"The fertility transition in Kenya : patterns and determinants"

Thèse diffusée initialement dans le cadre d'un projet pilote des Presses de l'Université de Montréal/Centre d'édition numérique UdeM (1997-2008) avec l'autorisation de l'auteur.In spite of considerable research on Kenya’s fertility, questions remain. This dissertation examines three of these issues - the national and sub-national trend patterns in the country’s fertility and related proximate determinants, factors in the transitions to second and third conceptions, and the determinants of contraceptive use. Results, presented below, are based upon data which comprised five sample surveys conducted between 1977 and 2003 among women of reproductive age, as well as a community and health facility survey implemented in 1999. First, an exploratory analysis of trends in fertility and its proximate determinants shows that a pattern of later family formation and of a higher level of fertility control is associated with the more modernized and developed regions (urban areas and rural Central Province). Secondly, using survival analysis, the relative hazards of transition to the second and third conceptions for the 12-year periods during which fertility fell rapidly (1977-1989) and the pace of decline reduced (1991-2003) are compared. Among the findings, although child survival has significant effects during both periods, its influence is more pronounced during the recent period. Thirdly, multivariate analysis of the determinants of contraceptive use shows that motivation for fertility control is significant, while access to family planning services is not. That proximity to family planning services might nevertheless be important is shown by the significance of exposure to family planning messages, many of which are often communicated from the health facilities. This dissertation makes contributions in three areas. One, it confirms the dichotomy in the pattern of fertility change and its proximate determinants in the country, not so much along the usual rural-urban separation, but rather between urban areas and rural Central versus the rest of rural Kenya. Two, it shows that the decreased pace of the fertility transition in Kenya, including constant fertility over 1998-2003, might be associated with the rise in infant and child mortality since the 1990s. Three, it shows the significance of education, motivation for fertility control, and exposure to media messages about family planning in contraceptive use, thereby pointing out where policy and program effort should be directed in order to sustain the fertility transition.Malgré de nombreuses études consacrées à la problématique de la transition de fécondité au Kenya, des questions subsistent. Cette thèse traite de trois d’entre elles : les tendances de la fécondité et ses déterminants proches, les facteurs liés au passage à la deuxième et à la troisième grossesse, et les déterminants de l’utilisation de la contraception. Les données proviennent de cinq enquêtes menées dans ce pays entre 1977 et 2003, auprès de femmes d’âge reproductif, ainsi que d’une étude, conduite en 1999, au niveau communautaire et de centres de santé. Les résultats montrent d’abord une tendance au mariage tardif et à un niveau plus élevé de contrôle de la fécondité dans les régions les plus modernisées et les plus développées (les villes et les zones rurales de la région de la Province Central). Deuxièmement, dans la comparaison des 12 années durant lesquelles la fécondité, mesurée par l’indice de fécondité, s’est réduite (1977- 1989) et celles où le pas de sa baisse a ralenti (1991-2003), on note une augmentation des effets relatifs de la mortalité infantile pendant la deuxième période. Troisièmement, la régression multi variée utilisée pour l’analyse des déterminants proches de l’utilisation de la contraception fait ressortir le rôle important de la motivation pour le contrôle de la fécondité. Bien que l’accès aux services de planification familiale ne constitue pas un facteur significatif en soi, il pourrait jouer néanmoins un rôle dans la mesure où les résultats montrent que l’exposition aux messages de planification familiale (généralement offerts dans les centres de santé) a un effet significatif. La contribution de cette thèse s’articule autour de trois aspects. Premièrement, elle montre une opposition dans les changements de la fécondité et de ses déterminants entre 1977 et 2003, non pas entre les zones urbaines et rurales comme d’habitude, mais plutôt entre zones urbaines et partie rurale de la Province Central d’une part et le reste du Kenya d’autre part. Deuxièmement, le ralentissement de la baisse de la fécondité, y compris le niveau stable observé entre 1998 et 2003, est probablement lié à la hausse, depuis les années quatre-vingt dix, de la mortalité infantile. Troisièmement, cette thèse confirme le rôle significatif de la scolarisation, de la motivation pour le contrôle des naissances, et de l’effet positif des messages sur l’usage des méthodes de planification familiale, montrant ainsi les domaines dans lesquels doivent intervenir les politiques et programmes afin de maintenir la transition de fécondité

