Contraceptives

Introduction

Kenya is characterized by high unmet need for family planning (FP) and high unplanned pregnancy, in a context of urban population explosion and increased urban poverty. It witnessed an improvement of its FP and reproductive health (RH) indicators in the recent past, after a period of stalled progress. The objectives of the paper are to: a) describe inequities in modern contraceptive use, types of methods used, and the main sources of contraceptives in urban Kenya; b) examine the extent to which differences in contraceptive use between the poor and the rich widened or shrank over time; and c) attempt to relate these findings to the FP programming context, with a focus on whether the services are increasingly reaching the urban poor.

Methods

We use data from the 1993, 1998, 2003 and 2008/09 Kenya demographic and health survey. Bivariate analyses describe the patterns of modern contraceptive use and the types and sources of methods used, while multivariate logistic regression models assess how the gap between the poor and the rich varied over time. The quantitative analysis is complemented by a review on the major FP/RH programs carried out in Kenya.

Results

There was a dramatic change in contraceptive use between 2003 and 2008/09 that resulted in virtually no gap between the poor and the rich in 2008/09, by contrast to the period 1993–1998 during which the improvement in contraceptive use did not significantly benefit the urban poor. Indeed, the late 1990s marked the realization by the Government of Kenya and its development partners, of the need to deliberately target the poor with family planning services. Most urban women use short-term and less effective methods, with the proportion of long-acting method users dropping by half during the review period. The proportion of private sector users also declined between 2003 and 2008/09.

Conclusion

The narrowing gap in the recent past between the urban poor and the urban rich in the use of modern contraception is undoubtedly good news, which, coupled with the review of the family program context, suggests that family planning programs may be increasingly reaching the urban poor.

Introduction

Family planning (FP) is now acknowledged as one of the most successful development interventions, with potential benefits on maternal and child health (MCH) outcomes, educational advances, economic development, and women’s empowerment [1]. Yet, 200 million women in the developing world want to delay pregnancy or stop childbearing, but are not using an effective method of contraception [2,3]. In developing countries as a whole, the proportion of married women using a method of contraception increased from 10% in the 1970s to nearly 60% in the late 1990s, while the total fertility rate (TFR) dropped from six children per woman to around three in the same period [2,4]. While Kenya followed a similar pattern of increased contraceptive use and substantial decline in fertility, unmet need for FP, which refers to the proportion of sexually active, fecund women who want to avoid or postpone childbearing but are not using any method of contraception [5], remains high at about 25% [6,7]. Noticeably, 42.7% of births in the five years preceding the 2008/09 Kenya Demographic and Health Survey (DHS) were reported to be unintended (25.2% mistimed and 17.5% unwanted), compared to 51.5% (34.9% mistimed and 16.6% unwanted) in 1993, representing a modest decline of just nine percentage points over a 15-year period [7]. According to the same study, the differences in unintended pregnancy by household wealth remained largely unchanged over time.

The consequences of low contraceptive use and high unmet need in terms of unintended pregnancies and births have been abundantly studied [2,8]. There is also ample evidence on the negative effects of unplanned pregnancy and fertility on infant, child, and mother’s health [2,6,9], household economic conditions, population growth, and the attainment of the Millennium Development Goals (MDGs) [10,11]. Equally well documented are the barriers to contraceptive uptake and the reasons for non-use [2,6,12,13].

Kenya, like most countries in sub-Saharan Africa, is experiencing an urban explosion. Its urban population made a great leap from about half a million in 1960 to about 2.5 million in 1980, further increased to reach about 9 million in 2010 (making up about 40% of the total population), and is projected to reach 40 million by 2050 [14]. While rural to urban migration is at play, evidence suggests that about 75% of urban growth in sub-Saharan Africa is due to natural population growth (difference between births and deaths), with only about 25% accounted for by migration to urban areas [15,16], pointing to the importance of access to FP services in urban areas, particularly among the urban poor.

Another dominant trend in Kenya’s population landscape is the growing urban poverty and deteriorated health outcomes among the urban poor. For example, over 60% of inhabitants of Kenya’s capital city, Nairobi, are estimated to be living in slums and other informal settlements [17], characterized by poor access to healthcare and reproductive health (RH) services, early sexual debut, and high-risk sexual behaviors [18,19]. Further, significant inequities in health and RH outcomes have been documented in urban Kenya, with the poor tending to have not only the lowest contraceptive use, but also the highest fertility and the highest unmet need for FP [18,20]. Admittedly, an important but largely neglected dimension of urban fertility dynamics is the reproductive outcomes of urban populations living in poverty [13]. In the new era of urban explosion and concomitant growth of urban slums and informal settlements, the urban population in general and the urban poor in particular, will increasingly play a dominant role in defining progress toward national and international development agendas, including the Millennium Development Goals (MDGs).

Within this background of high unmet need for FP in Kenya, high unplanned fertility, and urban population growth amidst increased urban poverty and deprivation, the objectives of the paper are three-fold. First, we describe inequities in modern contraceptive use, types of methods used, and the main sources of contraceptives in urban Kenya. Second, we examine the extent to which differences in contraceptive use between the better-off and less privileged groups widened or shrank over time. Third and finally, using a review of major FP programs implemented in the country, we attempt to relate these findings to the FP programming context, with a focus on whether the services are increasingly reaching the urban poor.

Population and family planning in Kenya: policy context and major achievements

Kenya is recognized for its robust population, FP and RH policy environment. It was one of the first countries in sub-Saharan Africa to develop a national population policy and launch a national FP program in the late 1960s; these policies laid the foundation for the onset of the Kenya demographic transition in the 1980s [21,22]. During the 1980s and early 1990s, the government continued to demonstrate considerable commitment to FP, with the development of new national policies and guidelines which paved the way for increased support for contraceptive supplies and extensive information, education and communication (IEC) campaigns [22,23]. Service provision expanded impressively during the period (80s to early 90s), while at the same time, the country registered a rapid decline in fertility – from an average of 8.1 children per woman in 1977 to 4.7 in 1998, and a steady rise in the modern contraceptive prevalence rate (CPR) from 7% in 1977 to 39% in 1998 [7,24].

In the mid-1990s the national FP program started to dwindle, and external funding for FP services and IEC declined, as other competing priorities gained traction in the global and national agendas (particularly the HIV/AIDS pandemic). The positive trends described above came to a halt in the late 1990s, with stalled contraceptive prevalence and fertility decline [21,24,25]. The 2004 Kenya Service Provision Assessment Survey found that in the five years preceding the survey, the proportion of health facilities offering any method of FP declined from 88% to 75% [26].

From the mid-2000s, champions of FP/RH within the Kenyan Government began to play important roles in refocusing energies on FP through policy and advocacy activities, providing a framework for equitable, efficient, and effective delivery of high-quality RH services throughout the country, and emphasizing reaching those in greatest need and most vulnerable [26,27]. A line item for contraceptive commodities was eventually included in the 2005 national budget, allocating 200 million Kenyan Shillings (or US$2.62 million), increasing to 300 million Kenyan shillings in the 2006/7 financial year [21,23]. The latest data indicate that contraceptive use once again registered an increase in 2008/09 – to 46% from 39% in 2003 - while fertility declined modestly to 4.6 births per woman, down from 4.9 in 2003, returning just below its 1998 level of 4.7 [7]. While these national trends in FP use and fertility are essential to assess progress towards the MDGs, understanding the urban dynamics and the vulnerabilities of the urban poor, is of special interest, as the country becomes increasingly urban.