‘We first have to agree’: childbearing decision-making among HIV sero-different couples along Lake Victoria, Kisumu, Kenya

Among couples, gender-based power dynamics regarding childbearing decision-making can impact reproductive health outcomes. Guided by interdependence theory, we examined power and gender roles in childbearing decision-making among HIV sero-different couples to inform programmes and interventions supporting safer reproductive decisions to prevent HIV infection. This dyadic qualitative study was conducted between November 2023 and February 2024, with 16 HIV sero-different heterosexual couples (n = 32) in rural fishing communities in Kisumu County, Kenya. During in-depth interviews, participants shared perspectives on childbearing decision-making to elicit dyadic factors involved. Data were analysed at individual and dyadic levels using framework analysis. This study revealed three primary themes associated with childbearing decision-making within couples: (1) a strong desire for children; (2) the importance of gender and societal norms that shape the perceptions of men and women about power; and (3) a tension between collaborative joint decision-making that happens within couples and women’s constrained individual autonomy which led to women’s control of pregnancy timing through both overt and covert means. Despite norms of male-led reproductive decision-making, most couples demonstrated collaborative, unity-focused approaches, indicating nuanced shared power dynamics. Future programmes and interventions could focus on couple unity and agreement to support safer conception outcomes in HIV sero-different couples.