (RR) = 0.78, 95% CI = 0.68–0.89) and comparing the postpartum period (RR = 0.85, 95% CI = 0.73–0.99). Estimated population‐level risk for HIV acquisition and acute infection in pregnancy/postpartum was lower than would be inferred directly from per‐condomless‐coital‐act estimates in most countries, over the time of most risk of mother‐to‐child transmission, though there was variation by country and month of pregnancy/postpartum.

Conclusions

Estimates of population‐level HIV acquisition risk in sub‐Saharan Africa should not be taken directly from per‐condomless‐coital‐act studies to estimate vertical transmission. Changes in sexual behaviour and differences in HIV‐serodiscordancy during pregnancy/postpartum reduce the impact of increased risk of HIV acquisition per‐condomless‐coital‐act, this will vary by region.

Postpartum sex taboos and child growth in Tanzania: Implications for child care

The social context and cultural meaning systems shape caregivers' perceptions about child growth and inform their attention to episodes of poor growth. Thus, understanding community members' beliefs about the aetiology of poor child growth is important for effective responses to child malnutrition. We present an analysis of caregivers' narratives on the risks surrounding child growth during postpartum period and highlight how the meanings attached to these risks shape child care practices. We collected data using 19 focus group discussions, 30 in‐depth interviews and five key informant interviews with caregivers of under‐five children in south‐eastern Tanzania. Parental non‐adherence to postpartum sexual abstinence norms was a dominant cultural explanation for poor growth and development in a child, including different forms of malnutrition. In case sexual abstinence is not maintained or when a mother conceives while still lactating, caregivers would wean their infants abruptly and completely to prevent poor growth. Mothers whose babies were growing poorly were often stigmatized for breaking sex taboos by the community and by health care workers. The stigma that mothers face reduced their self‐esteem and deterred them from taking their children to the child health clinics. Traditional rather than biomedical care was often sought to remedy growth problems in children, particularly when violation of sexual abstinence was suspected. When designing culturally sensitive interventions aimed at promoting healthy child growth and effective breastfeeding in the community, it is important to recognize and address people's existing misconceptions about early resumption of sexual intercourse and a new pregnancy during lactation period.

Factors contributing to the duration of postpartum abstinence among Nigerian women: semi-parametric survival analysis

Background

The duration of postpartum abstinence is on the decrease but has not been met with increased uptake of contraceptive in Nigeria. This imbalanced transition could result in shorter birth intervals and worsen maternal and child health outcomes. There is a paucity of information on the duration and predictors of time to end of postpartum abstinence in Nigeria. This study was aimed at understanding the time to end of postpartum abstinence and factors predicting the duration in Nigeria.

Methods

The NDHS 2013 data was used. Data of all women who had ever given birth were included. The time to end of postpartum abstinence was censored among currently breastfeeding mothers. The Kaplan Meier Product Limit method was used to estimate the survival and hazard function while the Cox regression was used to fit a model for time to end of postpartum abstinence at 5% significance level. Data were weighed and provisions were made for multicollinearity.

Results

The overall average duration of postpartum abstinence in Nigeria is 3 month. In all, 58% ended postpartum abstinence within the first three months while 18%, 10%, and 14% ended it within 4–6 months, 7–12 months and after one year respectively. Postpartum abstinence did not last beyond 3 months among 83% of the women in the North-West region, compared with 23% in the North Central region, and 34% in the South East. The Muslims had the highest proportion of women who ended postpartum abstinence within the first three months after delivery at 72% compared with Catholic women (31%). The median time to end of postpartum abstinence was lowest (2 months) among women from North West, Muslims, in poorest wealth quintiles and those with no education. The “hazard” of earlier resumption of sexual activity after birth was over 3 times more likely among women in the North West than those in the North Central (aHR = 3.09, 95% CI: 2.95–3.24). Women using contraceptives had a 40% hazard of ending postpartum abstinence earlier. Rural women were 7.6% times less likely to end postpartum abstinence compared to their urban counterpart. Women from rich households have an excess risk of 14% to end postpartum abstinence early compared to women from poor households.

Conclusion

Women of reproductive age in the North West, who are Muslims and with no education are at higher risk of ending postpartum abstinence early. Hence, policymakers and reproductive health stakeholders should design effective intervention targeted at this group of women as a means of controlling fertility.

Sexual Behavior and Vaginal Practices During Pregnancy and Postpartum: Implications for HIV Prevention Strategies

BACKGROUND

Understanding sexual behaviors and vaginal practices of pregnant and breastfeeding women in sub-Saharan Africa is critical to inform HIV prevention strategies during these periods.

