African Woman and Child Feature Service

A record number of Kenyan women are abandoning the use of family planning methods a few weeks or months after picking them from government health facilities, a move that has shocked reproductive health experts.

Nearly 40 percent of family planning users in Kenya discontinue their method within the first year of use, with more than half of the users not being adequately counseled about the methods they are about to use, according to the MDGs and Family Planning: Perspectives of Clients and Providers on Quality of Service in Public Family Planning Clinics in the Rift Valley Province of Kenya, a recent study done by Constance Ambasa-Shisanya et al.

Stopping usage of family planning was either due to poor counseling or making a client use a method that was not her preferred choice, the study found.

The study established that about 50 percent of family planning clients in the country were offered methods regardless of their preferred choices. This means women who preferred using pills were given injectable contraceptive or pills when they wanted implants like Norplant.

This is worrying especially when considered on the backdrop of low contraceptive prevalence of 39 percent (Kenya Demographic and Health Survey (KDHS), 2003).

Of the 256 family planning clients interviewed during the study, 63 percent said the method they were using was disadvantageous, while 62 percent said the method was suitable to them. Another 63 percent said they were aware of potential side-effects of the method they were using.

These findings confirm the worries of the 2003 KDHS, in which the authors say: “there has been an apparent increase in contraceptive discontinuation rates over the previous five years from 33 percent in 1998 to 38percent in 2003.”

Method failure (6 percent), desire to become pregnant (5 percent), and switching to another method (8 percent), are captured in the survey as the leading reasons for discontinuation. Discontinuation was high among condom users (59 percent) and pills users (46 percent).

There are fears the findings of the 2008 KDHS to be released before the end of this year may show further increase in the rates of discontinuation.

Take the case of Agnes. When she went to have her usual injection at one of the health centres in sprawling slums of Kibera in Kenya, what the nurse offered her were the pills. She refused to take them, arguing that she messed-up while on pills when she forgot to take them as required.  “I conceived while on pills because I used to forget to take them routinely as required,” says Agnes.

But the nurse at the health centre urged her on saying it will work well.  After much convincing, she gave in to the nurse’s pleas to use the pills once again as she waited for the injectable contraceptive.  No one knows if she conceived again while on these pills.

Agnes’ case is a classic example of women who head to health facilities hoping to get their preferred contraceptives only to be told they are not there, and in many cases end up being offered alternatives. Many of them never use these alternative methods or abandon them after a short while as they wait for their preferred ones. Meanwhile, during this intervening period, they are unprotected and vulnerable to pregnancy.

In their research, Ambasa-Shisanya et al say the high rate of discontinuation can be blamed on the poor quality counseling offered before a woman or couple decides which contraceptive method they want to adopt.  Counselling usually precedes the initiation of family planning. In some cases, the quality and comprehensiveness of FP information given to clients was wanting.

The researchers found other obstacles that contribute to the poor quality of family planning services offered. The constant contraceptive stock-outs were leaving health facilities with few products, limiting the choices of the clients. Conducting counseling in open spaces denied women privacy and made them less confident to ask certain questions and make informed choices on the method they want to use.

Other problems are: shortage of qualified staff to offer family planning services; insufficient family planning commodities; and shortages of equipments.

Ambasa-Shisanya et al argue that what is happening in public facilities does not augur well for the achievement of millennium development goals on reducing maternal and child mortality and reducing incidences of HIV/AIDS.

In their Research, The Quality of Family Planning Services and Client Satisfaction in the Public and Private Sectors in Kenya published this year by Oxford University Press, Sohail Agha and Mai Do, amplified this concern of such missed opportunities.

They say the prevailing problems in the public sector made private family planning providers preferred because they were better at managing interpersonal aspects of care and giving greater attention to clients who seek their services, resulting in higher client satisfaction.

While public health facilities offer family planning services free of charge and in accessible places, the study found, they are less frequented or utilized by individuals needing such services.

This behaviour among clients, low contraceptive prevalence rates, and the unmet need, have raised many questions as to what would be the reasons why individuals prefer services in the private facilities to those offered in public hospitals for free.

One of the complaints that continue to be registered by women seeking services is lack of quality family planning services in some public health facilities.  They have also complained of not getting contraceptives of their choice in public facilities.

Quality Assessment of Family Planning Services in Ife Administrative Health Zone: Client Perspective, a study by Orji E, et al of Nigeria, argues that quality family planning is crucial as it determines whether a client will accept, use effectively and continue to practice contraception

Ambasa-Shisanya and Sohail Agha and Mai Do agree that to ensure quality of family planning, the country will have to offer couples or individuals appropriate family planning methods, accurate and complete information; and constant supply of contraceptives.

They will have to further ensure the services offered affordable and accessible; train enough personnel; and put in place the necessary logistics to guarantee free flow of contraceptive, especially in the rural areas.

Other proposals include monitoring the delivery of these services, and establishing facilities and equipment required for provision of long-term and permanent family planning methods such as Norplant, intrauterine devices, tubal ligation and vasectomy.

Ambasa-Shisanya and Sohail Agha want family planning clients to be more assertive when seeking relevant information on available contraceptive methods and their side-effects.

To the government and other actors, they want them to address the perceived provider disposition towards a certain family planning method which makes it difficult for the clients to discuss it; and financial constraints which limit women from using their preferred family planning methods.

The current scenario calls for retraining of the service providers, eliminating biases of family planning providers, and ensuring availability of family planning methods all year around, are some of the issues that require urgent attention. Integration of family planning into the curriculum of nurses, midwives and other health personnel will be important, propose the researchers.