Reproductive Decision Making among Couples with HIV/AIDS in Taiwan
Nai-Ying Ko, RN Ph.D.
Department of Nursing
National Cheng Kung University
Research Background
Global perspectives Women of reproductive age constitute
one of the fastest growing groups being diagnosed with HIV/AIDS. By the end of 2002, 19.2 million women
were living with HIV/AIDS Eighty percent of women with HIV
infection are of childbearing age 2.5 million of the 200 million pregnant
women each year are HIV positive
AIDS Epidemic in Taiwan At the end of 2002, 4,373 cases with HIV/AIDS
had been reported. MSM and heterosexual contacts are two major
routes of transmission The male-to-female ratio of AIDS decreased
from 41:1 in 1989 to 11:1 in 2002 Over 56% of them are 20-39 years old Over 80% of the 318 HIV positive women were
infected through their male partners. Free HAART treatment and health care
Significances of The Study Few studies of reproductive health have included
male participants. The role that gender-based power relationships
play in the process of reproductive decision-making has been neglected
Relatively few studies have explored how the societal, cultural, and professional institutions have constructed couples’ reproductive decisions.
Limited literature from Taiwan has addressed reproductive health issues of people with HIV/AIDS.
Purpose of The Study
The purpose of the proposed study is to explore the gender-based power relationships, and social and cultural influences on reproductive decision-making among heterosexual couples with HIV/AIDS in Taiwan.
Specific Aims 1. Describe reproductive health among couples
with HIV/AIDS in the past year 2. Explore gender-based power relationships
between intimate partners and explore their influence on making reproductive decisions among couples with HIV/AIDS in Taiwan.
3. Explore political, social and cultural perspectives on reproductive decisions of couples with HIV/AIDS in Taiwan society.
Methodology
Feminist Ethnography Ethnography emphasizes interaction, and
explores how the subject’s experiences are constituted in social context.
Visweswaran (1997) defined feminist ethnography as ethnography that foregrounds the question of social inequality vis-à-vis the lives of men, women, and children.
Gender and power are the central realm for feminist ethnographic analysis.
Critical Discourse Analysis Critical discourse analysis sees discourse- language
use in speech and writing- as a form of ‘social practice’.
Discourse as social practice implies a dialectical relationship between a particular discursive event and the situation(s), institution(s), and social structure(s) which frame it. (Fairclough & Wodak, 1997)
Action, context, power and ideology are the central aims for critical discourse analysis.
Selecting fields and settings
The proposed study was conducted in Southern Taiwan, including the two metropolitan cities Tainan and Kaohsiung.
Research settings include the participants home, governmental agencies, AIDS clinics, and NGOs
Participants Fourteen heterosexual couples with HIV/AIDS
at least one partner is HIV positive female partner is between 20 and 45 of age both of partners have been informed of each
other’s HIV status by their healthcare providers. were confronting or having confronted
reproductive decisions during HIV disease trajectory
be able to communicate comfortably in Mandarin, Taiwanese dialect, or English.
Profiles of Couples with HIV Age: Male: 26-47 ; Female: 24-45 (3 foreign brides) Education: all above junior high school Marriage year: six months to 20 years HIV status : 7 HIV concordant and 7 HIV discordant
couples (All male participants are HIV positive) Time of HIV+: one month to eleven years Children: 7 couples with children (5 month to 20 years
old)
Profiles of Health Professionals Eleven healthcare and social services providers, and
policy makers 4 physicians, 1 head nurse, 1 social worker, 3 AIDS
NGO representatives 2 governmental representatives from Taiwan CDC
Ages ranged from 26 to 45 years (mean = 32 years). The working years for caring PLWHA ranged from 4
to 15 years (mean = 10.6 years).
Ethnographic Data CollectionRecruitment I (e)mailed a written explanation of this study to
healthcare/service providers and wait for their initiative to contact me.
I asked healthcare/service providers to refer eligible couples to me.