METHODS

HIV-uninfected women presenting for antenatal care in western Kenya were enrolled and followed through 36 weeks postpartum. Sexual behavior and vaginal practices were ascertained by structured questionnaires. Logistic regression was used to assess correlates of unprotected sex, vaginal washing, and vaginal drying.

RESULTS

Among 1252 women enrolled, 78.4% were married (of whom 15.1% were in polygamous unions), 1.4% had a known HIV-infected partner, and 33.6% had a partner of unknown HIV status. At enrollment, 58.5% reported sex in the past month (94.3% unprotected) and 4.5% reported forced sex. Odds of unprotected sex at enrollment was >11-fold higher in married than in unmarried women (P < 0.001) and lower among women who reported partners of unknown HIV status or HIV-infected compared with HIV-uninfected partners. Median time to postpartum resumption of sex was 7 weeks (interquartile range 4-12). Prevalence of unprotected sex in the past week increased from 6.6% to 60.0% between 2 and 36 weeks postpartum (P < 0.001). Vaginal washing was reported by 60.1% of women at enrollment and prevalence remained stable postpartum; vaginal drying was reported by 17.9% at enrollment and decreased to 6.1% at 36 weeks postpartum (P < 0.001). Vaginal washing and drying were associated with forced sex.

CONCLUSIONS

High rates of unknown partner HIV status, polygamy, and less frequent condom use among pregnant/postpartum women underscore the need for female-controlled HIV prevention interventions. Vaginal washing and drying may present challenges to microbicide use.

Resumption of intercourse after childbirth in southwest Nigeria

OBJECTIVE

To determine the history of resumption of intercourse after childbirth and associated contraceptive practices among women in the southwest region of Nigeria.

METHODS

A cohort of 181 women with live births was followed up for 6 months after delivery. Enquiry about the time of first intercourse after childbirth, associated dyspareunia, use of contraception, etc was made during the postnatal clinic visits and/or by telephone contact.

RESULTS

Fifty (27.6%) had coitus within six weeks of childbirth, it increased to 115 (63.3%) at three months and 127 (70.2%) by six months post-delivery. Prevalence of dyspareunia was 36.2%. Eighty three (65.4%) of sexually active women practiced contraception which was predominantly use of male condom and withdrawal method. Co-habitation with husband (adjusted OR: 6.30; 95% CI: 2.56-17.01; p = 0.001) and mode of delivery (adjusted OR: 2.45; 95% CI: 1.30-4.73; p = 0.006) were strong predictors of commencement of sexual intercourse within six months postpartum. Significantly fewer women who had Caesarean section resumed coitus within six months when compared with those who had vaginal deliveries (59.2% versus 78.4%). Perineal injury did not predict resumption of coitus or experience of dyspareunia.

CONCLUSION

In contrast to the norm, more women in southwest Nigeria are resuming coitus soon after childbirth. It is imperative to scale up counselling on postpartum sexuality and contraception within the maternal health services in this region.

Incident HIV during pregnancy and postpartum and risk of mother-to-child HIV transmission: a systematic review and meta-analysis

BACKGROUND

Women may have persistent risk of HIV acquisition during pregnancy and postpartum. Estimating risk of HIV during these periods is important to inform optimal prevention approaches. We performed a systematic review and meta-analysis to estimate maternal HIV incidence during pregnancy/postpartum and to compare mother-to-child HIV transmission (MTCT) risk among women with incident versus chronic infection.

METHODS AND FINDINGS

We searched PubMed, Embase, and AIDS-related conference abstracts between January 1, 1980, and October 31, 2013, for articles and abstracts describing HIV acquisition during pregnancy/postpartum. The inclusion criterion was studies with data on recent HIV during pregnancy/postpartum. Random effects models were constructed to pool HIV incidence rates, cumulative HIV incidence, hazard ratios (HRs), or odds ratios (ORs) summarizing the association between pregnancy/postpartum status and HIV incidence, and MTCT risk and rates. Overall, 1,176 studies met the search criteria, of which 78 met the inclusion criterion, and 47 contributed data. Using data from 19 cohorts representing 22,803 total person-years, the pooled HIV incidence rate during pregnancy/postpartum was 3.8/100 person-years (95% CI 3.0-4.6): 4.7/100 person-years during pregnancy and 2.9/100 person-years postpartum (p = 0.18). Pooled cumulative HIV incidence was significantly higher in African than non-African countries (3.6% versus 0.3%, respectively; p<0.001). Risk of HIV was not significantly higher among pregnant (HR 1.3, 95% CI 0.5-2.1) or postpartum women (HR 1.1, 95% CI 0.6-1.6) than among non-pregnant/non-postpartum women in five studies with available data. In African cohorts, MTCT risk was significantly higher among women with incident versus chronic HIV infection in the postpartum period (OR 2.9, 95% CI 2.2-3.9) or in pregnancy/postpartum periods combined (OR 2.3, 95% CI 1.2-4.4). However, the small number of studies limited power to detect associations and sources of heterogeneity.

