Improving Access to Quality Family Planning Services in Kenya by Addressing Contraceptive Discontinuation

Contraception has a significant impact on pregnancy-related risks, maternal and child survival. Kenya a low middle-income country in sub-Saharan Africa has a high contraceptive use of over 60% among women of reproductive age. However, one out of three women discontinue the use of a method by 12 months. High discontinuation rates result in women having an unmet need for modern contraceptives, meaning, they want to avoid a pregnancy but are not using a modern method thus negating the gains made. For instance, more than a third of pregnancies in Kenya are unintended, contributing to the high rates of maternal mortality. This thesis used qualitative and quantitative research methodology to explore contraceptive discontinuation, specifically the trends, reasons, and quality of care offered to women seeking contraception in Kenya. Findings presented in this thesis, indicate that majority of women in Kenya who currently use a contraceptive method are on a short-term method specifically injectables, which have been documented to have higher discontinuation rates compared to other long-acting methods. Side effects and costs are among the leading causes of discontinuation. The health system has not adequately supported women’s reproductive health needs by ensuring that they receive adequate information regarding their chosen contraception at initiation. Moreover, the burden of use of contraception continues to be with women, with some being covert users due to lack of spousal support. Family planning programs need to focus on the reproductive needs of women who have initiated contraceptive use to ensure their fertility desires are met

Access to information and use of adolescent sexual reproductive health services : qualitative exploration of barriers and facilitators in Kisumu and Kakamega, Kenya

Background: Kenya has a high prevalence of adolescent pregnancy and low access to and use of adolescent sexual reproductive health services. Despite the enactment of evidence-based policies to address this problem, adolescents continue to face health problems and barriers to adolescent sexual reproductive health information and services. Main objective: This study describes barriers to and facilitators of access to adolescent sexual and reproductive health services in Kisumu and Kakamega counties, Kenya. Methodology: We used a qualitative design. Through 61 data collection sessions, 113 participants were engaged in key informant interviews, in-depth interviews, and/or focus group discussions. Trained Research Assistants (RAs) engaged adolescents, health care workers, teachers, county leaders, and community representatives. Data were captured using audio recorders and field notes. Socio-demographic data were analyzed for descriptive statistics, while audio recordings were transcribed, translated, and coded. Thematic analysis was done with NVivo. Results: Findings show that the barriers of access to sexual reproductive health services and information were negative health workers’ attitudes, distance to the health facility, unaffordable cost of services, negative social cultural influences, lack of privacy and confidentiality. Facilitators to adolescent sexual reproductive health services were few and included getting priority for school going adolescents and enabling environment for partnerships on adolescent health issues. Conclusions: Adolescents in Kakamega and Kisumu face a myriad of barriers when seeking sexual reproductive health information and/or health services. We recommend that counties sensitize all stakeholders on adolescent sexual reproductive health problems, and support development of multi-sectoral, sustainable solutions to adolescent health needs

Assessing quality of family planning counseling and its determinants in Kenya:Analysis of health facility exit interviews

BACKGROUND: Available evidence suggests that provision of quality of care in family planning services is crucial to increasing uptake and continuation of use of contraception. Kenya achieved a modern contraceptive prevalence rate of 60% in 2018, surpassing its 2020 target of 58%. With the high prevalence, focus is geared towards improved quality of family planning services. The objective of this study is to examine the quality of family planning counseling and its associated factors in health facilities in Kenya. METHODS: We conducted a secondary analysis of the 2019 Kenya Performance Monitoring and Action, client exit data of women who had received family planning services. Quality of counseling was assessed using the Method Information Index Plus. We conducted a multivariable ordinal logistic regression analysis of data from 3,731 women to establish determinants of receiving quality family planning services. RESULTS: The Method Information Index Plus score for higher-quality counseling was 56.7%, lower-quality counseling 32.4%, and no counseling 10.9%. Women aged 15-24 years (aOR = 0.69, 95% CI = 0.56-0.86, p = 0.001) had lower odds of receiving better counseling compared to women aged 35 years and above. Those with no education (aOR = 0.52, 95% CI = 0.33-0.82, p = 0.005), primary (aOR = 0.56, 95% CI = 0.44-0.71, p<0.001) and secondary (aOR = 0.79, 95% CI = 0.65-0.98, p = 0.028) were less likely to receive better counseling compared to those with tertiary education. Women who received long acting and reversible contraception methods (aOR = 1.75, 95% CI = 1.42-2.17, p<0.001), and those who were method switchers (aOR = 1.24, 95% CI = 1.03-1.50, p = 0.027), had a higher likelihood of receiving better quality of counseling as compared to those on short-term methods and those who were continuers, respectively. CONCLUSION: The quality of family planning counseling in Kenya is still sub-optimal considering that some women receive no form of counseling at service delivery point. There is need to review the existing FP guidelines and training packages to increase focus on the quality of counseling services offered by health providers. Social accountability strategies that empower women to demand quality services should be included in community-level family planning interventions

A qualitative exploration of contraceptive use and discontinuation among women with an unmet need for modern contraception in Kenya

