World Journal of AIDS, 2011, 1, 198-207
doi:10.4236/wja.2011.14029 Published Online December 2011 (
Copyright © 2011 SciRes. WJA
Determinants of Fertility Desires among HIV
Positive Women Living in the Western Highlands
Province of Papua New Guinea
Marie Lucy Aska, Jiraporn Chompikul*, Boonyong Keiwkarnka
ASEAN Institute for Health Development, Mahidol University, Salaya, Thailand.
E-mail: *
Received July 22nd, 2011; revised September 29th, 2011; accepted October 11th, 2011.
The objective of this study was to identify determinants of fertility d esires in HIV positive women living in the Western
Highlands Province, Papua New Guinea, a male-dominated, patrimonial society. A cross-sectional study was con-
ducted to collect data in February, 2010. Two hundred and ninety one HIV-infected women participated in personal
interviews using a structured questionnaire. Sixty-six percent of the respondents were in polygamous relationships.
Thirty-four percent of the participants desired a child in the future. Chi-square tests revealed that variables associated
with desire for a child were age, marital status, number of children, current co-habitation with a partner, duration of
time with a partner, receipt of the bride price, domestic physical violence, sexual activity in the previous th ree months,
partners desire for a child, and current contraceptive use. Using multiple logistic regression, a partners positive de-
sire for a child was th e strongest predictor, with an odds ratio of 13.04 (95% CI = 5.68 - 29.91). Fertility desires were
largely influenced by dominant culturally sensitive issues and the family-oriented culture. The integration of effective
counseling and reproductive health care service into HIV clinics is recomm ended. Holistic , culturally-relevant and fam-
ily-oriented reproductive health counseling should provide more positive outcomes for both HIV-infected women and
their children.
Keywords: Fertility Desires, HIV Positive Women, Papua New Guinea, Reproducti v e H ea lth, Patrimonial Society
1. Introduction
As HIV treatment has become more widely available and
improved the life expectancy and overall health of HIV
positive men and women, there is an increasing need to
understand the reproductive desires and sexual behavior
of women living with HIV/AIDS. Women of reproduc-
tive age constitute one of the fastest growing and largest
groups infected with HIV/AIDS according to UNAIDS
[1,2]. Of the 14,000 infections per day worldwide, 1600
are through vertical transmission, that is, from mother to
child transmission of HIV [3]. In the past, pregnancy has
been discouraged among women living with HIV/AIDS
(WLWHA) because of ethical and clinical concerns about
vertical transmission and maternal health [4]. However,
more recently, as HIV treatment has improved and be-
come more widely available, there is interest in the re-
productive desires and sexual behavior of WLWHA.
Antiretroviral therapy (ART) is one reason people living
with HIV/AIDS (PLWHA) in Nigeria have reconsidered
or resumed sexual relationships and childbearing [5].
Vertical transmission has been reduced by the introduc-
tion of Zidovudine proph ylaxis [6,7 ] an d through electiv e
caesarean section [8]. Though not available in Papua
New Guinea (PNG), advanced western medical technol-
ogy, including assisted techniques such as artificial in-
semination and in vitro fertilization (IVF), have also re-
duced the risk of horizontal transmission [9,10]. More-
over, mentors like Amnesty International and the Inter-
national Community of Women Living with HIV/AIDS
have promoted human rights and fundamental freedoms,
especially in the areas of sexual and reproductive rights,
addressing the reproductive health care needs of WLWHA
These medical advances and ART are not widely
available in all provinces in PNG, and are therefore inef-
fective in reducing the childbearing risks faced by
WLWHA in this region. Because of the strong family
oriented cu lture and the cultural expectations fo r women,
Determinants of Fertility Desires among HIV Positive Women Living in the Western Highlands 199
Province of Papua New Guinea
this makes it increasingly important to address the issue
of reproductive counseling and management for HIV
individuals during their reproductive years. It is also im-
portant to determine factors related to fertility desires.
Psychosocial, cultural and medical factors greatly influ-
ence the reproductive decisions of WLWHA [13]. How-
ever, no such study has been carried out in PNG which
may have unique cultural and social traditions, not often
encountered in other countries.
