Rural Community-Based Family Planning Project of Western Kenya: Demonstration Phase,

Transcription

1 Rural Community-Based Family Planning Project of Western Kenya: Demonstration Phase, Report of the 2010 Baseline Survey August

2 2

3 Rural Community-Based Family Planning Project of Western Kenya: Demonstration Phase, Report of the 2010 Baseline Survey i

4 This report presents the findings of the baseline household survey conducted in 2010 in rural areas of Western region of Kenya for a community-based family planning project. The report has been prepared by the African Population and Health Research Center (APHRC) in collaboration with Marie Stopes Kenya (MSK), Family Health Options of Kenya (FHOK), the Great Lakes University of Kisumu (GLUK), and the Ministry of Public Health and Sanitation. The baseline survey was implemented by APHRC and GLUK in collaboration with the Kenya National Bureau of Statistics (KNBS). The community-based contraceptive project is implemented by a consortium led by APHRC. We acknowledge the David and Lucile Packard Foundation who funded the community-based family planning project. The opinions expressed in this report are those of the authors and do not necessarily reflect the views of the donor organization. General support grants to APHRC from Sida (Grant number ), and the William and Flora Hewlett Foundation (Grant number ) was also critical in assisting APHRC staff develop this report. Additional information about this report and the project may be obtained from: The Principal Investigator Packard Western Kenya-Community Family Planning Project African Population and Health Research Center (APHRC) P.O. Box Nairobi, Kenya Telephone info@aphrc.org Additional information about the community-based family planning project of Western Kenya may be obtained from APHRC; Website: Recommended citation: African Population and Health Research Center (APHRC) Report of the 2010 Baseline Survey of the Community-Based Family Planning Project of Western Kenya: Demonstration Phase, ; Nairobi: APHRC. APHRC 2013 ii

5 Contents List of Figures v List of Tables vi Foreword vii List of Abbreviations viii Executive Summary ix Chapter 1: Introduction 1 Overview of Population and Fertility in Kenya 1 Overview of Family Planning Program and Reproductive Health Policies in Kenya 2 Strengthening Reproductive Health and Family Planning in Nyanza and Western Region of Kenya 4 Population and Health Priorities of the Project Areas 5 Objectives and Organization of the Report 7 Data and Methods of Analysis 8 Chapter 2: Characteristics of Household Population and Respondents 11 Household Population by Age and Sex 11 Household Composition 12 Household Environment 13 Sources of Drinking and Water Sanitation facilities 15 Household Wealth 16 Background Characteristics of Respondents 17 Access to Mass Media 19 Employment Status of Women 20 Employment Status of Partner 22 Women s Control over Earnings 23 Women s Participation in Decision Making 24 Freedom of Women in Decision Making 26 Perceptions about Family Planning and Child Bearing 27 Chapter 3: Fertility Preferences 28 Birth Intervals 28 Age at First Birth 29 Teenage Pregnancy 30 Desire for More Children 30 Mean Ideal Number of Children 32 Fertility Planning Status 33 iii

6 Chapter 4: Family Planning 35 Knowledge of Contraceptive Methods 35 Ever Use of Modern Contraceptives 36 Current Use of Modern Contraceptives (CPR) 39 Knowledge of Fertile Period 41 Source of Modern Contraceptives 42 Challenges in Obtaining Contraceptives 42 Women Acceptance of Contraceptives from Community Health Workers 43 Informed Choice 44 Reasons for Non-Use of Family Planning 45 Future Intentions to Use Contraceptives 46 Discussions of Family Planning with Spouse 49 Self-efficacy in Use of Family Planning 51 Locus of Control in Contraceptive Use 53 Chapter 5: Other Proximate Determinants of Fertility 55 Current Marital Status 55 Age at First Marriage 56 Age at First Sexual Intercourse 56 Recent Sexual Activity 57 Chapter 6: Integration of Family Planning with Maternal Child Health Services 59 Place of Delivery 59 Assistance during Delivery 59 Reasons for Not Delivering in a Health Facility 61 Exposure of Family Planning Interventions to Maternal and Child Health Clients 62 Chapter 7: Conclusion and Programmatic Implications ` 64 General Population Characteristics 64 Implication 64 Fertility Preferences in Western Region 64 Implication 65 Knowledge and Use of Contraceptives 65 Implications 65 Integration of FP with Delivery, Maternal and Child Health Services 66 Implication 67 References 68 Appendices 71 iv

7 List of Figures Figure 1 Map of Kenya Showing Counties 6 Figure 2 Distribution of Age and Sex of Population in Bondo, Siaya, Busia and Teso Districts 12 Figure 3 Access to Mass Media 19 Figure 4 Planning Status of Births 34 Figure 5 Figure 6 Figure 7 Figure 8 Current Use of Contraception among Married Women by Wealth and Level of Education 41 Common Challenges Faced when Obtaining Hormonal Methods and Condoms 43 Acceptance of Selected Types of Contraceptives from Community Health Workers 44 Reasons Given for Non- Use of FP among Women not currently using a Method 45 Figure 9 Reasons for not Delivering in a Health Facility 62 Figure 10 Exposure to FP Information or Counseling During Delivery, Child Health and Maternal Health Visits 63 List of Tables Table 1 Results of the Household and Individual Interviews 10 Table 2 Household Population by Age, Sex and Region 11 Table 3 Household Composition 13 Table 4 Household Characteristics 14 Table 5 Household Possessions 15 Table 6 Household Drinking Water and Sanitation 16 Table 7 Wealth Tertiles 17 Table 8 Background Characteristics of Respondents 18 Table 9 Exposure to Media 20 Table 10 Employment Status of Women 21 Table 11 Employment Status of Partners 22 Table 12 Control Over Women s and Partner s Cash Earnings 24 Table 13 Women s Participation in Decision-making 25 Table 14 Freedom among Women to Make Certain Decisions 26 Table 15 Women s Perceptions on Family Planning and Child Bearing 27 v