BACKGROUND: Addressing the unmet need for modern contraception underpins the goal of all family planning and contraception programs. Contraceptive discontinuation among those in need of a method hinders the attainment of the fertility desires of women, which may result in unintended pregnancies. This paper presents experiences of contraceptive use, reasons for discontinuation, and future intentions to use modern contraceptives. METHODS: Qualitative data were collected in two rural counties in Kenya in 2019 from women with unmet need for contraception who were former modern contraceptive users. Additional data was collected from male partners of some of the women interviewed. In-depth interviews and focus group discussions explored previous experience with contraceptive use, reasons for discontinuation, and future intentionality to use. Following data collection, digitally recorded data were transcribed verbatim, translated, and coded using thematic analysis through an inductive approach. RESULTS: Use of modern contraception to prevent pregnancy and plan for family size was a strong motivator for uptake of contraceptives. The contraceptive methods used were mainly sourced from public health facilities though adolescents got them from the private sector. Reasons for discontinued use included side effects, method failure, peer influence, gender-based violence due to covert use of contraceptives, and failure within the health system. Five reasons were provided for those not willing to use in the future: fear of side effects, cost of contraceptive services, family conflicts over the use of modern contraceptives, reduced need, and a shift to traditional methods. CONCLUSION: This study expands the literature by examining reasons for contraceptive discontinuation and future intentionality to use among women in need of contraception. The results underscore the need for family planning interventions that incorporate quality of care in service provision to address contraceptive discontinuation. Engaging men and other social influencers in family planning programs and services will help garner support for contraception, rather than focusing exclusively on women. The results of this study can inform implementation of family planning programs in Kenya and beyond to ensure they address the concerns of former modern contraception users

Moving policy to practice: role of advocacy in enabling provision of injectable contraceptives by pharmacists in Kenya

Expanding access to contraceptive services by making them available in pharmacies and drug shops is a family planning high-impact practice. In 2018, Kenya's Ministry of Health amended its family planning guidelines to allow pharmacists and pharmaceutical technologists throughout the country to provide subcutaneous and intramuscular depot medroxyprogesterone acetate. Amending the policy did not necessarily mean that the policy would be implemented. The Advance Family Planning project launched an advocacy campaign to engage key stakeholders to work with the Ministry of Health to implement the policy. Consequently, a family planning training package for pharmacists and pharmaceutical technologists was developed and rolled out. The advocacy process also led to strengthening family planning reporting by the trained pharmacists and pharmaceutical technologists. To further enhance sustainability by ensuring a continuous pool of pharmacy professionals equipped with skills to provide family planning services, Advance Family Planning and its partners advocated with universities and the Pharmacy and Poisons Board to revise the pre-service training curriculum to include family planning as a competence area for pharmacists and pharmaceutical technologists. A key lesson learned is that policy formulation does not necessarily translate to policy implementation. Advocacy is often needed to move policy to practice, especially where resources are required. Policy implementation also requires incremental achievement of milestones and the need for advocacy for each step in the process. Implementation of the policy provision that allows pharmacists and pharmaceutical technologists to provide injectable contraceptives has implications beyond family planning programs. It provides a point of reference for allowing pharmacists to offer other primary health care services, such as immunization, injectable HIV prophylaxis, and other interventions that might not be provided for in policy

Evaluating the effectiveness of a combined approach to improve utilization of adolescent sexual reproductive health services in Kenya : a quasi-experimental design study protocol

Background: Access to and utilization of adolescent sexual and reproductive health (ASRH) services remains poor. ASRH services in Kenya are primarily offered in health facilities and include counselling, information, and services on family planning, sexually transmitted infections, and HIV and basic life skills. The Ministry of Education also provides age-appropriate sexual and reproductive health information in schools. This paper presents a study protocol that will evaluate the effectiveness of a combined approach toward improving utilization of ASRH services. Methods: This will be a quasi-experimental study utilizing qualitative and quantitative methods. During the formative phase, data will be collected through focus group discussions, in-depth interviews, and key informant interviews to explore the barriers and facilitators of provision and utilization of ASRH services. A quantitative design will be used to obtain baseline and endline data through household surveys and client exit interviews. Following the formative and baseline household and client exit assessments, an intervention focusing on provision of ASRH service package targeting boys and girls will be implemented for 18 months. The package will include contextualized ASRH services, including counselling and age-appropriate, comprehensive sexual education for behavior change with an aim to increase utilization of ASRH services. An analysis of the primary outcome (utilization of ASRH services) will be undertaken to establish the difference in difference between the control and intervention arm, before the intervention (using the baseline survey data) and after the intervention (using the endline survey data). Discussion: Adolescents have now been included in the World Health Organization's Global strategy for women's, children's and adolescents' health (2016-2030), acknowledging the unique health challenges facing young people and their pivotal role as drivers of change in the post-2015 era. This study will generate evidence on whether a combined school, facility, and community approach works toward improving utilization of ASRH services. The information generated from the study will be beneficial for programming as it will identify underlying reasons for low utilization of ASRH services. Results will help to shape ASRH programs and reduce teenage pregnancy within Kenya and other similar low middle-income countries