In the United States of America (USA), HIV infected
women are put in a difficult position when it comes to
reproductive decisions [14]. WLWHA struggle to decide
between their personal desires and socio-cultural expec-
tations concerning fertility, wh ile simultaneo usly fighting
psychological condemnation and stigmatization regard-
ing HIV infection, pregnancy and fear of vertical trans-
mission [14,15]. Despite this dilemma, studies have
shown that WLWHA still express their desires to bear
children even after learning their status [15-21]. In Nige-
ria, wh ere marri age and famil y are impo rtant, res earch in
2007 indicated that PLWHA whose health has been re-
stored by ART have strong desires for marriage and
children. This poses a very real and practical danger as
public health messages and infection preventative meas-
ures clash with social expectations [5].
PNG is known as one of the world’s most culturally
diverse countries. Eighty-seven percent of the population
lives in rural areas with little access to basic health care
services due to the difficult terrain. PNG is a male domi-
nated society with strong cultural practices [22]. Gender
inequities, sexual violence and social acceptance of vio-
lence against women in PNG have been identified as
major factors contributing to the rapid spread of HIV/
AIDS in the country [23].
PNG has one of the highest HIV prevalence of 1.28%
in 2008 in the Pacific region with heterosexual sexual
intercourse being the most common mode of transmis-
sion [24-25]. Infection in females is highest in younger
women aged 19 to 29, at the peak of their reproductive
lives [25]. Reproductive decisions in PNG are further
complicated by social issues and the traditional practices
of paying a bride price and polygamous marriages [26].
Antiretroviral therapy (ART) and prevention of mother to
child transmission (PMTCT) services are currently bein g
implemented across the country, now in their fifth year
[27]. It has been observed that HIV positive women are
becoming pregnant. Therefore, there is ample need for
this study in the country; it may establish a baseline for
preventio n of mother-to- child HIV infection. As it is be-
coming increasingly important to address the issue of
reproductive counseling and management for HIV indi-
viduals during their reproductive years, it is also impor-
tant to understand the issues and factors related to their
fertility desire. This study, therefore, identifies factors
associated with the fertility desires of WLWHA in the
Western Highlands Province (WHP) of PNG as they face
the challenges of living with HIV infection in a strongly
male dominated culture.
2. Materials and Methods
2.1. Study Design and Study Sites
This was a cross-sectional descriptive study conducted in
February 2010. The study took place in the WHP of PNG,
where HI V p revalence was high [25].
2.2. Target Population
The target population was women aged 18 to 45 years
old who had been confirmed as HIV positive using blood
tests at the Tininga or Rebiamul Clinics at least three
months prior to the interview, and who were residing in
the WHP. Sexual and marriage traditions are similar
throughout the Highlands region [26]. Women were ex-
cluded from the study if they were single, had HIV stage
3 or 4 at the time of interview, had a history of or current
psychiatric problems, or had a history of tubal ligation or
hysterectomy. The exclusion of women at HIV stages 3
and 4 from the study was due to medical concerns that
such women would be too sick to be interviewed and
also because, at those stages, they could be distracted and
be unable to complete the interview completely. Women
younger than 18 years were excluded because of con-
cerns about guardians’ permission and disclosure of their
HIV status.
2.3. Data Collection Methods and Tools
Participation was voluntary; participants were recruited
during follow-up visits to the clinics on their appoint-
ment dates, and after the purpose of the study had been
made known in the clinics. Those who volunteered were
given further information in a private room in one of the
clinics, where a consent form was signed and interviews
were conducted by a trained and experienced interviewer.
Interviews lasted 15 to 20 minutes. Because the lead au-
thor was also the principal researcher and interviewer
and had had extensive experience working as a medical
practitioner in the two clinics for over 2 years, a strong
degree of mutual trust and respect had been developed
with most of the participants. There was, in fact, no re-
luctance or prevarication on their part in answering the
questions posed.