8 Table 16 Birth Intervals 28 Table 17 Median Age at First Birth 29 Table 18 Teenage Motherhood 30 Table 19 Desire for More Children 31 Table 20 Desire for More Children among Spouses of Currently Married Women 32 Table 21 Mean Ideal Number of Children 33 Table 22 Fertility Planning Status 34 Table 23 Knowledge of Contraceptive Methods 35 Table 24 Ever Use of Contraception-Nyanza 37 Table 25 Ever Use of Contraception-Western 38 Table 26 Current Use of Contraception -Nyanza 39 Table 27 Current Use of Contraception-Western 40 Table 28 Knowledge of Fertile Period 41 Table 29 Source of Modern Contraception Methods 42 Table 30 Acceptance of Contraceptive Methods from Community Health Workers 43 Table 31 Informed Choice 45 Table 32 Future Use of Contraception 46 Table 33 Preferred Method for Future Use 48 Table 34 Discussion About the Number of Children to Have 49 Table 35 Women s Source of Influence to Use Contraception 50 Table 36 Support of FP from Religious and Government Leaders 51 Table 37 Women s Self Efficacy in Contraceptive Use 52 Table 38 Locus of Control in Contraceptive Use 53 Table 39 Current Marital Status 55 Table 40 Age at First Marriage 56 Table 41 Age at First Sexual Intercourse 57 Table 42 Recent Sexual Activity 58 Table 43 Place of Delivery 60 Table 44 Assistance During Delivery 61 Appendix A: Survey Team 71 Appendix B: Questionnaires 73 vi

9 Foreword The Packard Western Kenya (PWK) Project seeks to establish a community-based family planning program in Western Kenya aimed at increasing access and voluntary uptake of family planning services. The project aims at increasing the contraceptive prevalence rates, reverse the stall in fertility levels, and reduce unwanted and mistimed pregnancies, levels of unsafe abortions, and maternal and infant mortality rates. The project is implemented by a consortium led by APHRC and funded by the David and Lucile Packard Foundation. As part of its objective to expand the knowledge base of, and evidence on, community-based family planning project, APHRC conducted a baseline survey in 2010, among women age The survey sought to generate data to inform the design of the FP project and provide baseline information for evaluating the effectiveness of the intervention. I am delighted to present this report which was written by the PWK project team led by the African Population and Health Research Center (APHRC). I would like to acknowledge the various individuals who contributed in different ways to this report. Dr. Gwendolyn Morgan of APHRC conceived the study and was its lead Principal Investigator. Dr. Jean-Christophe Fotso of APHRC and Dr. Richard Muga of GLUK gave leadership in the design of the survey tools for the baseline study; Ms. Carol Mukiira of APHRC supervised data collection and oversaw the completion of this report; Mr. James Nganga of KNBS led the calculation and placement of data weights; Mr. Michael Mutua of APHRC supported the design of data entry program and data analysis; Ms. Ekirapa Akaco of APHRC led the development of the first draft of this report; and Mr. Paul Kuria of APHRC who led the field implementation of the study, supervised data analysis, reviewed all data tables, and helped with writing the final draft of this report. I would also like to acknowledge the contributions of PWK staff from FHOK, MSK, and GLUK to this report. It is my sincere hope that this report will shed light on the situation of family planning and reproductive health in Western Kenya and provide the health programmers with critical information for the design and delivery of effective rural community-based family planning interventions. It is also my hope that GLUK whose responsibility it is to monitor the project and engage the policy public with the emerging evidence will disseminate this report widely. Dr. S. K. Shariff, MBS, MBChB, M.Med, DLSHTM, MSc Director, Ministry of Health vii

10 List of Abbreviations AIDS AMREF APHRC CBS CBD CPR TFR DHMB DHMT FHOK FP GLUK HIV ICPD ILO IUD KHPF KNBS MDG MSK MCH MOH MOMS NCAPD NCPD NHSSP NRHS PWK RH USAID WHO Acquired Immunodeficiency Syndrome African Medical Research and Education Foundation African Population and Health Research Center Central Bureau of Statistics Community Based Distribution Contraceptive Prevalence Rates Total Fertility Rate District Health Management Board District Health Management Team Family Health Options of Kenya Family Planning Great Lakes University of Kisumu Human Immunodeficiency Virus International Conference on Population and Development International Labor Organization Intrauterine Device Kenya Health Policy Framework Kenya National Bureau of Statistics United Nation s Millennium Development Goals Marie Stopes Kenya Maternal Child Health Ministry of Education Ministry of Medical Services National Coordinating Agency for Population and Development National Council for Population and Development (formerly NCPD) National Health Sector Strategic Plan National Reproductive Health Strategy Packard Western Kenya Project Reproductive Health U.S. Agency for International Development World Health Organization viii

11 Executive Summary Background Strong evidence base is required to effectively develop and deliver targeted reproductive health programs to underserved populations. The Packard Western Kenya (PWK) Project is a rural community-based family planning intervention funded by the David and Lucile Packard Foundation to reverse the fertility stall in Western Kenya, increase access and utilization of voluntary family planning services, and reduce unsafe abortions, infant and maternal mortality. The PWK project is a two-year demonstration imitative implemented in four rural districts of Western Kenya, namely Siaya, Bondo, Teso and Busia by a consortium led by APHRC. Other partners in the consortium are Family Health Options of Kenya (FHOK), Great Lakes University of Kisumu (GLUK), Marie Stopes Kenya (MSK), and the Ministry of Public Health and Sanitation. The consortium conducted a baseline survey in May 2010 among women age to provide reference information for use in the measurement of the impact of the project and to inform a three-year scale-up phase planned to begin in The baseline survey was designed to assess knowledge and use of contraception, perceived availability and accessibility of FP services at the community level, desired number of children, planning of pregnancies, women ability to make decisions and control selected resources, the sexual behavior and marriage practices, exposure to family planning messages, and opportunities of integrating FP services with delivery, child and maternal health services in health facilities. Results General Population Characteristics Kenya s Western Region has a youthful population with majority of the people being in the age category of 0-24 years (70 percent of males and 65 percent of females). Over one-third of the households (37 percent) were headed by women. The mean household size was estimated at 4.7 persons in Nyanza and 5.5 persons in Western. Less than 10 percent of households in the region were connected to electricity and over 70 percent of the dwelling units had walls made of earth or dung. One-half of the households had access to improved sources of water and about 70 percent owned a radio. Only three in every five women in the region owned a mobile phone. Approximately one-third of women were in the lowest wealth status with the highest proportion (52 percent) occurring in Teso. Sixty percent of women surveyed were married and about one in every ten women was in a polygamous union. The proportion of women who had completed primary school was 75 percent in Nyanza compared to 66 percent in Western. One-fifth of women had secondary education or higher. Data on exposure to mass media show that radio was the most popular medium while slightly less than 20 percent of women had access to newspapers and television. One-half of the women were currently working and 74 percent of partners of the married women were currently working. About 65 percent of currently married women who earn cash reported that they make decision on how the earnings are spent. ix