CONCLUSIONS

Pregnancy and the postpartum period are times of persistent HIV risk, at rates similar to "high risk" cohorts. MTCT risk was elevated among women with incident infections. Detection and prevention of incident HIV in pregnancy/postpartum should be prioritized, and is critical to decrease MTCT.

Is the risk of HIV acquisition increased during and immediately after pregnancy? A secondary analysis of pooled HIV community-based studies from the ALPHA network

BACKGROUND

Previous studies of HIV acquisition in pregnancy have been in specific population groups, such as sero-discordant couples which have shown an increased risk of HIV acquisition during pregnancy and studies of sexually active women where the results have been ambiguous. However these studies are unable to tell us what the overall impact of pregnancy is on HIV acquisition in the general population.

METHODS

Data from six community-based HIV cohorts were pooled to give 2,628 sero-conversions and a total of 178,000 person years of observation. Multiple imputation was used to allow for the uncertainty of exact sero-conversion date in surveillance intervals greater than the length of a pregnancy. Results were combined using Rubin's rules to give appropriate error bounds. The analysis was stratified into two periods: pre- and post- widespread availability of prevention of mother-to-child HIV transmission services. This allows us to assess whether there is reporting bias relating to a person's knowledge of their own HIV status which would become more widespread in the latter time period.

RESULTS

Results suggest that women while pregnant have a lower risk of acquiring HIV infection over all periods (HRR 0.79, 95%CI 0.70-0.89) than women who were not pregnant. There is no evidence for a difference in the rate of HIV acquisition between postpartum and non-pregnant women (HRR 0.92 95%CI 0.84-1.03).

DISCUSSION

Although there may be immunological reasons for increased risk of HIV acquisition during pregnancy, at a population level this study indicates a lower risk of HIV acquisition for pregnant women. Pregnant women may be more likely to be concordant with their current sexual partner than non-pregnant women, i.e. either already HIV positive prior to the pregnancy or if negative at the time of becoming pregnant more likely to have a negative partner.

Determinants of condom use by men in extramarital relationships in Nigeria

BACKGROUND

Extramarital sex is a high-risk behavior in terms of Human Immunodeficiency Virus (HIV) transmission, yet condom use in extramarital relationships is an understudied area in Africa, and Nigeria in particular, where such liaisons are not uncommon. This study highlights key determinants of condom use among men who engage in extramarital sex in Nigeria.

METHODS

Results are based on a subsample of 642 married men from a combined dataset from three waves of the National HIV/AIDS and Reproductive Health Survey (NARHS), a set of multiround nationally representative surveys. Logistic regression was employed to explore possible determinants of condom use in extramarital sex. The motivation, opportunity, and ability model was applied in selecting the determinants.

RESULTS

HIV risk-reduction knowledge was found not to be associated with condom use. At the full logistic regression model, being of the Yoruba tribe, having no misconception about HIV transmission, ability to discuss condom use, and ability to wear condoms were the key variables significantly associated with condom use in extramarital sex.

CONCLUSION

Implementing HIV risk-reduction behavior change requires more than knowledge. Behavioral skills in condom use are critical. Intervention efforts should move away from knowledge about risk to concentrate on improving skills on how to discuss condom use and wear condoms correctly.

Prolonged sexual abstinence after childbirth: gendered norms and perceived family health risks. Focus group discussions in a Tanzanian suburb

Background

Prolonged sexual abstinence after childbirth is a socio-cultural practice with health implications, and is described in several African countries, including Tanzania. This study explored discourses on prolonged postpartum sexual abstinence in relation to family health after childbirth in low-income suburbs of Dar es Salaam, Tanzania.

Methods

Data for the discourse analysis were collected through focus group discussions with first-time mothers and fathers and their support people in Ilala, Dar es Salaam, Tanzania.

Results

In this setting, prolonged sexual abstinence intended at promoting child health was the dominant discourse in the period after childbirth. Sexual relations after childbirth involved the control of sexuality for ensuring family health and avoiding the social implications of non-adherence to sexual abstinence norms. Both abstinence and control were emphasised more with regard to women than to men. Although the traditional discourse on prolonged sexual abstinence for protecting child health was reproduced in Ilala, some modern aspects such as the use of condoms and other contraceptives prevailed in the discussion.