A structured questionnaire was used to collect data. It
was designed to elicit information about participants’
demographical background, relationship status, psycho-
Copyright © 2011 SciRes. WJA
Determinants of Fertility Desires among HIV Positive Women Living in the Western Highlands
200 Province of Papua New Guinea
social factors, medical factors, and fertility desires. Psy-
chosocial factors included experience of domestic vio-
lence, sexual activity in the previous three months, sex-
ual assault in the relationship, payment of the br ide price,
and disclosure of status. Medical factors included ART
status and duration of treatment, time since HIV diagno-
sis, clinical stage for HIV at the time of diagnosis,
knowledge regarding prevention of mother to child
transmission (PMTCT), contraceptive use, and accessi-
bility and efficacy of the reproductive services provided
in the clinics.
Fertility desires is defined as a psychological state in
which someone has the personal motivation to have a
child. Such motivatio n represents the first step towards a
decision to act, typically followed by an intention to do
so [28-29]. One question in the structured interview in
particular asked about fertility desires: “What best de-
scribes your thinking about having a child in the near
future?”. Respondents could answer: 1) “I want a child in
the near future”; 2) “I am unsure or undecided now”; 3)
“I have decided that I do not want to have a child in the
future”. Additional open-ended questions were asked
about the reasons for their particular fertility desire
choice, and the results were grouped into main themes,
and used to sup port the findings obtained from the stat is-
tical analysis.
Five questions were asked about PMTCT. For a possi-
ble maximum score of five; correct answers scored 1
while incorrect or unsure answers scored 0. Using Bl-
oom’s criteria, a total score of 80% or more indicated
good knowledge; 60% - 80% indicated moderate knowl-
edge; and a score of less than 60% indicated poor
knowledge. Before data collection, the questionnaire was
pretested on a group of 30 HIV positive women aged 18
to 45 years from a HIV clinic in the WHP of PNG. The
reliability of the questions regarding PMTCT, using the
Kuder-Richardson Formula 20 (KR-20), was 0.5.
2.4. Ethical Aspects
The study proposal was approved by the Mahidol Uni-
versity Institutional Review Board and also by the PNG
National AIDS Council Secretariat Research Advisory
Committee. All participants were informed of the objec-
tives of the study and of their right to choose to partici-
pate or not and of th eir righ t to leav e th e study at anyti me
they wished. The purpose of the study was explained to
all participants before informed written consents were
obtained. Women who could not read or write had the
consent read and explained to them; those volunteering
to participate made a mark on the consent form with their
right index fingers as a sign of their willingness to par-
ticipate. Data were kept strictly confidential.
2.5. Data Analysis
Data were analyzed using Minitab; results have been
analyzed with descriptive statistics and inferential statis-
tics, using Chi-square tests and multiple logistic regres-
sion. The confidence interval was set at 95% and the
p-value was <0.05 for a significant association. Re-
sponses to the open-ended questions indicated why par-
ticipants had a positiv e or negative desire for a ch ild. The
reasons were then grouped into main theme areas; some
representative quotes are presented to illustrate their re-
3. Results
A total of 296 HIV positive women were interviewed.
Five did not meet the criteria (two were single, two had a
history of tubal ligation and one was not from the High-
lands provinces of interest in this study). Therefore, the
final sample size used for analysis was 291.
3.1. Reasons for and against Fertility Desires
Out of the 291 participants, 34% desired a child, 59%
had no desire for a child and 7% were unsure or unde-
cided about whether they wanted a child in the near fu-
ture or not, as shown in Table 1. The participants in this
study offered a co mplex range of reasons for and against
having a child. The most common reasons given for not
having a child were related to medical concerns. Some
respondents feared infecting a new partner (31%); some
feared of infecting the child (23%) and some were con-
cerned about the det eri o rat i o n of their o wn heal t h (2 5%).
Reasons for a positive desire for a child seemed to be
more socially and culturally oriented. The most common
reasons for wanting a child were that the participants
wanted someone to replace them (35%), followed by
their desir e for protection and suppor t in old age (22%).
3.2. Socio-Demographic, Medical and
Psychosocial Characteristics
Table 2 shows most participants were aged 26 - 35 years,
were in polygamous marriages, and were subsistence
farmers with very low incomes. Forty percent were
childless. Table 3 shows most patients had AIDS when
they were first diagnosed, had received ART for over 18
months and had a fair degree of knowledge about
PMTCT. Table 4 shows 45% of patients had been the
subject of bride price payments in their marriages; 54%
had experienced domestic physical assault; 52% had ex-
perienced sexual violence in their marriages; and 42%
were sexually active.