12 Fertility Preferences The overall median birth interval was 30 months with the most common birth interval category occurring between 24 and 35 months; and the least common interval occurring between 7 and 17 months. The median age at first birth was 18.2 years and was lowest among poor women estimated at 17.9 years. Women with at least some secondary level of education began child bearing about three years after women with no education (20 years compared to 17 years). Teenage pregnancy was prevalent in Western Kenya with 44 percent of women age having begun child bearing. A higher proportion of women aged years in Bondo (71 percent) had begun child bearing. Teenage pregnancy was higher among women in the lowest wealth status. Overall, there was a widespread desire for children. More than half of the women indicated that they would like to have between 3-4 children and a quarter desired to have 5 or more children. The study shows that about one-third of births in Western region were unwanted or were mistimed (wanted later). Family Planning Knowledge of family planning was nearly universal with over 90 percent of women reporting awareness of a modern method or a traditional method. Only one-third of all women were currently using a modern method of family planning. Most of the women obtained contraceptives from public sources (76 percent) compared to private sources (5 percent in Nyanza and 11 percent in Western). The high cost of transportation to the facility (84 percent), periodic stockouts of contraceptives (64 percent), and long waiting hours to receive the method at the source (42 percent), were the most commonly cited challenges faced by current users of FP when obtaining modern methods of FP. The acceptability of contraceptive methods from community health workers was moderate with almost one third of women reporting willingness to receive condoms, an injectable or pill contraceptive from a community health worker. Fertility related reasons were the most commonly cited (72 percent) factor for not using contraceptives. One third of women not currently using a method of FP cited health concerns, fear of side effects, lack of access of the method, unaffordability of the method and inconvenience of use. The survey data indicate that spousal communication on family planning was moderate in the Western region of Kenya. About 40 percent of women had never discussed the number of children they wanted to have with their spouses. The baseline survey showed that onehalf of women (54 percent) had heard of a government official talk in favor of family planning. Women from Western were more likely (33 percent) to report hearing of a religious leader talk positively about family planning compared to women in Nyanza (25 percent). Generally, women had favorable perceptions on self-efficacy to influence or use contraceptive irrespective of circumstances such as side effects or peer and spousal influence. x

13 Integration of Family Planning with Delivery and Maternal Child Health Services One-half of births in Western Kenya were delivered at home and 48 percent of births were delivered in a health facility. One half of deliveries in Western Kenya occurred under supervision of a skilled birth attendant, usually nurse or a doctor. Traditional birth attendants assisted in 23 percent of births. Forty four percent of women who delivered in a health facility received some information or counseling about use of FP. About one-quarter of women received information or counseling on FP during visits for child health services while 41 percent of women who had gone to a health facility in the past one year for any given maternal health services such as prenatal or post-partum received FP counseling or information during their last visit. Programmatic Implications a) The PWK intervention has the potential to promote smaller families and should target young person s particularly women in union and women of low parity. The project needs to position family planning in a manner to demonstrate the link between size of the family with labour, survival and livelihood to overcome large family sizes. b) The intervention should consider the use of radio, mobile phones and community-based communications channels such as meetings to effectively reach segments of population with highest unmet need of family planning with necessary FP messages. Newsprint and television medium may be less effective in reaching out to wider audiences in the Western region. The high penetration of mobile phone presents an opportunity to the proposed project to pilot e-reproductive health initiative in the intervention areas. c) The FP project should consider incorporation of an integrated youth and school reproductive health intervention promoting abstinence and delay of age at first marriage. d) The project should also include a community advocacy activities intervention targeting young and elderly men to discourage men from having sex with young girls below ages 18. e) The FP project has the opportunity to use the community-led family planning strategy to tackle the current challenges faced by users including high costs of transport and stockouts of contraceptives by delivering contraceptives, information and services closest to the consumers. The strategy should consider networking with the private sector health facilities and pharmacies in addition to the public sector facilities to ensure consistency in supply of FP information, counselling and products and establishment of a comprehensive RH referral network. f) The PWK intervention has the opportunity to address factors driving non-use of FP by increasing awareness of couples of the risk of pregnancy despite low-perceived frequency of sex among the population. The service delivery points, health care providers and community health workers need to adequately counsel women of the side effects expected from contraceptive use and empower them to favourably negotiate with partners on use of FP. A comprehensive Education, Information and Communication (IEC) FP program should be designed and rolled out in the intervention areas to dispel myths on effect of the contraceptives on the health of women. xi

14 g) Support of the FP project from the local government and religious leaders is essential to increase acceptability of the intervention h) The PWK project has the opportunity to focus on health and well-being of whole family through improvement of the health status of every person in the family including the new born. The project should aim at reducing the number of births occurring at home and linking couples to the health sector for counselling and uptake of FP. i) The intervention has the opportunity to demonstrate effectiveness of linking a community FP strategy with facility based services as well as the effectiveness of offering integrated health services such as provision of post-partum FP services, provision of FP to women seeking child health services including immunization and disease management; and provision of FP counselling, information and products among prenatal and post natal clients. xii

