Factors influencing contraceptive uptake among women of reproductive age in Kenya

Introduction

A modern contraceptive method is defined as a product or medical procedure that interferes with reproduction from acts of sexual intercourse¹. Modern contraceptive methods (MCM) are in line with addressing reproductive health needs as reflected in Sustainable Development Goal 3.7² which calls for universal access to family planning by 2030². Birth spacing and limitation by utilizing current family planning (FP) methods have the potential to prevent 1.5 million maternal deaths and almost two million children deaths each year, as well as contribute to overall economic growth and development. Unmet FP demand on the other side contributes to unintended pregnancies and unsafe abortions^3,4. Of the 1.11 billion women of reproductive age who needed family planning services in 2019 only 842 million got them, leaving 270 million women around the world with unmet demands. The unmet need for family planning services is significantly worse in the low and middle income countries where more than 232 million women cannot receive MCM when necessary⁵. Every year, approximately 14 million unintended pregnancies occur in sub-Saharan Africa alone⁶ with teenager girls and women between the ages of 15 and 24 being the most vulnerable. For example, in Benin, adolescence is seen as the start of the continuity of medical care for reproductive newborn, maternal, and pediatric health. During this time poor access to and utilization of contraception are likely to have a negative impact on health outcomes overall⁷.

Modern contraceptives are so effective that they reduce maternal death by more than 20% and newborn mortality by 17%⁸. Contraceptive prevalence rates (CPR) are often lower in areas with high fertility rates and the sub-Saharan Africa (SSA) region is not an exception^9,10. The majority of underdeveloped countries including Kenya, however, utilize few contraceptive methods hence they have a lot of unmet needs¹¹. According to the UN's 2017 World Family Planning highlight levels of unmet family planning need greater than 20% are considered high, and those less than 10% are deemed low¹². Studies have shown that, in some countries in Africa, 38% of contraceptive users stopped using them after the first year^13,14. Kenya is not exempt from this - 31% of users of contraceptives discontinued use within a year of beginning use¹⁵. Even though Kenya has made a sizable effort in raising knowledge about the methods and encouraging the use of contraceptives, some women with unmet need for family planning were previous contraceptive users. Modern contraceptive prevalence rates among married women are 57.0% and among sexually active unmarried women aged 15–49 years, 59%. which is still a low contraceptive prevalence rate¹⁵ by Kenyan survey. The availability of high-quality healthcare facilities such as hospitals and health centers have an impact on one's selection of contraception and the unmet need for FP¹⁶. In addition, insufficient stocks and restricted usage of available methods create conditions that ultimately restrict women’s choices and use and are likely contributing factors to the prevalence of contraceptive discontinuations¹⁷. To ensure that individuals and couples can select their chosen contraceptive method and meet their fertility objectives, it is crucial to have an appropriate choice of methods at various tiers of the health care system¹⁸.

Healthcare financing of reproductive health is critical that promotes equitable access due to affordability of services. The Kenyan health sector is financed from public, private, and donor sources accounting for 37%, 39.6%, and 23.4% of total health expenditure. Out-of-pocket (OOP) costs for households make up a sizable amount (26.1%) of all medical expenses¹⁹. It is the State’s fundamental duty to respect, protect, promote and fulfil the right to the highest attainable standard of reproductive health care by ensuring the provision of a health service package at all levels of the health care system including FP services²⁰.

In this context, this study will examine the factors influencing the uptake of modern contraception among Kenyan women of reproductive age and fill this gap using the most up-to-date Performance, monitoring for Action (PMA) survey data available in Kenya which may help decision-makers, stakeholders and planners develop efficient tactics to reduce the terrible consequences of unintended pregnancy while also raising the level of socioeconomic status across the country and geographical area⁸. Finally, we shall come up with solid recommendations on how to improve contraceptive uptake and usage with the ultimate goal of accelerating the country's growth and development. This study's specific objectives were to describe the socio-demographic factors associated with contraceptive uptake among women of reproductive age, to describe the prevalence of MCM uptake among women of reproductive age and to determine the effects of health system factors on contraceptive use among Kenyan women of reproductive age.