3.3. Factors Associated with Fertility Desires
Chi-squ are tests indic ated age, numb er of children, mari-
Copyright © 2011 SciRes. WJA
Determinants of Fertility Desires among HIV Positive Women Living in the Western Highlands
Province of Papua New Guinea
Copyright © 2011 SciRes. WJA
Table 1. Fertility desires and reasons for fertility desires.
Number Percent
Fertility Desire
Desire for a child
No desire for a child
Concern or fears about fertility desires
(more than one answer possible)
Fear of infecting a new partner
Fear of my health deteriorating during and after childbirth
My family is complete
Fear of having an infected child
Economic burden o f raising a fami ly
Partner dead or absent (I’m alone)
Stigmatization by the community
Reasons for positive fertility desires
(more than one answer possible)
I need a replacement in the future
For protection, support and to look after me
I have no children I want a child
I have only one child I want another
Partner wants a child
I want a boy
To strengthen marriage
Community pressure
I want surplus land
Believes ART/PMTCT allows for an uninfected baby
Still young
Replacing baby who died
cNumber of r espondents who were unsure or desired not to have a child; dNumber of respondents who desired to have a child.
tal status, current co-habitation with a partner, period of
time living with a partner, bride price payment, physical
assault, sexual activity in the previous three months,
partner’s desire for a child, and use of contraception each
had a significant association with fertility desires (Table
5). Women aged 18 to 25 years were six times more
likely to desire a child than those women over the age of
36. Women who had had no children were four times
more likely to desire a child than those who had more
than two child ren alread y. Cov ariates (educatio n , religion ,
position in a polygamous marriage, occupation, history
of child death due to HIV, having a female child, HIV
stage, ART status, duration on ART, PMTCT knowledge,
and accessibility and efficacy of reproductive services)
which had no significant association are not included in
Table 5. Having a male child in the family and disclo-
sure of HIV status to a partner were found to be strongly
but not significantly associated with fertility desires.
The results of multiple logistic regression (Table 5)
revealed that predictors for desires for a child were:
younger age, having no children, and having a partner
who desired a child. A partner’s positive desire for a
child, as perceived by their wives, was the strongest pre-
dictor, with an odds ratio of 13.04 (95% CI = 5.68 -
4. Discussion and Conclusions
This study found that 34% of HIV positive women ex-
pressed a desire for a child in the future. Women who
desired a child were younger, married, in a sexually ac-
tive relationship with no children, and had partners who
desired a child.
Most factors associated with fertility desires in this
study are related to the influence of a patrimonial society,
culture, gender inequ ities and psycho so cial issues of such
variables as bride price and domestic violence, spousal
desires, and number of children. Traditional PNG High-
lands society places a very strong belief in male domin-
ion over the land and family. The man is the leader of th e
family. Family decisions are final when the husband
speaks. Women hold an inferior position. It was, there-
fore, not surprising to find that the strongest pred ictor for
Determinants of Fertility Desires among HIV Positive Women Living in the Western Highlands
202 Province of Papua New Guinea
Table 2. Socio-demographic characteristics of study participants.
