ICRH Monograph Rhoune Ochako Patterns of Contraceptive Use among Vulnerable Populations in Kenya

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November 23rd Ms. Rhoune Ochako defended her thesis: entitled: “Patterns of Contraceptive Use among Vulnerable Populations in Kenya” in Ghent

 

Supervisors Prof. Dr. Marleen Temmerman and Dr. Ian Askew

EXECUTIVE SUMMARY
This thesis describes contraceptive use dynamics among selected vulnerable populations in Kenya. More specifically, this thesis provides an in-depth analysis of the subject and gives recommendations for family planning programs and policy makers to address the specific needs of these population groups. We studied young urban women, women who have experienced unintended pregnancy, women living in slum settlements and middle class non-slum settlements, female sex workers, migrant and non-migrant women, and sexually active men by assessing the characteristics of those who use modern contraceptives in Kenya.
The study of urban young women was conducted in purposively selected urban and peri-urban districts in the former administrative units of Nyanza, Coast, and Central provinces of Kenya. In depth interviews were conducted with sexually active women aged 15-24, including users and non-users of contraceptives, drawn from randomly selected households. The results show that the respondents were familiar with some modern methods of contraception and most could describe their general mechanisms of action. Condoms were not considered as contraception by many users. Use of contraception was sometimes associated with perceptions of promiscuity. Fear of side effects and adverse reactions were major barriers to use. The biggest fear was that a method could cause infertility. Many fears were based on myths and misconceptions. Young women learn about both correct and incorrect side effects primarily from their social networks. The findings confirm that awareness and knowledge of contraception do not necessarily translate to use, and that myths and misconceptions, especially concerning side effects, are the main barriers to modern contraceptive use among young women, with both users and non-users exhibiting a lack of detailed and correct information on the different contraceptive methods. Additionally, the influence of social network/peer approval, beyond the individual's beliefs was emphasized, hence the need for targeted and proactive engagement with the wider community. We suggest the use of mass media and peer campaign strategies to help dispel myths and share accurate information about contraception among young women to enhance uptake and sustained use (Article 1).  
To assess and compare prevalence of contraceptive use, as well as factors associated with contraceptive method choice, in slum and non-slum contexts, we interviewed 1,873 women, 926 in slum settlements and 947 women in middle class areas in Nairobi, Kenya. Contraceptive method choice was similar across slum and non-slum residents: slightly over a third of women (34.3%) in slum communities and 28.1% of women in non-slum communities were using short-term methods. Long-term methods, such as female and male sterilization, intrauterine devices and implants, were more often used by women in non-slum areas (9.2%) as compared to 3.6% in slum communities.  As expected, older women were less likely to use short-term methods, while currently married women were more likely to use modern rather than traditional contraceptives. Women with three or more children were more likely to use long term methods. Women working outside the home or in formal employment used modern methods of contraception more than those in self-employment or unemployed. Investments in increasing access to various contraceptive options among women living in slum and non-slum settlements are urgently needed to expand access to contraceptives and consequently increase contraceptive choice and use, especially among married couples. Ensuring a wider range of services to serve the diverse needs of couples in long term or stable partnerships in both slum and non-slum areas is needed. Some women, especially from slum settlements, could benefit from extra awareness and education campaigns to dispel myths and misconceptions around contraceptive use (Article 3).   
The impact of a history of unplanned pregnancies on contraceptive behaviour among women living in slum and non-slum urban settlements showed that Kenya, like most countries globally, continues to experience high levels of unintended pregnancies, with predictable adverse consequences on desired family size, fertility decline and population growth. The quantitative and qualitative data showed that women who have had an unintended pregnancy are “ready for change”, meaning they are ready to use modern contraceptives. We recommend that family planning program implementers utilize antenatal, delivery and post-delivery care services as entry points to identify women whose pregnancy is unplanned, and provide them with information and services to prevent a repeat unplanned pregnancy, thereby strengthening the integration of family planning with maternal and child health services.  Further, there is need for concerted efforts to address barriers that women face in accessing these services; more data are needed to understand underlying barriers for maternal and child health information and services (Article 2).  