Conclusion

Discourses on sexuality after childbirth are instrumental in reproducing gender-power inequalities, with women being subjected to more restrictions and control than men are. Thus, interventions that create openness in discussing sexual relations and health-related matters after childbirth and mitigate gendered norms suppressing women and perpetuating harmful behaviours are needed. The involvement of males in the interventions would benefit men, women, and children through improving the gender relations that promote family health.

Polygyny, partnership concurrency, and HIV transmission in Sub-Saharan Africa

We study the relationship between polygyny and HIV infection using nationally representative survey data with linked serostatus information from 20 African countries. Our results indicate that junior wives in polygynous unions are more likely to be HIV positive than spouses of monogamous men, but also that HIV prevalence is lower in populations with more polygyny. With these results in mind, we investigate four explanations for the contrasting individual- and ecological-level associations. These relate to (1) the adverse selection of HIV-positive women into polygynous unions, (2) the sexual network structure characteristic of polygyny, (3) the relatively low coital frequency in conjugal dyads of polygynous marriages (coital dilution), and (4) the restricted access to sexual partners for younger men in populations where polygynous men presumably monopolize the women in their community (monopolizing polygynists). We find evidence for some of these mechanisms, and together they support the proposition that polygynous marriage systems impede the spread of HIV. We relate these results to the debate about partnership concurrency as a primary behavioral driver for the fast propagation of HIV in some parts of sub-Saharan Africa.

High HIV incidence and sexual behavior change among pregnant women in Lilongwe, Malawi: implications for the risk of HIV acquisition

Background

HIV incidence is higher among pregnant women than their non-pregnant counterparts in some sub-Saharan African settings. Our aims were (1) to estimate HIV incidence during pregnancy and (2) to compare sexual activity between pregnant, postpartum, and non-pregnant women.

Methods

We examined a retrospective cohort of 1087 women to identify seroconverters using antenatal and labor ward HIV test results. We also conducted a cross-sectional survey, including a quantitative questionnaire (n = 200) and in-depth interviews (n = 20) among women in early pregnancy, late pregnancy, postpartum, and non-pregnancy. Outcomes included measures of sexual activity, reported spouse’s risky behavior, and beliefs about abstinence.

Results

11 of 1087 women seroconverted during pregnancy yielding a 1% seroconversion risk and an incidence rate of 4.0/100 person years (95% CI 2.2–7.2). The reported sexual activity of the early pregnancy and non-pregnancy groups was similar, but significantly higher than the late pregnancy and postpartum groups (p<0.001). During pregnancy, sex acts decreased as gestation increased (p = 0.001). There was no reported difference in the spouse’s risky behavior. Most women believed that sex should cease between the 6^th and 8^th month of pregnancy and should not resume until 6 months postpartum. Some talked about conflict between their cultural obligation to abstain and fear of HIV infection if their spouses find other partners.

Conclusions

HIV incidence is high among pregnant women in Malawi, and sexual activity decreases during pregnancy and postpartum. Pregnant women need to be informed of their increased risk for HIV and the importance of using condoms throughout pregnancy and the postpartum period.

Community-level gender equity and extramarital sexual risk-taking among married men in eight African countries

CONTEXT

In many parts of Africa, women are most likely to become infected with HIV by having unprotected sex with their husbands, who may have acquired the virus through extramarital sex. However, the ways in which aspects of community environments-particularly those related to gender equity-shape men's extramarital sexual risk-taking are not well understood.

METHODS

Demographic and Health Survey data from eight African countries (Chad, Ghana, Malawi, Nigeria, Tanzania, Uganda, Zambia and Zimbabwe) were used to examine associations between married men's engaging in risky extramarital sex (i.e., having had both unprotected sex and extramarital sex) and indicators of gender equity and other community characteristics. Separate multilevel logistic regression models that incorporated individual, household and community measures were created for each country.

RESULTS

In five countries, men who lived in communities with more equal ratios of women to men with at least a primary education were less likely to report risky extramarital sexual activity (odds ratios, 0.4-0.6). A similar relationship was found in four countries for the ratio of women to men who were employed (0.4-0.5). In three countries, men who lived in communities with more conservative attitudes toward wife-beating or male decision making had elevated odds of extramarital sexual risk-taking (1.1-1.5).

CONCLUSIONS

While HIV prevention programs should focus on reducing gender inequities, they also need to recognize the conservative cultural factors that influence the formation of men's masculine identities and, in turn, affect their sexual behavior.