Characteristics Number (%) Characteristics Number (%)
Age Group
18 - 25 years old
26 - 35 years old
36 - 45 years old
Mean = 29.61, SD = 5.43
Min = 18 , Max = 45
Origin (Province)
Western Highlands
Southern Highlands
No education
University/Tertiary collage
Subsistence farmer
Government employee
Private company employee
Small business operator
Average monthly income (PNG Kina)
Less than K100
K100 - K500
K500 and over
Mean = K191 SD = 319, Min = K10, Max = K3000
78 (26.80)
169 (51.08)
44 (15.12)
198 (68.04)
41 (14.09)
40 (13.75)
12 (4.12)
113 (38.38)
114 (39.18)
56 (19.75)
8 (2.75)
189 (64.95)
8 (2.75)
8 (2.75)
16 (5.05)
35 (11.34)
37 (12.71)
203 (69.76)
69 (23.71)
19 (6.53)
Roman Catholic
Seventh Day Adventist
Other small denominations
Marital status
Position in polygamous marriage
1st & only wife
1st wife with subsequent wives
2nd wife
3rd or more wif e
Have a male chi l d
One or more
Have a female child
One or more
History of child death due to HIV/AIDS
Currently living with a partner
Duration of time with current partner
Less than 1 year
1 - 5 years
More than 5 years
75 (25.77)
43 (14.78)
8 (2.75)
42 (14.43)
106 (36.43)
17 (5.84)
156 (53.16)
87 (29.90)
48 (16.49)
99 (34.02)
90 (30.93)
63 (21.65)
39 (13.40)
49 (27.84)
127 (72.16)
60 (34.09)
166 (65.91)
65 (22.34)
226 (77.66)
166 (57.04)
125 (42.96)
14 (8.43)
61 (36.75)
91 (54.82)
aTotal number of respondents who currently have biological son; a# Total number of respondents who currently have biological daughter; b Total number of
respondents currently living with a partner.
fertility desires was the male partners’ desires for a child.
Bride price payment is a psychosocial issue. A woman
whose husband and family have paid a bride price to her
family feels obligated to bear a child. Bride price pay-
ment by a male spouse and his clan generates reciprocal
expectations and demands to bear a child to contribute to
the male’s kin and community. Child bearing and nur-
turing largely defines a woman’s social identity and
status in PNG. Being childless is a disappointment to and
a disgrace for a couple. Children, especially male chil-
dren, are a valuable asset in terms of security, strong
tribal alliances and support [30]. Studies from Brazil [18],
South Africa [21], Uganda [31], and the USA [19] also
show that the number of children is associated with the
desire for a child.
Age is also a predictor for fertility desires. As the HIV
epidemic has spread in PNG, the highest rate of infection
has occurred in women aged 15 to 29 [24,25] and coin-
cides with the beginning and peak of their reproductive
lives. It is, therefore, critical to establish reproductive
service programs in HIV clinics to assist WLWHA in the
prevention of unwanted pregnancies and also to ensure
that desired conception and birth take place as safely as
possible. The need for reproductive counseling is all the
more urgent in light of the study finding that about 80%
of respondents in this study had never asked questions
about or discussed their reproductiv e health issues with a
health worker in the clinics.
Male child preference is still evident in the Highlands
of PNG, as it is in the African [31] and Asia regions
Copyright © 2011 SciRes. WJA
Determinants of Fertility Desires among HIV Positive Women Living in the Western Highlands 203
Province of Papua New Guinea
Table 3. Medical characteristic s of study participants.
Characteristics Number (%) Characteristics Number (%)
HIV Clinical Stage at the first diagnosis
Time since HIV dia gnosis
<6 months
6 - 18 months
>18 months
ART status
Duration on ART
<6 months
6 - 18 months
>18 months
Knowledge regarding PMTCT
Mean = 3.60, SD = 0.96, Max = 5, Min = 0
15 (5.15)
59 (20.27)
164 (56.36)
53 (18.21)
63 (21.65)
79 (27.15)
149 (51.20)
240 (82.47)
57 (17.53)
44 (18.33)
72 (30.00)
127 (51.67)
35 (12.03)
216 (74.23)
40 (13.73)
Accessibility and efficacy of reproductive service
Ever asked questions about reproductive intention, PMCTC
or family planning to health worker
Health workers’ attitude and role towards reproductive
intentions, PMTCT and family planning services
Do not talk about this at all
Provide very little information
They seem to ignore or discourage the topic
They are helpful
Current use of contraception
59 (20.27)
232 (79.73)
107 (36.77)
105 (36.08)
22 (7.56)
57 (19.59)
85 (29.21)
206 (70.79)
Table 4. Psychosocial characteristics of study participants.