Methods

Results

A total of 9477 women and 945 service delivery points completed the survey and were eligible for the analysis. Table 1 shows the socio-demographic characteristics of the sample. Majority of the respondents (39.2%) in the survey were aged young women 15–24 years while about (7.8%) were 45–49 years. More than half (53.4%) of the women were married, about a third (32.0%) were unmarried. About eight in every 10 women had basic education (primary and secondary levels), while (4.5%) had no basic education level. Majority of the women were Protestants (70.7%) and nearly all study participants (98.4%) were aware of modern contraceptive methods. Women who had at most one child were more (44.1%), whereas those who had two to three or four and more children were less common (28.8%) and (27.1%), respectively. Dispensaries (30.1%) were the most preferred source of contraceptives. Half (50.7%) of the facilities that offered contraceptive methods experienced or had an episode of contraceptive stock outs. More than half of the facilities (53.4%) supported community health volunteers in providing family planning services. The NHIF-covered facilities with FP services were less prevalent (7.14%) than those without NHIF (92.86%). Adolescents were more (51.95%) likely to use FP services in facilities that offered counseling, provision, and prescription of family planning methods.

Discussion

We analyzed the secondary data collected by PMA 2019 survey. The survey gathered quantitative data to examine the factors associated with the uptake of modern contraception among Kenyan women of reproductive age. From these study findings, we found out that the prevalence of modern contraceptives in the 11 Counties in Kenya during the performance monitoring survey 2019 was 43.2%. A larger number (21.6%) of respondents were between the ages of 15 and 19, while most (53.4%) were married, the majority (69.8%) lived in rural areas, and just 4.5% had no formal education. We also discovered that the majority of health facilities (92.86%) with FP services were not covered by NHIF. The Kenya Demographic Health Survey²¹ reports modern contraceptive prevalence rates among married women is (57.0%) and sexually active unmarried women aged 15–49 years is 59%.

Our study found that modern contraceptive use was high among the older women (greater than 20 years) while least among the adolescents 12.1% (95% CI; 10.4, 14.05) and those above 45 years 34.0% (95% CI; 29.74,38.46, p=0.000). This is consistent with another prior studies in Kira-Uganda⁵ which reported more limited MCM use among adolescent girls when compared to older age groups. Similarly a previous study done in Kwale county-Kenya noted that healthcare system constraints such as a lack of youth-friendly services, sexual and reproductive health commodities, with deeply rooted negative attitudes, significant anxiety and myths and misconceptions among adolescents serve as impediments to the beginning and ongoing utilization of contraceptive use and side effects²². It is therefore critical to promote family planning education and information to dispel myths and misconceptions²² and provide a variety of service options to fit their needs²². The study further found that about roughly five in every 10 married women were using a modern contraceptive while only about two in every 10 of the unmarried were using a modern contraceptive. This suggests that married women have a greater desire to space or limit pregnancies²³ by study done in Uganda. The study further shows that the level of education was a determinant of contraceptive use as the level of education increased from non-formal education 24.7% (95% CI; 19.45, 30.7) so was the increase in contraceptive use among those with tertiary level 47.8% (95% CI; 40.79, 54.9). Two previous studies^23,24 in Uganda and Ghana reported that the use of contraceptives is significantly influenced by education this suggests that persons with higher levels of education were definitely more conscious of the advantages and significance of using contraceptives, they are also more informed which enhances access to services and offers them greater negotiating power when making decisions about using contraceptives. This study's further conclusion demonstrates that in comparison to Catholics, women associated with the Islam faith were less likely to use modern methods of contraception (aPOR 0.6, 95% CI; 0.42, 0.89). This is consistent with a study undertaken in five countries (Democratic Republic of the Congo, India, Kenya, Nigeria, and Burkina Faso)²⁵ that found Muslim married women have lower probabilities of using MCM than their Catholic counterparts. Likewise, a study in three African nations²⁶ found that having a strong religious identity can affect women's uptake of MCM.

The consumption of contraceptives was also linked to a woman's parity, according to our study, women who had two to three children used MCM at a rate of about 59.9%, compared to only 25.3% among women who have less than one child. This could mean that women of low parity are under pressure to have more children as reported by study^5,27 from two countries Uganda and India. Another research study which was done in India reported that women with no child once married are forced to prove their fertility due to pressures from spouses, in laws and communities²⁷.