Menstrual pattern, sexual behaviors, and contraceptive use among postpartum women in Nairobi urban slums

Postpartum months provide a challenging period for poor women. This study examined patterns of menstrual resumption, sexual behaviors and contraceptive use among urban poor postpartum women. Women were eligible for this study if they had a birth after the period September 2006 and were residents of two Nairobi slums of Korogocho and Viwandani. The two communities are under continuous demographic surveillance. A monthly calendar type questionnaire was administered retrospectively to cover the period since birth to the interview date and data on sexual behavior, menstrual resumption, breastfeeding patterns, and contraception were collected. The results show that sexual resumption occurs earlier than menses and postpartum contraceptive use. Out of all postpartum months where women were exposed to the risk of another pregnancy, about 28% were months where no contraceptive method was used. Menstrual resumption acts as a trigger for initiating contraceptive use with a peak of contraceptive initiation occurring shortly after the first month when menses are reported. There was no variation in contraceptive method choice between women who initiate use before and after menstrual resumption. Overall, poor postpartum women in marginalized areas such as slums experience an appreciable risk of unintended pregnancy. Postnatal visits and other subsequent health system contacts provide opportunities for reaching postpartum women with a need for family planning services.

Joy, struggle and support: postpartum experiences of first-time mothers in a Tanzanian suburb

OBJECTIVES

To explore and describe postpartum experiences of first-time mothers in a Tanzanian, multiethnic, low-income suburb.

METHODS

Individual qualitative interviews with 10 first-time mothers, 4-10 weeks postpartum in Ilala suburb, Dar es Salaam, Tanzania.

RESULTS

The first-time mothers enjoyed motherhood and the respectful status it implied. To understand and handle the infant's needs and own bodily changes were important during postpartum. The tradition of abstaining from sex up to 4 years during breastfeeding was a concern as male's faithfulness was questioned and with HIV a threat to family health. Partner relationship changed towards shared parental and household work and the man's active participation was appreciated. Support from family members and others in the neighbourhood were utilised as a resource by the mothers. In instances of uncertainties on how to handle things, their advice was typically followed. The new mothers generally had good experiences of health care during the childbearing period. However, they also experienced insufficiencies in knowledge transfer, disrespectful behaviour, and unofficial fees. KEY CONCLUSIONS AND IMPLICATION FOR PRACTICE: The mothers' perspective of postpartum revealed that they actively searched for ways to attain infants' and own health needs, and family health in general. Prolonged sexual abstinence was considered a risk for the partner having other sexual partners and contracting HIV. The mothers relied heavily on the informal support network, which sometimes meant risking family health due to misinformation and harmful practices. Health care and informal support systems should complement each other to attain adequate support for the families postpartum.

Extra-marital sexual partnerships and male friendships in rural Malawi

Extra-marital sexual partnerships (EMSPs) are a major route of HIV/AIDS transmission in sub-Saharan Africa. In this paper, we investigate the roles of two types of male friendships - best friends and friends with whom they talk about AIDS - in determining whether men have EMSPs. Using data from men in rural Malawi, we find that men's current extra-marital sexual behavior is most closely correlated with their best friends', but that the behaviors of both types of friends are associated with men's subsequent EMSPs. These findings suggest that men's friendships could be used to help combat the AIDS epidemic.

From prenatal HIV testing of the mother to prevention of sexual HIV transmission within the couple

The first step in preventing mother-to-child HIV transmission (PMTCT) programmes is offering HIV counselling and testing to pregnant women. In developing countries where HIV testing remains rare, it represents a unique opportunity for many women to learn their HIV status. This prenatal HIV testing is not only the entry point to prevention of mother-to-child HIV transmission, but also an occasion for women to sensitize their male partner to sexual risks. Here we explore if these women, HIV-tested as mothers, apply the prevention recommendations they also receive as women. In the Ditrame Plus PMTCT program in Abidjan, Côte d'Ivoire, two cohorts of women (475 HIV-infected women and 400 HIV-negative women) were followed up two years after the pregnancy when they were offered prenatal HIV testing. In each cohort, we compared the proportion of women who communicated with their regular partner on sexual risks, prior to and after prenatal HIV testing. We analysed socio-demographic factors related to this communication. We measured two potential conjugal outcomes of women HIV testing: the level of condom use at sex resumption after delivery and the risk of union break-up. Prenatal HIV testing increased conjugal communication regarding sexual risks, whatever the woman's serostatus. This communication was less frequent for women in a polygamous union or not residing with their partner. Around 30% of women systematically used condoms at sex resumption. Among HIV infected ones, conjugal talk on sexual risks was related to improved condom use. After HIV testing, more HIV-infected women separated from their partners than HIV-uninfected women, despite very few negative reactions from the notified partners. In conclusion, offering prenatal HIV counselling and testing is an efficient tool for sensitizing women and their partners to HIV prevention. But sexual prevention in a conjugal context remains difficult and need to be specifically addressed.