Characteristics Number (%) Characteristics Number (%)
Bride price payments in marriage
Physical assaults/violence
Sexual assault
Sexually active in last 3 months
131 (45.02)
160 (54.98)
156 (53.66)
135 (46.39)
152 (52.23)
139 (47.77)
123 (42.27)
168 (57.73)
Disclosure of HIV status
a) To Partner
b) To Public community
Partner’s desire for a child
238 (81.79)
53 (18.21)
89 (30.58)
202 (69.49)
79 (27.15)
173 (59.45)
39 (13.40)
[32,33]. A male heir in this patrimonial society is valu ed,
especially because of customary land rights. Sons and
brothers form strong alliances [30]. This is true espe-
cially in parts of the Highland s of PNG where tribal con-
flicts and ethnic clashes are frequent [34]. Although there
was a strong but not significant association in this study,
preference for a male child was a common reason for
wanting a child.
There was no significant association between medical
factors and fertility desires, except for use of contracep-
tion. Respondents who used contraception tended to be
more likely to desire a child, although a similar study in
Canada found no such association [20]. In the present
study, women who used contraception were more likely
to desire a child than those who did not. There may well
be a simple explanation for this apparent paradox. The
use of contraception did not necessarily indicate a desire
not to have a child. Rather, the use of contraception was
intended to control the timing of conception and birth.
Those women who had not experienced domestic
physical violence/assaults were more likely to desire a
child than those who experienced domestic violence in
their relationships (OR = 1.64, 95% CI = 1.01 - 2.68),
although this was not a predctor after multiple logistic i
Copyright © 2011 SciRes. WJA
Determinants of Fertility Desires among HIV Positive Women Living in the Western Highlands
204 Province of Papua New Guinea
Table 5. Relationships between independent variables and fertility desires.
Characteristics Total
n = 291 Desire a child
(%) Unadjusted OR
(95% CI) P-value Adjusted Odds Ratio
(95% CI) P-value
Age group
36 - 45
26 - 35
18 - 25
Number of children
2 & more
Having a male c h ilde
Marital Status f
Currently living with partner
Duration of time with partnerg
>5 years
1 - 5 years
<1 years
Bride price payment in marriage
Physical violence in marriage
Sexually active in last 3 months
Disclosure of HIV status to partner
Partner’s desire for a child
Not sure/No
Use of contraception
n = 176a
n = 166b
4.41 (1.65 - 11.77)
5.72 (2.03 - 16.08)
2.45 (1.22 - 4.91)
4.23 (2.26 - 7.92)
1.97 (0.95 - 4.07)
0.58 (0.33 - 1.01)
0.12 (0.04 - 0.34)
0.27 (0.15 - 0.46)
3.05 (1.55 - 5.97)
1.38 (0.44 - 4.34)
2.03 (1.24 - 3.32)
1.64 (1.01 - 2.68)
0.30 (0.18 - 0.49)
0.51 (0.25 - 1.02)
17.25(9.07 - 32.82)
3.94 (2.31 - 6.67)
4.37 (1.20 - 15.97)
5.51 (1.36 - 22.38)
2.04 (0.81 - 5.11)
3.63 (1.48 - 8.90)
0.76 (0.27 - 2.13)
1.09 (0.54 - 2.20)
1.71 (0.89 - 3.30)
1.11 (0.44 - 2.80)
1.37 (0.55 - 3.42)
13.04(5.68 - 29.91)
0.43 (0.18 - 1.02)
atotal number of respondents who currently have biological son; btotal number of respondents currently living with a partner; eHaving a mal e chi ld was no t us ed
in multiple logistic regression as n was only 176; fMarital status was not included in multiple logistic regression as it was a cofounder of currently living with
partner; gDuration of time with partner was not used in multiple logistic regression as n was less than 291, even though significant.
regression analysis. The women who desired children
were also more likely to live in stable, happy relation-
ships with their partners. However, over 50% of the par-
ticipants experienced domestic violence and other studies
have also shown that the majority of PNG women report
having been beaten by their boyfriends or husbands be-
cause of sexual jealously or for refusal of sex on demand.