Long-Acting Reversible Contraception Uptake and Associated Factors among Women of Reproductive Age in Rural Kenya

In the last two decades, the use of short-acting methods of contraception has driven the increase of contraceptive use in Kenya. We assessed the factors associated with uptake of long-acting reversible contraception by women seeking family planning services in public health facilities in Kakamega County, Kenya. A mixed methods cross-sectional study through client exit surveys among 423 women seeking family planning services was done at 12 public health facilities in Kakamega County. Twelve in-depth interviews with health care providers from the study facilities further explored practices in provision of long-acting reversible contraception (LARC). Among women initiating contraceptive use, LARC method utilization was 20.6%. Women&rsquo;s tertiary education level, Protestant Christian religion, age at first birth, and having no desire for more children were significantly associated with utilization of LARC. Structural factors including shortage of human resource, provider bias and lack of adequate skills on provision of services were identified as key barriers to uptake of long-acting reversible contraception services

Determinants of Contraceptive Use among Unmarried Young Women in Kakamega County, Kenya

Adolescent pregnancies adversely impact mental and reproductive health as well as educational and socio-economic outcomes. In Kakamega County, Kenya, 20% of adolescents begin childbearing by age 19. To inform interventions to reduce adolescent pregnancy, Jhpiego used the Barrier Analysis methodology, which is based on the Doer/Non-Doer study model, in which participants are categorized according to whether they are “Doers” or “Non-Doers” of the study behavior. This study examines the determinants of the behavior, “young unmarried women currently use modern contraceptive methods”. Participants included young women aged 15–19 who were sexually active, unmarried, and were using (“Doers”) or not using (“Non-Doers”) modern contraception. The findings reveal that the majority of Doers (88%) and Non-Doers (80%) understand the pregnancy risk associated with non-use, and there is no statistically significant difference between Doers’ and Non-Doers’ understanding of contraceptive benefits. Knowledge of side effects and misconceptions, such as the belief that contraception causes infertility, does not deter Doers from using contraception. Seventy percent of Doers note that contraception is accessible/available, while 39% of Non-Doers state the opposite. Doers are almost three times more likely than Non-Doers to say that most people approve of their contraceptive use, while Non-Doers are twice as likely as Doers to say that most people would not approve. Doers are four times more likely to indicate approval from their mothers and boyfriends. Non-Doers are five times more likely than Doers to have specific professional goals for the future. These findings illustrate the importance of moving away from fear-based messaging and instead highlighting social acceptability and contraception’s role in achieving future goals

Missed opportunity for self-injectable contraception awareness and adoption: Insights from client exit interviews in Uganda and Nigeria

Objectives: To assess the extent to which self-injection contraceptive information and services are provided to women in Uganda and Nigeria. Study design: We conducted a descriptive information cascade analysis using data from a cross-sectional exit interviews with 492 family planning clients in Uganda and 720 in Nigeria. Results: More than a third of respondents in Uganda (31.2%) and Nigeria (40.5%) reported not receiving any information about the self-injection contraceptive during service provision. Only 45.6% clients who adopted self-injected DMPA-SC in Uganda and 1.7% in Nigeria were issued with additional doses to take home. Conclusion: The findings suggest that there are missed opportunities to provide women with information and services on DMPA-SC self-injection. Implication: A contraceptive counseling and services cascade can be a useful tool for identifying gaps in the quality and person-centeredness of family planning services, and ultimately improving the experience of clients

Trends and determinants of adolescent pregnancy : results from Kenya demographic health surveys 2003–2014

Background Adolescent pregnancy increases the risk of disability and death due to unsafe abortion, prolonged labour and delivery, and complications after birth. Availability of accurate data is important to guide decision-making related to adolescent sexual reproductive health (ASRH). This study analyses the trends in prevalence and factors associated with adolescent pregnancy in Kenya using data from three national Demographic Health Surveys (2003, 2008/2009, 2014). Methods Our analysis focused on a subsample of data collected from women aged 20 to 24 years. A trend analysis was performed to establish a change in the rate of adolescent pregnancy in 2003, 2008/2009, and 2014 survey data points. Binary Logistic regression and pooled regression analysis were used to explore factors associated with adolescent pregnancy. Results The percentage of women aged 20 to 24 years who reported their first pregnancy between ages 15 and 19 years was 42% in 2003 and 42.2% in 2009 but declined to 38.9% in 2014. Using regression analyses, we established that education status, marital status, religion and wealth quintile were associated with adolescent pregnancy. Trend analysis shows that there was an overall decreasing trend in adolescent pregnancy between 2003 and 2014. Conclusion Although Kenya has made strides in reducing the prevalence of adolescent pregnancy in the last decade, much more needs to be done to further reduce the burden, which remains high. Definition Adolescents: Although WHO defines the adolescence period as being 10-19 years, this paper focuses on the late adolescent period, 15-19 years, here in referred to as adolescents