Beneficial effects of offering prenatal HIV counselling and testing on developing a HIV preventive attitude among couples. Abidjan, 2002-2005

Prenatal HIV counselling and testing is mainly an entry-point to the prevention of mother-to-child transmission of HIV, but it may also play an important role in triggering the development of spousal communication about HIV and sexual risks and thus the adoption of a preventive attitude. In Abidjan, Côte d'Ivoire, we investigated couple communication on STIs and HIV, male partner HIV-testing and condom use at sex resumption after delivery among three groups of pregnant women who were offered prenatal counselling and HIV testing: HIV-infected women, uninfected women, and women who refused HIV-testing. The proportion of women who discussed STIs with their regular partner greatly increased after prenatal HIV counselling and testing in all three groups, irrespective of the women's serostatus and even in the case of test refusal. Spousal communication was related to more frequent male partner HIV-testing and condom use. Prenatal HIV counselling and testing proposal appears to be an efficient tool to sensitize women and their partner to safer sexual practices.

Prevalence of and factors associated with extramarital sex among Nigerian men

This study used data on currently married and cohabiting men aged 15 to 64 years from the 2003 Nigeria Demographic and Health Survey to examine the prevalence of and factors associated with extramarital sex. The results show that 16% engaged in extramarital sex in the 12 months preceding the survey and had an average of 1.82 partners. The results also show statistically significant association between extramarital sex and ethnicity, religion, age, age at sexual debut, education, occupation, and place of residence. Based on the study results, it could be concluded that significant proportions of Nigerians are exposed to HIV infection through extramarital sex. A fundamental behavioral change expected in the era of HIV/AIDS is the inculcation of marital fidelity and emotional bonding between marital partners. The promotion of condom use among married couples should be intensified to protect women, a large number of whom are exposed to HIV infection from their spouses who engage in unprotected extramarital sex. And, because of gender-based power imbalances within the family, a large number of the women are unable to negotiate consistent condom use by their partners.

Polygyny and HIV in Malawi

We review the relationship between polygyny and HIV and identify a positive individual-level correlation, and a negative ecological correlation. We subsequently examine two mechanisms that contribute to the individual-level correlation. First, we find that men in polygynous marriages have more extramarital sex than men in monogamous unions (both in terms of self reports and in terms of spousal reports of the suspicion of adultery). Second, we find evidence of adverse selection of HIV positive women into polygynous unions via an investigation of the relationship between marriage order and polygyny status. We conclude with reflections about possible explanations for the distinct individual and ecological correlations.

Marital strategies for regulating exposure to HIV

In a setting where the transmission of HIV occurs primarily through heterosexual contact and where no cure or vaccine is available, behavioral change is imperative for containing the epidemic. Abstinence, faithfulness, and condom use most often receive attention in this regard. In contrast, this article treats marriage as a resource for HIV risk management via mechanisms of positive selection (partner choice) and negative selection (divorce of an adulterous spouse). Retrospective marriage histories and panel data provide the evidence for this study and results indicate that men and women in Malawi increasingly turned to union-based risk-avoidance strategies during the period that the threat of HIV/AIDS materialized. Although both sexes strategize in a similar fashion, men are better equipped than women to deploy these strategies to their advantage. The article concludes with reflections on the long-term and population-level implications of these coping mechanisms.

Determinants of Zambian men's extra-marital sex: a multi-level analysis

Research interest in extra-marital sex has increased as scholars have become aware of its role in sustaining epidemics of STDs in sub-Saharan Africa and elsewhere. While most research has used the socioeconomic and demographic features of individuals as determinants of extra-marital sexual behavior, this study examined the role played by community characteristics. Using data from the 2003 Zambian Sexual Behavior Survey for a sample of 1,118 men aged 15-59 and multilevel logistic regression techniques, the study analyzed the effects of community social and demographic characteristics on involvement in extra-marital sex while controlling for the men's individual-level characteristics. Men's involvement in extra-marital sex was found to vary with the characteristics of communities. The chances of men's involvement in extra-marital sex increased with community-level ethnic heterogeneity and urbanization, decreased in commercial centers, and in communities with a demographic surplus of males, health workers active in AIDS prevention, and access to the mass media. These results show that scholars trying to understand the motivations for extra-marital sex must pay attention to the characteristics of both individuals and communities.

