Culture, cost limit access to family planning services

Zubedah Mwinyi, a 39-year-old resident of Zowerani sub-location in Kilifi North sub-county, has given birth to eight children in the last 17 years, all of whom are alive. She is proud of her family, speaking of her children with the tone of a career overachiever, and justifiably so – she doesn’t remember a period when, as a wife, she wasn’t either carrying a baby in her womb or in her arms.

Sitting side by side are her religious and cultural beliefs that having many children is a blessing and the struggle her husband, a fisherman, has to endure without ever meeting their daily needs. For years, she has lived in the middle – between triumph and regret, tradition and reality.

“Life is hard but what can you do? If God has already blessed you with children, how then do you complain?” she says.

Their firstborn, a 17-year-old girl, sat the Kenya Certificate of Primary Education exam last month after being in and out of school due to the family’s financial hardships. Her other children have not been lucky either, with the much younger ones occasionally put down by illnesses related to malnutrition.

Zubedah and her husband know just too well that there’s little she can do to change the past. But even as they remain careful not to antagonise divine providence, they have resolved to be more involved in planning their future. Their one-year-old son will be their last, the reason she used a modern contraceptive for the first time two months ago. For three years, the implant will help them avoid another pregnancy after which they will seek a more permanent measure.

It was not the first time she was hearing of modern contraceptives. “I had wanted to have just four children but somehow I just found myself postponing using this family planning. That is how I have ended up where I am today,” she says.
Initially, I had heard from fellow women only of how modern contraceptives will harm me, especially that they cause cancer,” she recalls.

Like Zubedah, one in seven married women age 15-49 who need contraceptives to space or delay their next birth lack them, resulting in many unintended pregnancies, according to data from the Performance Monitoring and Accountability 2020 (PMA2020), which monitors family planning indicators in 11 counties in Kenya.

The reason given for non-use of birth control among all women seeking to delay the next birth two or more years are health-related concerns (26 percent), opposition to use (13 percent) and lack of access/knowledge (four percent).

A NationNewsplex review of family planning data shows that women in the lowest wealth quantile have the highest share of unmet needs of 20 percent, compared with their counterparts in the highest wealth quantile (12 percent), implying that equality and equity are some of the issues that still needs to be looked into.

“If you live in a good neighbourhood, chances are that you will go to a good hospital that offers high-quality family planning services. That is not the case for the poor,” says Dr Griffin Manguro, director and CEO at the International Centre for Reproductive Health Kenya (ICRHK).

It is therefore little surprise that one in 13 public health facilities did not provide at least three modern contraceptive options in 2018, according to PMA2020. The study also finds that a few public health facilities (five percent) charge general user fees and three-quarters of modern contraceptives are paid for out of pocket. This too locks out many needy people.
Additionally, most women of lower socio-economic status also have less education, undermining their ability to learn about family planning and decide to take it up. “Poor women are not the final decision-makers on family planning, because it is when the woman is more educated that she becomes intellectually liberated and empowered to make a choice on family planning,” says Dr Manguro.

Zubedah’s breakthrough and that of many other women in her village are a result of the efforts of a team of community health workers (CHWs) who go from door to door with information and service, essentially reaching women who need the services but somehow find themselves waiting another day, by what time they have conceived against their wish.
“She (health worker) passed by my house and explained to me all the options available,” she tells Newsplex.

After she discussed the options with her husband and agreed to try a family planning method, they invited the health worker home and in minutes she had her implant in place.
“Sometimes they want to go to the health centre but they lack transport. Other times when they get there on a busy day, they are turned away because there is no room where the woman can be attended,” explains Martha Kaingu, the CHW who served Zubedah. Many of the women turned away from health facilities, though in dire need of contraception, hardly follow up. “Many times I meet women in the hospital and go with them to their homes for the procedure so that the opportunity is not lost,” she says.
Zubedah wishes she had met Martha much earlier. However, that does not water down her newfound freedom. “I am really grateful because this happened when I was just a few months from getting pregnant again. Now we can concentrate on raising the eight, which is already a big challenge.”
As the International Conference on Population and Development kicks off tomorrow (Tuesday) in Nairobi, participants from African countries will most certainly be reflecting on some of the key actions necessary to turn the continent’s population bulge into a socio-economic success.
“The conference represents a call to action to achieve zero unmet need for family planning information and services, zero preventable maternal deaths, zero sexual and gender-based violence and harmful practices against women and girls,” said Mr Dereje Wordofa, the United Nations Population Fund (UNFPA) deputy executive director, during the raising of the conference’s flag last Saturday.

In Kenya, as in many other African countries, sustainable and prosperous families, such as the one Zubedah had dreamt of, has been the target of a strong family planning drive, grounded on the constitutional right of access to health services, including reproductive health care.

Kenya has the lowest fertility rate per woman in the East African Community, 3.7, according to The Power of Choice: Reproductive Rights and Demographic Transition, a report by the UNFPA. This is a drop from 4.45 in 2012. Preliminary results from the Census 2019 show that the average annual population growth rate dropped to 2.2 percent from 2.9 percent a decade ago and the average household size too dropped to 3.9 from 4.2 in the same period. With respect to family planning promotion in the country, the conference’s theme “Accelerating the promise” appears to speak to the need to scale up all investments that have borne fruit and fill the gaps.

More than a third of sexually active young women age 15-24 report pressure from a partner to not use birth control or that a partner agreed to use a condom then removed it during sex, according to a study done in June-August this year by PMA 2020 in Nairobi. A third of the young women also relied on the men to procure contraceptives.

To try and promote access and equity in family planning, ICRHK, with funds from the UNFPA, runs a youth-friendly facility for first-time young mothers designed to provide comprehensive age-appropriate sexual and reproductive health support. Such initiatives promote contraceptives uptake among young poor women who want to either space birth or limit the number of children.

Half of women in Kenya age 18-24 had their first sexual encounter by age 18, of which only one in 10 used contraception, leading to many unplanned pregnancies. One in six of the young women had their first birth by age 18. The average age of marriage and first birth is 22 years.

The country’s adolescents (age 15-19) birth prevalence rate stands at 82 births for every 1,000 deliveries, the third-highest in the East African Community. Generally, girls start sex early but use contraceptives for the first time four years later.

Family planning information is generally available, with 87 percent of respondents in the PMA2020 study reporting having accessed birth control information in the last few months to the study. However, the Nairobi study brought into doubt young people’s level of knowledge on contraception. Only two in five could identify the more efficient method of preventing a pregnancy between condoms and an IUD (coil) and two-thirds failed to indicate the more effective method between injectable and standard days/cycle beads.

According to PMA2020, two in five last births to mothers of reproductive age last year were either intended for later or not intended at all.