Female Sex Workers (FSWs) are vulnerable to a broad range of social, sexual and reproductive health problems, such as sexually transmitted infections (STIs)/HIV, unintended pregnancy, exploitation, stigma and discrimination, and violence. As a result, FSWs are in dire need of comprehensive and integrated sexual and reproductive health services. Despite these needs, existing programs pay little attention to the broader sexual and reproductive health and rights of these women, often focusing on prevention, care and treatment of HIV and other STIs while neglecting their reproductive health needs, including access to a wide range of contraceptive methods. The aim of this study was to explore FSWs’ experiences with existing contraceptive methods while also looking at their role in access and use of contraceptives. We focused on women aged 15-49 years, who reported current sex work, defined as ‘providing sexual services in exchange for money or other material compensation as part of an individual’s livelihood’. Our findings reveal that while some FSWs know about modern contraceptives, others have no idea or altogether refuse to use contraceptives for fear of losing clients. Their interactions with different client types also act as a barrier but sometimes provide opportunities for contraceptive use among some FSWs. Most FSW acknowledge the importance of dual protection for HIV/STI and pregnancy prevention, nevertheless, pervasive myths and misconceptions on contraceptive use still exist and act as barriers to uptake of contraceptives. Furthermore, fear of being tested for HIV at family planning clinics and long queues at the clinics hinder access to SRH services and could potentially result in a loss of existing clients. We recommend delivery of contraceptives to FSWs via a multi-sectoral approach involving community based distribution. We also recommend the introduction of targeted counseling services to provide information on the benefits of non-barrier contraceptive methods with additional support services to manage side effects arising from their use to encourage uptake and dual use of contraceptives for both pregnancy and STI/HIV prevention (Article 4).
Use of modern contraceptives among migrant (women engaged in movement from rural to urban, urban to urban, and urban to rural) and non-migrant (women living in urban or rural areas without change of residence) populations was assessed and compared. In a country where regional differentials in population growth and poverty reduction continue to be priorities in the post Millennium Development Goal (MDG) development agenda, understanding the relationships between contraceptive use and internal migration is highly relevant. We use data from the 2008-09 Kenya Demographic and Health Survey (KDHS) from 5,905 women aged 15-49 years who reported being sexually active in the last 12 months prior to the survey. Results show that modern contraceptive use was significantly higher among women in all migration streams (non-migrant urban (OR=2.8, p<0.001), urban-urban migration (OR=2.0, p<0.001), urban-rural migration (OR=2.0, p<0.001), rural-urban migration (OR=2.6, p<0.001), rural-rural migration (OR=1.7, p<0.001), compared with non-migrant rural women. We conclude that women who internally migrate within Kenya, whether from rural to urban or between urban centres, were more likely to use modern contraception than women living permanently in rural areas. This distinction appears likely due to a combination of selection theory (migrants are a self-selected group with characteristics different from non-migrants in rural areas, including higher levels of education, later age at marriage, lower pre-migration fertility and participation in gainful employment), adaption theory (socio-cultural norms in the migration destination influences those moving from rural to urban areas), and disruption theory (migration leads to physical separation of sexual partners which in turn helps postpone or space child bearing). Programmatically, the differentials in modern contraceptive use by the different migration streams should be considered when designing family planning programmes among migrant and non-migrant women. It was also evident that certain factors, such as higher levels of education and employment, acted as enabling factors for modern contraceptive use regardless of migration status. Overall, the DHS data available for our analysis were limited, and so there is need for additional research to understand the differentials in contraceptive use between migrant and non-migrant women and come up with strategies and policies to inform future interventions and thereby improve access to and use of modern contraceptives among these various populations (Article 5).
In Article 6 we sought to understand the determinants of modern contraceptive use (by partners and male methods) among sexually active men. We use data from the nationally representative 2014 Kenya Demographic and Health Survey (KDHS) of men aged 15-54 years and restrict our analysis to 9,514 men who reported being sexually active in the past 12 months prior to the survey, as they were likely to report doing something or not to avoid or delay pregnancy. We considered explanatory factors contributing to modern contraceptive use among sexually active men and their partners. Men with no education, and low awareness of contraceptives were less likely to use modern contraceptives, being poorly informed about contraceptives and their benefits. Men from North-Eastern Kenya lag far behind other regions, with religion and gender attitudes seeming to shape contraceptive behaviours and practice among them. Our analyses suggest that interpersonal communication and mass media have a positive effect on modern contraceptive use by men and their partners. Informative provider-client interactions, as well as access to information through mass media, are linked with better knowledge and increased use of modern contraceptives. Concerted sensitization campaigns should focus on sub-groups of men whose contraceptive use remains low. Additional studies of men are recommended to broaden understanding of the drivers and barriers to contraceptive use among sub-populations of men.  
The analyses described in this thesis highlight the barriers/disadvantages that vulnerable women from various backgrounds, such as those living in slums, young girls living in urban areas, migrant women, female sex workers as well as men, face in the use of contraceptives. These barriers include myths and misconceptions, information gaps and misinformation.  The analyses have highlighted several evidence gaps, and so we further recommend more research to broaden and deepen understanding of the main drivers and barriers to contraceptive use among these vulnerable populations. Additionally, we recommend additional service delivery strategies be considered to expand access to a broader range of contraceptives to meet the particular needs of each of these populations.   
 

Authors & affiliation: 
Rhoune Ochako - Supervisors: Prof. dr. Marleen Temmerman and Dr. Ian Askew
Published In: 
ICRH Monographs
Publication date: 
Thursday, November 23, 2017