15 CHAPTER 1 Introduction Overview of Population and Fertility in Kenya Kenya s population was 8 million in 1960 and by 2009 it was 38.6 million (Central Bureau of Statistics [CBS], 1970; KNBS 2010). In the past half a century, Kenya s rural population grew rapidly from 7,505,633 in 1960 to 26,122,722 in 2009 and in the last five years, at an annual rate of 2.1 percent in 2008, 2.2 in 2009 and 2.4 in 2010 (World Bank 2011; KNBS and ICF Macro, 2010). Being a predominantly agricultural country, the rise in the population has had serious constraints on the environment, agricultural productivity, and other social and economic resources. Kenya has in the past two decades experienced rapid rural urban migration with devastating impacts on the social economic infrastructure in both rural and urban areas. While currently the population growth appears steady, the factors driving it are fundamentally changing. Until about the year 2000, population growth was explained by the increasing numbers of children. On the other hand, mortality rates increased in the 1980s, largely as a result of high numbers of AIDS-related deaths, decline in health services and pervasive poverty. Additional factors contributing to the continued population growth include higher life expectancy at birth and presence of an increasing number of women in their twenties and thirties (World Bank, 2011). Indeed, Population and Housing Census of 2009 reported that Kenya is characterized by a youthful population with about 42 percent aged below 15 years and only 3 per cent are aged 65 years and older. Between the mid-1970s to the late 1990s, Kenya experienced a sharp decline in the Total Fertility Rate (TFR) and an increase in contraceptive prevalence rates (CPR). In 2009, the average number of children per family was 4.6 as compared to 8.1 in 1978, and it is projected to decline further to 2.4 children by 2050 ( World Health Statistics, 2011; KNBS and ICF Macro, 2010). Over the same period, CPR among women of reproductive age rose from 7 percent to 49 percent, with a stall occurring between 1998 and 2003, when CPR rose to 39 percent. Despite an increase in CPR among rural populations from 37 percent in 2003 to 43 percent in 2008, the TFR of the rural populations remained unchanged in the past decade at 5.2 children per woman of reproductive age. There are notable variations on fertility trends by region. Over time, Nyanza and Western regions which are largely rural, have consistently recorded high TFR levels above the national average. Between 1998 and 2009, for example, the TFR in Western region was highest at 5.6 in 1998, before increasing to 5.8 in 2003 and falling to 5.6 in 2009 (KNBS and ICF Macro, 2010). The stall in fertility decline particularly in the rural areas has raised alarm in the development and population fields as policy-makers, program implementers, development partners, and scholars strive to understand what could be driving the stall, what are the implications of the stall on population growth, and what can be done to reverse it. The potential adverse implications of these trends for social and economic development in the region have engendered new research interests, debates and discourses, including the role of voluntary family planning (FP) 1

16 as a principal policy instrument in addressing high rates of population growth in the region (Bongaarts J and Sinding SW, 2009; Bongaarts J, 2008). Overview of Family Planning Program and Reproductive Health Policies in Kenya The rapidly rising population size between 1960 and 1980 stimulated the government of Kenya to adapt policy strategies that laid the foundation for the onset of fertility transition in the late 1980s. In 1967, Kenya adopted its first national population policy and launched the national FP program. The government sought to integrate family planning into national and sub national programs by creating maternal and child health/family planning units. FP activities were initiated mainly in areas that had adequate health services and depended on clients going to fixed service delivery points for family planning services (APHRC, 1998; ILO, 1972). In 1968, Kenya opened the first family planning centre in Central Province (FPAK, 1985). The government was the main provider of FP services and the national development blue prints during this period emphasized on the need for expanding access of FP programs in rural areas through, among other strategies, recruitment and training of rural family health field educators (Ajayi and Kekovole, 1998). The results of the 1978 fertility survey showing that Kenya had the highest TFR rates in the world further reinvigorated the government s interests to continue to invest in population management policies and programs and in 1982, the Government established the National Council for Population and Development (NCPD) to be in charge of population policy and to coordinate all research activities on population and development in the country. There were also changes on various laws and regulations such as procurement, manufacture, and distribution of contraception, with an aim of presenting new opportunities for expanding FP programs to all parts of the country. These changes gradually led to an increase in the availability of contraceptive methods, through clinics and community-based distribution (CBD) programs. In 1979, the first CBD of family planning commodities was established in Kenya. The intervention led by Pathfinder International was a one-year pilot project distributing condoms and pills and creating awareness of FP through community gatherings. The program expanded access and knowledge of FP, as well as stimulated acceptance, created awareness and ownership of Reproductive Health and Family Planning services (Pathfinder International, 2006). During the period between 1987 and 1988, the number of health workers trained in family planning grew from 1,207 to 2,170 while the number of service delivery points (SDPs) increased from less than 100 to 465; and the number of new acceptors increased exponentially from less than 100,000 annually to more than 300,000 (National Research Council, 1993).With time, Kenya came to be regarded as the country with the greatest diversity in CBD programs and activities in the world (Phillips et al., 1999). During early 1990s, the use of traditional health practitioners such as CBD agents is credited with significantly increasing CPR (AMREF and the Population Council, 1993). Following the 1994 Plan of Action of the International Conference on Population and Development (ICPD), the Kenyan government prepared and adopted the Sessional Paper Number 1 of 2000 on the National Population Policy for Sustainable Development (Republic of Kenya, 2001). Though established at a time of low donor funding for FP in favor of HIV programs and other 2

17 priorities, the policy acknowledged the continued high levels of unmet need for FP, the need for quality RH services, and the continued differentials in fertility, mortality, knowledge and use of contraceptives in rural and urban areas. The policy however faced multiple challenges soon after, premeditated by the introduction of health sector and national macro structural adjustment reforms that instituted cost sharing policy to fund health services. The government sought to sustain RH programs mainly through user-fees, which led CBD agencies to reduce the scale of their activities and also led them to promote service fees and income-generating activities for their workers to sustain motivation in absence of honoraria (Karanja et al., 2005). The service fee model was unpopular among CBD agents, was unsustainable, and diverted the attention of CBD workers from their core business of supplying contraceptives to other activities (Ferguson, 2001). The past vibrant and progressive CBD programs in Kenya began to shrink. The Kenya Health Policy Framework (KHPF) of 1994 while identifying population development as a priority strategy for achieving a balanced socio-economic development including FP, adolescent health and wellbeing of the entire family, provided an opportunity for health sector reform through implementation of well-defined medium term plans (Ministry of Health, [MOH] 1994). The First National Health Sector Strategic Plan I (NHSSP I) launched in 2000 is one of the critical plans produced during the life of the KHPF and it recommended, among other strategic decisions, a shift of resources from curative to preventive and primary health care services. This shift, to a greater extent, increased support and resources for family planning programs in Kenya and supported decentralization of health services and management (Republic of Kenya, 1999). During this period, the HIV and AIDS burden was at its peak in Kenya and CBD programs were adjusted to include HIV prevention, care, and treatment activities. For example in 1999, Pathfinder International launched in Kenya the Community-Based HIV /AIDS Prevention, Care, and Support Program (COPHIA) (Pathfinder International, 2006). The successor of the NHSSP was the 2nd National Health Sector Strategic Plan (NHSSP II, ) which was also credited for expanding much needed reforms in the health sector. NHSSPII specified the Kenya Essential Package for Health (KEPH) of women and children including the safe motherhood, FP, malaria, nutritional deficiencies among other services as key interventions to reduction of maternal and child mortality rates (MOH, 2004; Republic of Kenya 2006). In 2007, the country s first ever National Reproductive Health Policy was approved and launched in The policy laid greater emphasis on creation of sustained demand for family planning; contraceptive commodities security; constructive involvement of men in FP programs; promotion of community and private sector participation in provision and financing of services to expand access, and strengthening of the RH service delivery system at all levels (MOH, 2007). The capacity of the Division of Reproductive Health (DRH) in the Ministry of Health was improved to champion and oversee the delivery of family planning services. At the same time Kenya Parliamentary Network on Population and Development (founded in 2004), NCAPD, and civil society groups, made significant achievements in advocating and promoting family planning as national and government priority. As a result, a FP/RH budget line was established in the national budget and the government funding allocation increased from Ksh. 200 million in 2005 to Ksh. 500 million in 2009 and was projected to increase in the future (MOH, 2010). 3

