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