Community perceptions of malaria and vaccines in the South Coast and Busia regions of Kenya

<p>Abstract</p> <p>Background</p> <p>Malaria is a leading cause of morbidity and mortality in children younger than 5 years in Kenya. Within the context of planning for a vaccine to be used alongside existing malaria control methods, this study explores sociocultural and health communications issues among individuals who are responsible for or influence decisions on childhood vaccination at the community level.</p> <p>Methods</p> <p>This qualitative study was conducted in two malaria-endemic regions of Kenya--South Coast and Busia. Participant selection was purposive and criterion based. A total of 20 focus group discussions, 22 in-depth interviews, and 18 exit interviews were conducted.</p> <p>Results</p> <p>Participants understand that malaria is a serious problem that no single tool can defeat. Communities would welcome a malaria vaccine, although they would have questions and concerns about the intervention. While support for local child immunization programs exists, limited understanding about vaccines and what they do is evident among younger and older people, particularly men. Even as health care providers are frustrated when parents do not have their children vaccinated, some parents have concerns about access to and the quality of vaccination services. Some women, including older mothers and those less economically privileged, see themselves as the focus of health workers' negative comments associated with either their parenting choices or their children's appearance. In general, parents and caregivers weigh several factors--such as personal opportunity costs, resource constraints, and perceived benefits--when deciding whether or not to have their children vaccinated, and the decision often is influenced by a network of people, including community leaders and health workers.</p> <p>Conclusions</p> <p>The study raises issues that should inform a communications strategy and guide policy decisions within Kenya on eventual malaria vaccine introduction. Unlike the current practice, where health education on child welfare and immunization focuses on women, the communications strategy should equally target men and women in ways that are appropriate for each gender. It should involve influential community members and provide needed information and reassurances about immunization. Efforts also should be made to address concerns about the quality of immunization services--including health workers' interpersonal communication skills.</p

Factors influencing deliveries at health facilities in a rural Maasai Community in Magadi sub-County, Kenya

Abstract Background In response to poor maternal, newborn, and child health indicators in Magadi sub-county, the “Boma” model was launched to promote health facility delivery by establishing community health units and training community health volunteers (CHVs) and traditional birth attendants (TBAs) as safe motherhood promoters. As a result, health facility delivery increased from 14% to 24%, still considerably below the national average (61%). We therefore conducted this study to determine factors influencing health facility delivery and describe barriers and motivators to the same. Methods A mixed methods cross-sectional study involving a survey with 200 women who had delivered in the last 24 months, 3 focus group discussions with health providers, chiefs and CHVs and 26 in-depth interviews with mothers, key decision influencers and TBAs. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) using logistic regression were calculated to identify predictive factors for health facility delivery. Thematic analysis was done to describe barriers and motivators to the same. Results Of the women interviewed, 39% delivered at the health facility. Factors positively associated with health facility deliveries included belonging to the highest wealth quintiles [aOR 4.9 (95%CI 1.5–16.5)], currently not married [aOR 2.4 (95%CI 1.1–5.4)] and living near the health facility [aOR 2.2 (95%CI 1.1 = 4.4)]. High parity [aOR 0.7 (95%CI 0.5–0.9)] was negatively associated with health facility delivery. Barriers to health facility delivery included women not being final decision makers on place of birth, lack of a birth plan, gender of health provider, unfamiliar birthing position, disrespect and/or abuse, distance, attitude of health providers and lack of essential drugs and supplies. Motivators included proximity to health facility, mother’s health condition, integration of TBAs into the health system, and health education/advice received. Conclusion Belonging to the highest wealth quintile, currently not married and living near a health facility were positively associated with health facility delivery. Gender inequity and cultural practices such as lack of birth preparedness should be addressed. Transport mechanisms need to be established to avoid delay in reaching a health facility. The health systems also need to be functional with adequate supplies and motivated staff

Additional file 4: of Factors influencing deliveries at health facilities in a rural Maasai Community in Magadi sub-County, Kenya

Interview Guide: Key Birth Decision Influencer. Interview guide for Key Birth Decision Influencer (DOCX 26 kb