18 The second National Reproductive Health Strategy covering the period 2009 to 2015 was established with an overall thrust of involving the communities in reversing the decline in the health status of Kenyans through initiation and implementation of life-cycle focused health actions at community level. Through the Community Health Services Strategy launched in June 2006, NRHS aims at increasing coverage of reproductive health services including FP. Through the community based communications, NRHS aims to change attitudes and behaviors of families and individuals around reproductive health. NRHS acknowledges access to RH as being crucial to achieving Millennium Development Goals, Kenya s Vision 2030 (the long term social and economic development plan), and the 2010 National constitution (that promises citizens the highest attainable standard of health including reproductive health) (MOH, 2010, Government of Kenya, 2010). In 2010, Kenya repositioned family planning and major donors renewed their commitments to support community-led FP programs. The USAID/Kenya s Family Health program for example increased FP funding in 2010 to $20.8 million, while MCH funding grew to $8.25 million (USAID/ Kenya, 2011). Strengthening Reproductive Health and Family Planning in Nyanza and Western Region of Kenya In September 2000, Kenya set the UN Millennium Development Goals (MDGs) targets of reducing maternal mortality to 147 per 100,000 live births, attain TFR of 2.1, all facilities have full range of family planning services, reduce unmet need for FP to 6 percent and increase use of family planning among the poor to 32 percent, by 2015 (MOH, 2010). The performance of each of these indicators in Nyanza and Western region compared to other regions has remained below the national average since The two regions have high HIV prevalence and general disease burden. Nyanza Province recorded the greatest decline in poverty incidence from 61 percent in 1999 to 53 percent in 2005 while in Western Province, poverty incidence reduced from 65 percent to 47 percent over the same period (KNBS, 2007). In 2009, a community based project for distributing contraceptives was designed as a suitable rural intervention for regions with high fertility and HIV burden. The project titled, Reversing the Stall in Fertility Decline in Western Kenya Project or in short, the Packard Western Kenya project is a three-year, demonstration project on rural-based family planning that seeks to increase use of FP among women of reproductive age and reduce prevalence of unwanted and mistimed pregnancies through increased accessibility and knowledge of the full range of family planning methods available. Ultimately, the interventions aim at reducing the total fertility rate and unsafe abortions in the region. The project is funded by the David and Lucile Packard Foundation and implemented by African Population and Health Research Center in conjunction with Family Health Options of Kenya, Marie Stopes Kenya, The Great Lakes University of Kisumu, and the Ministry of Public Health and Sanitation (Division of Reproductive Health, and Division of the Community Health Services). The project is implemented in two rural districts of Nyanza Province (Bondo and Siaya Districts) and two rural districts in Western Province, (Busia and Teso Districts). 4

19 The specific objectives of PWK project are: To improve supply of family planning services through community-based contraceptives distribution systems To improve supply of long-acting and permanent methods of family planning services through training and supportive supervision of health care workers To improve delivery of family planning services through integrated out-reach and in-reach health programs To improve on informed demand for family planning services at the community level through interactive communications, and distribution of information, education and communication materials To provide evidence on the effectiveness of the intervention Population and Health Priorities of the Project Areas Population The Western region of Kenya is made up of two provinces namely Western Province and Nyanza Province (Figure 1). According to the 2009 Kenya Population and Housing Census report, Western Province is the fourth largest province in Kenya with a population of 4.3 million, while Nyanza Province is the sixth largest with about 5.4 million people (KNBS, 2010). 5

20 Figure 1: Map of Kenya Showing Counties Source Intervention Areas Former Western Province: Now Kakamega, Vihiga, Bungoma and Busia Counties Former Nyanza Province: Now Siaya, Kisumu, Homa Bay, Migori, Kisii and Nyamira Counties Health Priorities At the district level, the District Health Management Teams (DHMTs) and the District Health Management Boards (DHMB) are responsible for the management and governance of the health sector. Each financial year, the DHMT prepares the annual district health plans, which is a multi-sectoral road map of priority health issues, proposed strategies of addressing and tackling these issues including estimates of financial resources required. The annual health plans developed for the financial year 2009/2010 and 2010/2011 for the four districts indicate that institutional births, family planning, sanitation and personal hygiene, diarrhoea prevention and safe water systems, malaria prevention, HIV and AIDS prevention, care, treatment and support, and micronutrients for children especially intake of Vitamin A, and breastfeeding are top high impact priority health interventions in the region (MOH, 2010, 2011). 6

21 Following the enactment of the 2010 Kenya Constitution, administrative services were decentralized to the county level resulting in allocation of districts to counties. Busia district and Teso district constitute part of Busia County while Bondo district and Siaya district have become part of Siaya County. The devolution plan has implications on various programs in RH such as overall management of county health facilities, assets and liabilities, and the size of the health workforce at the county level. The majority of clients are expected to access health services at county health sector and procurement of supplies such as FP commodities is likely to happen at this level. A smooth transition from the national to the county health service systems is imperative to ensure RH service provision is not adversely affected and avoid delaying the achievement of key national and international RH goals (MOPHS and MOMS, 2011). Objectives and Organization of the Report This report generates data from a baseline survey of the community-based family planning project titled Reversing the Stall in Fertility Decline in Western Kenya (PWK), conducted in The overall goal of the study was to collect baseline information to inform the design of the PWK family planning program. The study provides baseline information for key program elements for use with follow-up survey data to evaluate performance of the PWK project. This data, when complimented with routine project monitoring information and aggregated data on costs of activities, will provide an accurate measure of the effectiveness of the intervention. The specific objectives of the baseline study are to: Measure levels in knowledge of modern contraceptives, ever use of contraception, and current contraceptive use patterns in the Western Kenya region Describe levels of fertility preferences and desire for more children in Western Kenya Examine the acceptability of services of community health workers in distribution of family planning commodities and information Describe women s perceptions on how FP clients are treated by service providers, perceptions about pregnancy, and perceptions around their abilities to negotiate use of FP Examine integration of FP services with maternal and child health services. The report is organized into the following chapters: Chapter 2 provides information on demographic and socio-economic characteristics of the household and individual survey respondents in the intervention areas. The characteristics covered include age and sex structure; the composition of households; background characteristics of the respondents; household characteristics; possession of durable goods, wealth, and educational attainment; exposure to mass media; status of employment; women s control over earnings and women s participation in decision making. 7

