1. Unplanned pregnancy in the 2011 Botswana Antenatal Clinic Sentinel Surveillance A.C. Voetsch, M.G. Anderson, E. Machakaire, S. Bodika, W. Jimbo, B.P. Yadav, M. Schann, T. Madidimalo, R. Lebelonyane AIDS 2012 - Turning the Tide Together

2. Outline Background – Reproductive health in Botswana – Botswana PMTCT program 2011 Botswana Antenatal Clinic Survey Unplanned pregnancy question analysis Recommendations/Next steps

3. Population = 2.1 million Middle income country Per capita GDP = $16,300 Adult HIV prevalence = 25% 300,000 PLWH Background

4. Reproductive health in Botswana Fertility rate3.2 Annual birth rate22 births/1,000 Antenatal care visits95% Skilled antenatal clinic provider94% Delivery in a health care facility94% Skilled provider at delivery 95% Outcomes Maternal mortality190/100,000 live births Infant mortality 57/1,000 live births

5. Botswana PMTCT program 2011 Pregnant women43,828 Tested for HIV and knew result 97% Tested HIV positive 30.6% Received ARVs to prevent MTCT93% HIV-exposed infants Tested for HIV 91% Tested positive for HIV <4%

6. Four prong approach 1. Primary prevention 2. Prevent unintended pregnancies 3. Prevent vertical transmission 4. Link to care, treatment, follow-up

7. Knowledge and current use of contraceptives Contraceptive methodKnowledgeCurrent use Condom96.5%41.7% Pill87.8%6.1% Injection87.1%6.8% IUD75.0%0.8% Female sterilization61.5%2.1% Periodic abstinence55.2%1.8% Male sterilization52.7%0.1% Withdrawal52.4%0.6% Diaphragm51.7%0.6% Other4.1%0.2%

8. ANC Sentinel Surveillance August 1 through October 28, 2011 262 selected antenatal clinics All 24 health districts Pregnant women aged 15–49 years First presentation One-page surveillance form Demographic information Gravidity HIV testing history Planned pregnancy (“Was this pregnancy planned?”)

9. Results 7209 eligible women 6745 (94%) women surveyed and tested Adjusted national HIV prevalence = 30.4% Prevalence varied by district and age

10. Age-specific HIV prevalence Age group (years)

11. HIV prevalence by district

12. Results 6667 (99%) answered planned pregnancy question 3383 (51%) current pregnancy was unplanned Highest among women 15-19 years (68%) and 40-49 years (67%) 4 or more pregnancies (67%) Divorced, widowed, separated (60%) Primary school education (61%) HIV-positive (56%)

13. Unplanned pregnancy by age and HIV status

14. Multivariable model CharacteristicAdjusted odds ratio95% confidence interval Unmarried2.171.81–2.60 Two or more previous pregnancies1.831.60–2.10 HIV-positive1.731.51–1.99 Unemployed1.291.15–1.44 Logistic regression model adjusted for linear and quadratic effects of age and for health district

15. Conclusions Gap between contraceptive knowledge and use Half of women in ANC survey reported unplanned pregnancy Both HIV-positive and HIV-negative women Younger/older, less educated, unmarried

16. Recommendations Strengthen HIV/Sexual Reproductive Health linkages Dual protection Guidance for women who want to become pregnant Target family planning services Improve supply chain for contraceptives

17. Next steps European Union grant UNFPA national coordinator Pilot co-location in 3 districts PEPFAR Education materials/flip charts Male/youth friendly services Supply chain

18. Acknowledgments Staff from the 262 clinics who collected the data 6745 pregnant women in the 2011 ANC survey This research has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention under the terms of grant number 5U62PS025095-05.

19. Ke a leboga (Thank you) The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.