Economic Status, Informal Exchange, and Sexual Risk in Kisumu, Kenya

Many observers believe that wealthy men play a disproportionate role in the continuing spread of HIV/AIDS infection in sub-Saharan Africa through their involvement in informal exchange relationships, where money and gifts (referred to as "transfers") are given to a range of nonmarital sexual partners. In this case, wealthier men are riskier sexual partners because they can afford to give larger transfers, which have been found to be negatively associated with condom use. Alternatively, wealthier men might have greater incentives to practice safe sex at later stages of the epidemic or wealthier men might match with female partners who have particularly strong preferences for condom use. Accordingly, economic status would be positively associated with condom use. We use survey data from urban Kisumu, Kenya, to investigate the various mechanisms through which economic status is associated with sexual risk behavior. Our results show that wealth is positively associated with transfers; wealth is uncorrelated with condom use, however. The characteristics of wealthier men's female partners also do not differ from the characteristics of poorer men's partners. We conclude that wealthier men have stronger preferences for condom use, which offsets the negative effect of larger transfers that they give to their sexual partners.

Adoption of safer infant feeding and postpartum sexual practices and their relationship to maternal HIV status and risk of acquiring HIV in Zimbabwe

OBJECTIVE

To examine the relationships between maternal knowledge and concern about HIV status, adoption of preventive practices and risk of acquiring HIV in Zimbabwe.

METHODS

Knowledge and behavioural data were collected via interview from 2595 mothers enrolled in ZVITAMBO, a randomized trial of postpartum vitamin A supplementation that also offered education on safer infant feeding and sexual practices. Mothers were tested for HIV at delivery; those uninfected at baseline were retested during study follow-up. Logistic regression methods were used to identify variables associated with adoption of preventive behaviours and, for HIV-negative mothers, their relationship to risk of acquiring HIV post-delivery.

RESULTS

A total of 518 mothers (20%) reported practicing safer sex and 289 mothers (11%) reported modifying their feeding behaviour because of HIV. Fear of transmitting HIV (50.4%) and protecting the baby's health (30.9%) were the most frequently cited reasons for behaviour change. Forty-nine HIV-negative mothers acquired HIV during the first postpartum year. After taking into account other significant covariates, mothers who were concerned about their own HIV status were 1.9 times more likely (95% CI: 1.05-3.52; P = 0.03), and those reporting safer sex practices were 58% less likely to become infected (adjusted odds ratio: 0.42; 95% CI: 0.17-1.04; P = 0.06). Married women who reported practicing abstinence to prevent HIV were 3.2 times more likely to become infected than non-abstaining mothers (P = 0.01), while there were no new HIV infections among abstaining single mothers.

CONCLUSIONS

Greater emphasis should be given to safer sex practices among women who test negative in mother-to-child HIV prevention programmes.

The potential impact of antiretroviral therapy on fertility in sub-Saharan Africa

Approximately 14 million women of child-bearing age are living with HIV/AIDS in sub-Saharan Africa. Women with HIV infection have between 25% and 40% lower fertility than noninfected women. As antiretroviral (ARV) therapy becomes increasingly accessible in sub-Saharan Africa, it is important to understand whether and how the associated clinical improvements correspond with changes in the incidence of pregnancy and fertility. Accordingly, this paper reviews the literature on the potential impact of ARV therapy on the fertility of women with HIV infection in sub-Saharan Africa. We use Bongaarts' proximate determinants of fertility framework (adapted for conditions of a generalized HIV epidemic) to examine the underlying mechanisms through which use of ARV therapy may impact the fertility of women with HIV infection. A conceptual framework is proposed to guide future research aimed at understanding how widespread use of ARV therapy may impact fertility in sub-Saharan Africa.

Extramarital sex among Nigerian men: polygyny and other risk factors

The AIDS epidemic in Nigeria is generalized, with infection primarily occurring through heterosexual transmission. It is important to understand patterns of sexual behavior to assess their impact on the epidemic and to design appropriate intervention strategies. This study examined risk factors for extramarital sex among Nigerian men, with a particular focus on polygyny and peri- and postpartum abstinence. Data from the 2003 Nigeria Demographic and Health Survey were analyzed for 1153 men and their wives. Eleven percent of men reported extramarital sex in the previous year. Logistic regression models showed that men with 3 or more wives were at the greatest risk for extramarital sex, followed by monogamous men, when compared with men with 2 wives. Other significant predictors included region, religion, wealth, age at sexual debut, and self-perceived risk of HIV infection. Peri- and postpartum abstinence was not significant. Based on these findings, HIV prevention programs should include men with 3 or more wives and those living in the southwest region, in addition to activities targeting men of all ages. Given the heterogeneity within Nigeria, further in-depth studies should be undertaken to explore the relation between number of wives, peri- and postpartum abstinence, and extramarital sex within specific communities.