22 Chapter 3 focuses on fertility preferences as well as proxy measures of fertility such as birth intervals, age at first birth, teenage pregnancy and motherhood, ideal number of children desired and unintended fertility. Chapter 4 presents the results on various aspects of family planning including knowledge, ever use, current use of contraception, sources of contraceptives, future intention to use FP, and exposure to mass media and spousal communication on family planning. The chapter also presents women perceptions about access and availability of family planning services in the intervention areas. Chapter 5 examines the principal factors other than contraception that affects risk of pregnancy such as marriage and sexual activities. Chapter 6 examines maternal and child health. Issues presented in this chapter include assistance during delivery, place of delivery and maternal and child health visits. Chapter 7 presents conclusions and suggests some programmatic implications Data and Methods of Analysis Survey Organization APHRC implemented the 2010 household baseline survey for the PWK, in collaboration with KNBS and GLUK. The David Lucile and Packard Foundation provided the financial support for the survey. APHRC provided the overall technical leadership and management of the study, while KNBS provided the sampling frame, sampled the study units and calculated data weights. GLUK assisted with recruitment of field workers, managed logistics related to training and provided platform for the initial dissemination of the survey results. The study received ethical clearance from the Ethical Review Committee (ERC) at Kenya Medical Research Institute (KEMRI). Study Design: Sampling and Questionnaires The household survey sample was drawn from the population residing in the rural areas of the four larger districts (Bondo, Busia, Teso and Siaya) of Western Kenya. A representative sample of 2125 households was drawn for the survey using the KNBS National Sample Survey and Evaluation Program (NASSEP IV). The frame was last updated in 2008 to support the National Demographic and Health Survey. Using a two-stage sampling design that first selects Enumeration Areas (EA) and then randomly selects households per EA, a total of 60 rural EAs were sampled distributed as follows: Siaya 20, Bondo 10, Busia and Teso 15 each). In each selected EA, 35 households were randomly chosen. In each sampled household, the head of the household (or his/her representative) was approached and asked for consent to participate in the survey. Information from the household head was gathered using a household questionnaire and was used to identify eligible women for the survey. In addition, the household head responded to questions about assets and environmental circumstances including information on characteristics of the household s dwelling unit, type of toilet facilities, source of drinking water, and ownership of durable goods and livestock. 8

23 After consent was received, the head of the household (or his/her representative) was asked for permission to approach eligible women for the survey. Women ages were contacted by a female interviewer and asked to participate in the study. For women aged years, interviewers sought consent from the parents or guardian of the respondent. These respondents were also requested to assent to participate in the survey. Interviews were conducted in a private place to protect the confidentiality of responses and enhance the comfort of respondents. Respondents proceeded to answer a series of questions from an individual-woman questionnaire that took between 30 and 50 minutes to complete. Respondents were asked about the following: Level of education attained, religion, reproductive history, knowledge and use of family planning methods, marriage and sexual activity, fertility preference, spousal and interpersonal communication, decision making process, and movement patterns within the rural and urban areas. The household and the women questionnaire (see Appendix b), were translated into the two most commonly spoken languages in Nyanza and Western Provinces (Dholuo and Kiwashili). Some of the criteria considered for an individual to be included in the survey were age, the ability to communicate in the survey languages and availability to participate in the survey within the two days field workers spent in an EA. All women ages 14 and below and those aged 50 and above were excluded from the study. Training for the Survey APHRC and GLUK recruited research assistants and supervisors in May 2010 based on a predetermined set of qualifications and experience in large scale national population based surveys. The personnel included 12 supervisors, 24 female research assistants and 5 reserves. A six day training course was conducted from May 23 to 29, 2010 at GLUK s Milimani campus in Kisumu. The trainers were drawn from the technical and program staff of APHRC and GLUK. One day of the training was set aside for further training of supervisors on how to manage survey teams, plan for the survey, handle field logistics, and ensure data quality. A day was spent conducting a pre-test survey organized by KNBS in six clusters located within the rural areas of Kisumu. At the end of the training, 12 field teams were constituted based on individual trainee s abilities to carry out different tasks of the survey. Each team consisted of a supervisor, two female enumerators and a driver (Appendix A). Data Collection and Data Processing Field work started on June 6 and was completed on June 23, In order to ensure that data of high quality was gathered, two members of staff from APHRC and one staff member from GLUK conducted regular field supervision and provided technical support in data collection process. In each district of study, the District Statistical Officer (DSO) from KNBS coordinated the survey logistics to ensure the study was implemented only in the sampled clusters and that personnel adhered to the survey design. The supervisors performed quality control checks and completed daily survey tracking sheets to account for the interviews completed, clusters completed, number of incomplete interviews, 9

24 and number of households covered. The supervisors reviewed all completed questionnaires and provided feedback on performance of their enumerators on a daily basis. The questionnaires were sent to the APHRC head office for editing and data entry. Editors checked for completeness and consistency of data and assigned codes to the open ended responses and missing responses. A data entry team was constituted and trained by APHRC data unit. Data was entered in SQL server version The data entry management module contained in-built consistency checks to arrest common data errors and inconsistencies. Preliminary cleaning was carried out on records using pre-written data cleaning programs. The questionnaires were stored in a room under lock and key. Fairly clean data were exported for analysis using statistical software (SPSS/ PASW version 17.0 and Stata version 10). Response Rates Of the 2,125 households selected for the survey, 2,299 women were found eligible, of whom 1,997 women consented and participated in the interview yielding a response rate of 86 percent (Table 1). The women response rates were highest in Teso (94 percent) and lowest in Bondo (81 percent). The main reason for no response among eligible women was the failure to find individuals at home or work places despite repeated callbacks made to the household by the interviewers. Table 1: Results of the Household and Individual Interviews Number of households, number of interviews and response rates, according to residence in four districts, Western Kenya 2010 Nyanza Western Total Bondo Siaya Total Busia Teso Total Households interviewed , ,125 Interviews with women age No. of eligible women , ,110 2,299 No. of eligible women interviewed ,010 1,997 No. of eligible women interviewed with ,973 complete interviews Eligible women response rate

