This study suggests women’s decision-making on pregnancy is influenced by a number of factors. These include individual perceptions, socio-cultural norms and medical advice. The findings reveal that participants value being pregnant and having children and that this is closely related to perceptions of female adulthood. The women also regarded motherhood as fundamental to female identity and status in their society. These results show a congruence with other findings in Southern Mozambique , as well as other sub-Saharan countries such as Botswana  and South Africa .
Perceptions of pregnancy by HIV positive women are anchored in the symbolism society places upon children . Together with the pressure of male partners and families, this largely influences the decision to become pregnant. The influence of male partners and families upon pregnancy decision-making has also been documented in other studies [38, 39].
Motherhood among HIV positive women is perceived no differently to other women: it represents a way of fulfilling a woman’s role prescribed by society. As paradigms of maternity suggest , women are expected to marry and perform their reproductive task so as to perpetuate the lineage of their husband’s family. In the context of HIV/AIDS, becoming a mother may also offer compensation for the negative social status of a HIV woman.
In Mozambican society, where traditions and religious norms are very influential , children have high social and economic value . Therefore, HIV positive women risk double stigmatisation if they do not have children: one related to their HIV positive status and the other related to being childless.
As studies  in sub-Saharan Africa have shown, childlessness may lead to stigma, rejection, and a loss of social status. However, as it has been documented in Zambia , participants were equally aware that a large number of children could burden their lives. Moreover, many women perceived, and were concerned about their own health-related risks as well as those of the baby during pregnancy.
This study revealed that most participants were unaware of their HIV positive status prior to pregnancy and had not complied with the medical advice recommended by the Ministry of Health of Mozambique concerning when to become pregnant. Those who did know their HIV positive status, some did not comply with antiretroviral therapy due to economic obstacles. These included, lack of money for transportation and food as well as insufficient knowledge regarding the benefits of antiretroviral therapy before pregnancy.
The correlation between the low adherence to antiretroviral therapy and economic obstacles has also been reported in Mozambique’s rural Zambézia province . However, a study in the country’s Sofala province suggested food assistance provided to HIV patients had no effect on their adherence to antiretroviral therapy . Nevertheless, lack of access to food is a critical barrier to consistent adherence to antiretroviral therapy. For example, in Mozambique approximately 54,7% of the population live on less than 2USD each day . Unless people are able to access enough food to meet their needs, adequate adherence to antiretroviral therapy will remain a challenge.
Food insecurity as a barrier to antiretroviral therapy adherence is also a challenge in several other sub-Saharan countries. A study in Uganda  also determined food insecurity contributed to the lack of adherence to antiretroviral therapy. In addition, discontinuation of the therapy occurred because patients experienced that antiretroviral drugs increased their appetites leading to intolerable hunger. Moreover, the same study highlighted antiretroviral drugs side effects were greater in the absence of food. However, patients believed they should skip doses or not start on antiretroviral therapy at all, if they could not afford to buy food . Similar findings were previously documented in Botswana and Tanzania , Zambia  and later in the Congo  as well as other sub-Saharan countries .
This study echoes many of the findings in the above countries which revealed how low adherence to antiretroviral therapy was related to several other significant factors: fear of HIV disclosure [50, 51]; stigma and discrimination; side effects of antiretroviral drugs [49, 52]; transportation costs; and long waiting periods at health facilities to obtain antiretroviral drugs [48, 53, 54]. A further factor was the inadequate use of modern contraceptives. The findings reveal that most participants became pregnant unintentionally. This has also been confirmed by other studies [17, 55, 56]. In general, women lack decision-making power over the use of contraception, and therefore over the appropriate time for them to get pregnant. Decisions to comply with medical advice, such as using modern contraceptives, tend to be the reserve of a woman’s male partner. This shows the extent to which women tend to rely on familial or communal norms  when deciding about pregnancy [57, 58].
Furthermore, the results suggest that contraceptive use and the risks of HIV-infection are less prominent than one ought to expect when it comes to decision-making about pregnancy. Following similar studies in Zambia  and Uganda , there is a pattern of HIV infection playing a minor role in family planning decisions. Most participants avoided healthcare providers because they regarded decisions about family planning as private matters; not as a consequence of insufficient knowledge. This belief may also be associated with the fact that sharing family planning intentions with healthcare providers was not a perceptible norm amongst the communities studied . As numerous studies [8, 12] have shown, decisions are based more upon women’s perceptions of health, and when they feel it is necessary to have children. Consistent with other studies, [35, 60] most participants did not associate having sex with HIV reinfection, nor did they acknowledge the risk factor of mother-to-child transmission of HIV. The fulfilment of motherhood, and compliance with social norms, appeared to be more important than preventing HIV-infection through contraceptive use .
Finally, despite their efforts in counselling about modern contraceptive use, healthcare providers missed opportunities to refer women to healthcare facilities prior to pregnancy. A greater emphasis on referral could strengthen the relationship between healthcare providers and HIV positive women with all the attendant benefits to health this could arguably bring. Others studies  have also disclosed HIV positive women did not often receive sufficient support for safe conception in sub-Saharan Africa. This result is congruent with findings in Kenya  and Lesotho . In short, the evidence suggests that healthcare providers must deal with non-compliance of women to medical advice for all the reasons cited above.
At the individual level, healthcare providers need to ensure that couples are cognizant of the benefits to consistent adherence to antiretroviral therapy while explaining its side effects. They should follow-up on patients’ experiences and advise all couples to seek medical instruction prior to pregnancy. Antiretroviral therapy should be considered a routine “medicine of the body” and the only way to ensure the health of the patients, rather than as an instrumental medication to prevent passing HIV from mother to infant. In addition, modern contraceptive use, including the use of condoms, should be explained to male partners. The study shows that when these issues are clearly explained to men, they are more inclined to accept their wives using contraceptives. However, both women and male partners should use modern contraceptives as a matter of routine, rather than a periodic measure during breastfeeding.
At the community/familial level, people should be informed about the impact of HIV, as well as the benefits of antiretroviral therapy and modern contraceptives to family planning. This information could be communicated via healthcare providers during their routine lectures to all people and when meeting patients at their clinics. Additionally, community health workers, community leaders, and non-government organisations could disseminate this information as part of their primary HIV prevention activities.
If consistent adherence to antiretroviral therapy is to be realised, a feasible strategy of antiretroviral drug distribution which does not require patients to go to the healthcare facility every month needs to be established on a national basis. This could minimise the burden of transportation costs for those who live great distances from the healthcare facility.