Obtained written Informed consent
Strategies for data collection Interview (individual and couple), participant observations,
and examination of available related documents
Data Analysis Ethnographic analysis procedures
Reading thoughtfully, coding and memoing, categorizing and sorting for patterns, constructing storytelling and applying theories. (Emerson, Fretz, & Shaw, 1995; D. Fetterman, 1998; Hammersley & Atkinson, 1995)
Critical discourse analysis followed the outlined by Fairlough (1992, 2001) Description, interpretation and explanation
The rigor of this study was examined using six criteria offered by Muecke (1994).
Findings
Reproductive Health of HIV Couples History of pregnancy & abortion
8 couples were parents or parents-to-be (1-4 children) 5 female partners never become pregnant 4 female partners had received abortions
Family Planning Desired number of children: one boy and one girl Contraception: oral pills, IDU, rhythm and withdrawal
methods, vasectomy and condom Condom: inconsistently use of condoms among four of
nine sexual active couples Sexual behaviors and relationships
9 couples are sexually active, secrecy of MSM
The stage of Family DevelopmentMarried couple(no children)
Childbearing families &Families with preschoolchildren (oldest childaged birth to 7 years)
Families withteenagers (oldestchild aged 13 to 20years)
Number of couples 6 6* 2HIV status (7:7)(concordant : discordant)
2: 4 5: 1 0: 2
Number of children incurrent marriage(range)
0 1-2 2-4
Plan to have one or morechildren(concordant : discordant)
4(1:3)
2(2:0)
0
Sexually active 4 4 1Having unprotected sex inthe past year**
2 2 0
Drawing an Picture of Ideal Family Reasoning for having children
Performance of filial piety A goal to pursue within the context of an intimate
relationship HIV impacts on childbearing plan
The stage of family development Couples’ HIV status and health conditions
Childbearing in not couple’s own affair Couples’ aged parents, either maternal or fatherly
family, concerned childbearing issues most Additional pressures came from couples’ neighbors,
colleagues or closed friends.
Reproductive Decisions Making Process
Decisions of planning or continuing childbearing
Encountering medical systems Searching for information Weighting the risk-benefit of childbearing
Decisions of Childbearing Plan Gendered based power relationship is exercised
in the dynamics of decision-making Only two couple discussed their childbearing plan
with each others Husbands have the final word
The considerations between two partners were different Men seemed to have a plan in minds and their
decisions remained static Women’s decisions fluctuated over time
Discourses of Health Professionals
Three prevailing discourses on the childbearing issues regarding couples with HIV/AIDS pro-children conditional pro-choice pro-rights
Encountering Medical Systems Once entering the medical systems, couples’
reproductive decisions were strongly influenced by health authority
The timing of diagnosis of HIV is a critical point to recognize couples’ reproductive health issues Reproductive health problems was easily to be
ignored Couples’HIV Status
Searching for Information Children’s health was the primarily concern for all
couples with HIV Information needs
effects of HIV infection and antiretroviral therapy on their pregnancies, labor, delivery and baby’s well-being
possible options regarding childbearing plans, and about likelihood of different outcomes among different options
Information sources healthcare providers, family members who knew their
HIV status, websites, newspaper, and reference books for parents-to-be
Weighting the risk-benefit Estimation of mother-to-child
transmission Psychosocial readiness for continuing
childbearing plan Perceived supports from family members Perceived supports from medical systems
Conclusion
Confucian influence of filial piety and son preference has continued to transcend couples’ reproductive decision-making
Men are the primary decision-makers about family planning, contraceptive use, and sexual activity.
Couples’ reproductive health was easily to be neglected unless they were diagnosed with HIV during pregnancy
HIV infection is not the sole determinate of couples’ reproductive decisions
Study Limitations A small sample size and a selected sample The validity of qualitative analysis The selective retention of information Memory retention after decisions had been
made
Future Implications Clinical practice
• Health policy and recommendations• Infertility treatment and services for HIV discordant couples• Comprehensive and gender-sensitive care plan
Research• The feasibility and safety of conducting ART• Couples’ reproductive health and the services they had received• Health professionals’ attitudes toward reproduction health and
services they had provided• Factors influencing healthcare providers’ knowledge, attitudes,
and practices