25 CHAPTER 2 Characteristics of Household Population and Respondents Household Population by Age and Sex The distribution of the de jure household population in the baseline survey is shown in Table 2 by five-year age groups, according to sex and region. The household population constitutes of 10,661 persons out of which 5,135 are males and 5,526 are females. The two provinces had more people in the younger age groups (0-24 years) compared to the older age groups for both sexes. However, more men fell in the younger age groups with ages 0-19 accounting for about two thirds of the total males compared to women who accounted for 57 percent of the total women. Table 2: Household Population by Age, Sex, and Region Percentage distribution of the usual resident (de jure) household population by five-year age group, according to sex and region, Western Kenya 2010 Age Nyanza Western Total Males Females Males Females Males Females n % n % n % n % n % n % Total

26 Figure 2 (a) to 2 (d) illustrates the age and sex distribution of the population in Bondo, Siaya, Busia and Teso in a population pyramid. The population structures vary significantly by district. In Bondo (Figure 2a), for example, the share of the population under 15 years of age was 24 percent while in Siaya (Figure 2b), there were more people in the younger age group with 35 percent of the population aged below 25. Figure 2: Distribution of Age and Sex of Population in Bondo, Siaya, Busia and Teso Districts Household Composition The data for household composition presented in Table 3 shows that in the study population, women headed 37 percent of the households, matching an almost similar estimate (36 percent) observed in the Kenya Demographic Health survey for the national rural households (KNBS, 2010). Females headed more households in Nyanza region (40 percent) compared to Western region (34 percent). The data also shows that the mean size of a household was higher in Western region (5.5 persons) as compared to Nyanza region (4.7 persons). 12

27 Table 3: Household Composition Percent distribution of households by sex of head of household and number of usual (de jure) household members according to region, Western Kenya 2010 Nyanza Western Total Characteristic Bondo Siaya Total Busia Teso Total Sex of household head Male Female Missing Number of usual members Overall Number of households , ,125 Mean household size Household Environment The physical characteristics of the dwelling in which the household lives are important determinants of the health status of household members. Table 4 shows that overall, less than 10 percent of the households were supplied with electricity. There are more households in Bondo (13 percent) and Busia (10 percent) with electricity compared to households in Siaya (7 percent) and Teso (3 percent). With regards to cooking arrangements, 73 percent of households in Western region had a separate room used for cooking compared to one-half of the households in Nyanza region. Nearly one out of ten of the households reported having employed a temporary worker. Slightly over three-quarters of the households (77 percent) lived in dwelling units with floors made of earth. The next most common type of flooring material was cement. The majority of households (77 percent) lived in dwelling units whose walls were made of earth. Overall, about 70 percent of the households used one room for sleeping, while about one fifth used two rooms. Overall, nearly three-fifths of the households lived in dwelling units with roof made of corrugated iron sheets. Roofs made of thatch were most common in Teso (63 percent) and least common in Bondo (24 percent). The most common cooking fuel in the study areas was wood; used by over 80 percent of households. About one tenth of the households used charcoal. As expected of the rural areas of Western and Nyanza regions, only about 1 percent of households reported ever skipping a meal in the past three months due to lack of food. 13

28 Table 4: Household Characteristics Percentage distribution of households by housing characteristics; percentage of households that employs temporary help; percentage of households that missed a meal due to lack of food in the past three months, and percentage using solid fuel for cooking according to region, Western Kenya 2010 Nyanza Western Total Household characteristics Bondo Siaya Total Busia Teso Total Electricity (yes) Has separate kitchen (yes) Employ temporary help (yes) Missed food to eat last 3 months (yes) Flooring material Earth/ Sand/ Dung Cement Main material of outside wall Earth/Sand/Dung Cement/ Mud Burnt bricks Other Main material of roof Grass/Thatch/Makuti Corrugated Iron (Mabati) Total rooms used for sleeping One Two Three or more Type of household cooking fuel Charcoal Wood Other Number of households The ownership of durable and consumer goods is one of the indicators of the household socioeconomic wellbeing. Table 5 presents the distribution of the availability of the selected household items by region of study. There are variations in ownership of assets by type and region. About 70 percent of the households in the study areas owned a radio, while about three-fifths owned a mobile phone. About 14 percent of the households owned a television, and approximately 60 percent of the households used a bicycle for transport. A majority of households (89 percent) owned a farm animal and 92 percent of them owned the structure where the household lived in. 14

29 Table 5: Household Possessions Percentage of households possessing various household effects, means of transportation, agricultural land and livestock/farm animals by region, Western Kenya 2010 Nyanza Western Total Bondo Siaya Total Busia Teso Total Household possessions Radio Television Mobile Phone Means of transport Bicycle Motor cycle Animal-drawn cart Vehicle Motor boat Others Own a farm animal Owns agricultural land Owns structure Owns land where structure stands Number of households , ,125 Sources of Drinking and Water Sanitation Facilities Access to improved drinking water and adequate sanitation facilities can lead to improved health status of a population. Table 6 present the percent distribution of households by source of drinking water and type of toilet facilities. At least one half of the households got drinking water from an improved water source. However, disparities existed by district, with a higher proportion of households in Busia (74 percent) having an improved source of water compared with households in Teso (48 percent), Bondo (34 percent) and Siaya (52 percent). Among the improved water sources, bore-hole and protected spring accounted for the highest proportion (15 percent) of households. Forty-four percent of the households got their drinking water from a non-improved source, mainly surface water from lake, rivers and streams (35 percent of households), a proportion that was highest in Bondo (64 percent) and Teso (38 percent). Regarding sanitation facilities, 85 percent of households used a toilet facility. Traditional pit toilet (58 percent) and slab pit latrine (26 percent) were the most commonly used type of toilet facility. Almost three out of ten households in Bondo did not have any toilet facility. 15