These were the most common reasons given for violence
in an established relationship [35-36]. In explaining her
reason for wanting a child, one participant in this study
said, “I want a child because my husband demands it and
he beats me up”. Physical domestic violence in WLWHA,
therefore, also needs to be investigated, and appropriate
counseling and reproductive options made available to
Copyright © 2011 SciRes. WJA
Determinants of Fertility Desires among HIV Positive Women Living in the Western Highlands 205
Province of Papua New Guinea
the victims of such behavior.
Over 50% of the respondents had been sexually as-
saulted in their relationships. Sexual assault is an issu e of
great concern in PNG. Of the 152 respondents who had
experienced sexual assaults, about 30% were using con-
traception, meaning that about 70% were not, and that
sexual assault may contribute to unwanted pregnancies
and an increased chance of pediatric HIV transmission.
This, in turn, further emphasizes the need for family
planning counseling and contraception to be more easily
Almost half of the women interviewed who had been
sexually active in the previous three months did not de-
sire a child, and of those, 56% were not on any form of
contraception. This constitutes risky sexual behavior
among HIV positive women and increases the risk of
transmitting an ART resistant virus to their sexual part-
ners if ART resistance had been developed by one part-
ner through poor ART adherence. A Ugandan study by
Maier et al found no significant association between be-
ing sexually active and fertility desires [37].
A partner’s positive desire for a child was very
strongly associated with positive fertility desires. This is
consistent with studies from Northeast Brazil [18,38].
Despite rapid social changes and westernization, PNG
still maintains its patriarchal traditions and gender based
power in relationships [23]. Masculine dominance is
pronounced and very evident in PNG communities. The
male is the family leader and the final decision maker,
and in most communities it has become the norm to
physically assault the female spouse [23]. Female inferi-
ority and lack of power are also evident at the national
level, where currently there is only one female in the
national House of Representatives out of a total of 109
In Uganda, the most common reasons for women
wanting a child included the desire for a successor, not
already having a boy, and having no children at all [31].
The similarity with this present study may lie in the
socio-cultural backgrounds of Uganda and PNG. Both
are male dominated societies; both accord lower status to
women; and both are polygamous.
The desire to ensure family continuity in the future, to
have offspring of their own to perpetuate their name and
lineage after they die, and to be supported in old age are
all reasons for the importance of a child in a patrimonial
society. The practice of polygamy still remains a threat to
married women and a child may strengthen and seal a
marriage. WLWHA may be willing to sacrifice the health
of an unborn child and their own health to save their re-
lationships. Moreover, reasons such as community pres-
sure and surplus lan d area show how culture and tradition
influence fertility desires.
In summary, the findings of this research relate mainly
to the culture, customs and psychosocial status of women
in PNG. Nevertheless, they demonstrate that medical
professionals practicing in this environment need to dis-
cuss and counsel WLWHA, and their partners, about
contraception and reproductive health more holistically.
They need to take into account that a patient is a social
being and not just an indiv idual with medical needs. It is
also extremely important to integrate reproductive health
and family planning services into the programs and rou-
tines of HIV clinics. Spousal expectations, community
pressure, domestic violence, sexual assault and bride
price payments all signify the influence of male domi-
nance. There still needs to be more advocacy at the
community level for the empowerment of women. Fur-
ther research into sexual behavior and contraceptive use
involving WLWHA and their spouses also needs to be
conducted, with the ultimate goal of reducing the inci-
dence of HIV infection and helping WLWHA and their
partners live happier and longer lives.
The most interesting finding is that PMTCT knowl-
edge did not correlate with desire for a child: women
independently desire a child regardless of whether they
know how to avoid vertical transmission or not. PNG’s
PMTCT services are only in the second year of operation
in the WHP and do not yet exist at all in oth er provinces
of PNG. More extensive advocacy, awareness and pro-
motion of PMTCT services, therefore, are particularly
urgent. Awareness of the possibilities and choices of-
fered through these services may be expected to contrib-
ute to the empowerment of WLWHA in particular.
5. Acknowledgements
We are greatly indebted to the women living with
HIV/AIDS in the Western Highlands Province of PNG
for participating in this study. We thank Mr. Peregrine
W.F. Whalley for his comments and suggestions about
language and style. We also acknowledge WHO and the
PNG National Aids Counsel Secretariat for partially
funding the study.
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