Resumption of Sexual Relations Following Childbirth: Norms, Practices and Reproductive Health Issues in Abidjan, Côte d'Ivoire

Before modern contraceptive methods were available in developing countries, post-partum sexual abstinence formed the backbone of birth spacing. With the changes occurring in African societies, how has post-partum sexual abstinence been affected? We conducted an exploratory study in 2000-2001 in Abidjan, Côte d'Ivoire with 23 women and 19 men who were parents of small children. Breastfeeding remains widespread and prolonged. Resumption of sexual relations after delivery was a mean of 11 months. Post-partum sexual abstinence was only distantly related to the traditional lactation taboo. Women expressed fears that their partner would seek elsewhere if they delayed sexual relations too long, and the risk of early pregnancy. Abstinence remained the main way to space births, given low contraceptive use. Mothers generally decided when to wean a child. Men usually made the first move to resume sexual relations, though most women negotiated timing and some insisted on condom use. Provision of condoms post-partum can play a contraceptive role for married couples and protect against STIs/HIV in extra-marital relationships, which are frequent post-partum. The duration of post-partum abstinence is in fact unclear because irregular sex may happen early and become regular only later. Women need post-partum information and services that address these issues.

Ethnic variations in observance and rationale for postpartum sexual abstinence in Malawi

Using quantitative and qualitative data from three culturally heterogeneous ethnic groups in Malawi, I show that differences in postpartum sexual abstinence are closely associated with community-specific rationales for the practice, particularly differences in the definition and timing of child-strengthening rituals that couples are required to perform before resuming intercourse. Contrary to conventional wisdom, the primary rationale for abstinence in the study areas is not linked to child spacing. Among Tumbukas in the north, most women perform the ritual immediately after resuming menstruation. Among the other ethnic groups, the rituals can be performed at any time after the end of postpartum bleeding. The study underscores the utility of the complementary micro-level approach in understanding reproductive behavior in sub-Saharan Africa.

The link between postnatal abstinence and extramarital sex in Côte d'Ivoire

Whether the link, found in Benin, between postnatal abstinence and husbands' extramarital contacts can be generalized to other West African countries is assessed in this study. Data from the 1994 Demographic and Health Survey, Côte d'Ivoire, obtained from monogamous husbands concerning their extramarital sexual behavior in the two months preceding the survey were linked to data reported by wives concerning postnatal abstinence over the same time period. Logistic regression was applied to assess the link between these two factors, net of the effects of possible confounders. A significant effect of postnatal abstinence on the probability that the husband reported at least one extramarital partner was found. Unprotected extramarital sex was two times more common among men who observed conjugal abstinence than it was among other men. Other predictors of extramarital sex were urban-rural residence, region, education, and whether or not husband and wife had the same religious affiliation. Because condom use is low in this population, the protective effect of marital abstinence is offset by an increased probability that husbands will seek extramarital partners during the postpartum period. The results confirm the earlier findings for Benin and can likely be generalized to most of West Africa.

Is fertility declining in Benin?

This study analyzes reproductive changes in Benin, a West African country with high fertility and low prevalence of use of modern contraceptive methods, using a combination of quantitative and qualitative approaches. Findings indicate that an irreversible fertility transition has started as the result of an emerging pattern of birth limitation and continued desire for the traditional long birth intervals. The data suggest that changes in childhood mortality in combination with an increase in women's education, although modest, have created a demand for fertility control among women; that induced abortion may be one of the means through which such demand is being met, particularly in urban areas; and that the economic crisis of the 1980s was the main catalyst that precipitated the onset of transition. Changes in reproductive preferences and practice suggest a diffusion process, from urban and more educated women to rural and less-educated ones.

Who's at risk? Men's STD experience and condom use in southwest Nigeria

Many STD/HIV-prevention programs worldwide assume that individuals' risk of acquiring sexually transmitted diseases, including HIV infection, is highest in the context of commercial sex. To address this assumption, research conducted in urban Southwest Nigeria combined qualitative and quantitative methods to examine men's sexual behavior, condom use, and STD experience in different types of sexual relationships (marital, casual, and commercial). Logistic regression analysis of survey data indicates that number of sexual partners and sex with sex workers are positively and significantly related to STD experience. Follow-up in-depth interviews with clients of sex workers indicate, however, that these men are actually more likely to report having contracted an STD from a casual sex partner than from a sex worker. Men are most uncertain about their vulnerability to STDs with casual partners. Men's condom use is highest in commercial sex, inconsistent in casual relationships, and lowest in marriage. STD/HIV-prevention programs need to address the range of sexual relationships and the meanings and behaviors associated with them.