Women from middle and high wealth quintiles had a higher odd of modern contraceptive use [aPOR 1.3, 95% CI; 1.04, 1.57] and [aPOR 1.4, 95% CI; 1.07, 1.8] as compared to those from the poorest wealth quintile. Findings from previous studies^5,28 in Uganda agrees with our results, married women living in communities with high poverty levels were less likely to use modern contraceptives compared to those who live in communities that were in low poverty levels. Economically needy communities may be less likely to invest in women’s education, resulting in a lower level of understanding of contraceptive use, and less autonomy²³ as was seen in a recent study in Uganda. Distance to health services may also be major barrier leading to very low contraceptive use^29,30 as seen in Guatemala - Latin America and USA. Additionally, study findings in Ghana discovered that communities with more working married women have higher likelihood of using modern contraception which is consistent with the results of our study. Women who work are able and willing to spend their money on the necessary medical expenses and they also have the freedom to decide on family planning with their partners, which may not be the case for married women who are reliant on their husbands and do not work²⁴. Residents of West Pokot [aPOR 0.3, 95% CI; 0.17, 0.44] were less likely to use modern contraceptives as compared to Bungoma county, this is in line with a study by Kenya health survey²¹ that reports that the percentage of currently married women using a modern method which is lowest in almost all counties of Northern part of Kenya; Mandera (2%), followed by Wajir (3%), Marsabit (6%), and Garissa (11%).

It was discovered from this study that the lower the level of the facility types, the less the MCM consumption, with dispensaries at 37.8% (95% CI; 32.9,43.1), and health centers at 42.7% (95% CI; 35.9,49.9) as compared to hospitals (46.5%) (95% CI; 36.2,57.2). The health system in a woman's environment may affect her choice to use contraception depending on factors like the availability of methods, accessibility to facilities and the level of care^31,32. Contraceptive prevalence was also low at 37.5% (95% CI; 32.8,42.5) among women who visited facilities with episodes of contraceptive stock outs, unlike those who visited facilities which did not experience stock outs. This is in line with 18 who reported that insufficient stocks and restricted usage of available methods create conditions that ultimately restrict their use. Additional research done in Kenya indicates that providing high-quality FP services can raise user satisfaction which will encourage clients to use the service repeatedly and consistently whenever they need a method¹³. In addition, this study found that the uptake of FP services was lower in facilities covered by NHIF (aPOR 0.5,95%CI; 0.29,0.98, p=0. 043) than in those not covered. This is corroborated by research conducted in Laos¹⁶ which found that equitable advances in the modern contraceptive prevalence rate (mCPR) across demographic groups cannot be guaranteed by the formal inclusion of family planning services in health insurance benefits packages. It has been reported that insurance plans payment structures for repaying providers for family planning services can either promote or discourage the provision of specific methods. This is consistent with a recent study in a Kenya³³ that indicates that despite the widespread belief that health care financing and spending lead to improvements in health status and the inclusion of family planning services, its data is scant and conflicting, especially for low and middle-income countries (LMICs) like Kenya.

Contraceptive prevalence is also higher among adolescents aged 15 to 19 years who were offered and prescribed FP services compared to those who were not offered any FP services. A previous study⁵ in Uganda states that the lack of youth-appropriate facilities limits young people's access to counseling and knowledge about contraception. Another study⁷ in Benin also demonstrates that unmarried young women are hesitant to obtain contraception despite their desire to avoid pregnancy since their communities perceive them as unsuitable for sexual activity. These can be addressed by providing a wide selection of modern contraceptive methods, whether through health institutions or community-based distributors, as well as client-centered thorough counseling to enable people to make informed and voluntary decisions about FP usage. Similarly, a steady availability of cheap contraceptive methods correlates to increasing and consistent use of modern contraception among this age group³⁴ by a study done in Kinshasa – Uganda.

Conclusions and recommendation

Our study shows that participants with higher levels of formal education were more willing to embrace MCM adoption than those with low education attainment. The result also indicates a relatively low overall contraceptive prevalence of 43.2%. Results also show that there was a period of commodity stock out, indicating that women are missing out on their preferred FP options.

County school health coordinators should ensure integration of sexual reproductive health sessions in the school curriculum. The county reproductive health coordinators and health promotion officers should advocate on modern contraceptive methods to increase services access to comprehensive education on FP service availability and MCM service alongside client centred contraceptive counselling to support a patient’s reproductive autonomy. County health products and technologies coordinators should ensure timely quantification and forecasting and availability of all family planning commodities in all health facilities.