30 Table 6: Household Drinking Water and Sanitation Percent distribution of households by source of drinking water; and percentage of households by type of toilet/latrine facilities, according to region, Western Kenya 2010 Characteristics Nyanza Western Source of drinking water Bondo Siaya Total Busia Teso Total Total Improved source of drinking water Piped into dwelling/yard/plot Public tap/ Stand pipe Tube well/ Bore hole Protected dug well Protected spring Rain water Bottled water Non-improved source of drinking water Unprotected dug well Unprotected spring Tanker/ Truck Cart with small tank Surface water (River/ Dam/ Lake) Other Type of toilet/latrine facility Flush toilet Slab pit latrine Traditional pit toilet (Wood plank floor) No facility/ Bush/ Field Other Number of households , ,125 Household Wealth Wealth index 1, is a background characteristic used throughout this report as a proxy for longterm standard of living of the household. The index is based on data from the household s ownership of consumer goods, dwelling characteristics, source of drinking water among other 1 The household wealth status presented in the report is a relative measure computed based on responses from series of questions measuring the following; a) Household characteristics and amenities such as; type of roofing of main house, type of toilet used at the women s household, main source of drinking water in household, number of rooms and whether or not the women s household had electricity supply, and b) Household ownership of assets such as; mobile phone, radio, electric/gas cooker, television, electric iron box, VCR/DVD, mattress, refrigerator and an electric fan. Using principle component analysis as used in demographic and Health Surveys (DHS), all data were reduced to a continuous index. This index is the latent/underlying outcome (poverty) which is manifest in the above list of assets and characteristics of household as observed by the interviewer during face-face interviews or as reported by the respondent, who in most cases, is the head of the household. A lower score was associated with a poorer household while a higher score was associated with a wealthier household. This index was then grouped into 3 almost equal portions such that each cluster contained 33 percent of all households nearest to each other in terms of their overall poverty score 16

31 characteristics that relate to household s socio-economic status. Table 7 presents percentage distribution of households by wealth tertiles. A higher proportion of households from Nyanza region fell in highest and middle wealth tertiles (36 percent) compared to households in Western region (30 percent). Almost one-half of the households in the rich tertile were from Bondo, while of the households in the lowest tertile, one half were from Teso. Table 7: Wealth Tertiles Percent distribution of the de jure population by wealth tertiles according to region, Western Kenya 2010 Wealth tertile Nyanza Western Total Bondo Siaya Total Busia Teso Total Rich Middle Poor Number of households , ,125 Background Characteristics of Respondents Table 8 presents the distribution of the 1,997 women aged years by district, wealth, marital status, education, religion, ethnicity and age, all of which are important determinants of fertility preferences and contraceptive use. Women in Siaya and Busia were almost evenly distributed by wealth tertiles compared to women in Bondo and Teso. In Bondo, nearly one-half of the women (48 percent) fell in highest wealth tertile while in Teso, nearly one-half (47 percent) of the women fell in the lowest wealth tertile. Approximately 60 percent of the women were in a union. Teso had the highest proportion of women who had never married (31 percent). More women in Nyanza (75 percent) had attained primary level of education compared to Western (66 percent). Over 95 percent of women were Christian. Distribution of respondents according to age categories showed that there were more women aged years in Teso (31 percent) compared to Siaya (23 percent), Busia (24 percent) and Bondo (15 percent). There were also more women in Nyanza falling in age category (39 percent) compared to those in Western region (28 percent). 17

32 Table 8: Background Characteristics of Respondents Percentage of women age by selected background characteristics; Western Kenya 2010 Characteristics Nyanza Western Total Bondo Siaya Total Busia Teso Total Wealth Rich Middle Poor Missing Marital status Never married Married ,240 Monogamy Polygamy Divorced/Separated Missing Education None Primary ,435 Secondary Missing Religion Catholic Protestant/Other Christian ,311 Muslim No religion Other Religiosity Strongly religious/ Born again Somewhat religious Not religious at all Missing Ethnicity Luhya Luo ,011 Teso Other Missing Age < Missing Total ,997 18

33 Access to Mass Media Information access is essential for increasing people s knowledge and awareness of health behaviors and practices. Programs intending to use mass media to influence behavior and knowledge require information on media preferences. Such data is useful in knowing what medium to use to reach different target audiences. Table 9 shows the percentage of women who were exposed to different types of media by region, wealth, level of education and age. Women in Bondo had more access to the three forms of mass media assessed in this study than women from the other districts. Figure 3 show the percentage distribution of women according to access to radio, television and newspapers by districts. Access to mass media increases with educational attainment and wealth index and the reverse is true. The proportion of women who listened to radio at least once a week rose from 54 percent of those in the lowest wealth tertile to 86 percent of those in the highest tertile. The percentage of women who read newspapers at least once a week rose from 2 percent of those with no education to 43 percent among those with secondary or higher levels of education. Access to mass media varied significantly by type of media and age of the women. More women aged years had access to newspapers (26 percent) compared to women in other age categories. More women in the age category had access to radio (77 percent) as compared to women in all other age categories. Figure 3: Access to Mass Media 19

34 Table 9: Exposure to Media Percentage of women age who are exposed to specific media on a weekly basis by background characteristics, Western Kenya 2010 Background characteristic Region Newspaper at least once a week Radio at least once a week TV at least once a week None No. of women* Nyanza Bondo Siaya Western ,010 Busia Teso Wealth Rich Middle Poor Education None Primary ,435 Secondary Age < Overall ,997 * N s in some variables are less than 1,997 due to missing data Employment Status of Women Respondents were asked whether they were employed at the time of the survey, and if not, whether they were employed in the week or the year that preceded the survey. Employment in this survey was defined as the type of work the respondent mainly does. Table 10 shows the percent distribution of women according to current and usual employment status. One-half of the respondents were categorized as currently working, while 15 percent had worked in the past 12 months even though they were not currently categorized as working during the time of the survey. Three out of ten women had not worked at all in the past 12 months. The proportion of women currently working at the time of the survey was highest among rich women (56 percent) compared to women in the middle (47 percent) and poorest (49 percent) tertile. There were minimal variations of the proportions of women currently working by level of education. One-half of women with little education were currently working at the time of the survey compared to 56 percent of women who had attained some secondary or higher 20

35 levels of education. Women age were more likely to be currently working as compared to younger women. Women without living children were least likely to be currently working. Among women with three to four children, 62 percent were more likely to be currently working compared to women with one or two children (52 percent), and those with five or more children (56 percent). Table 10: Employment Status of Women Percent distribution of women ages by their own employment status, according to background characteristics, Western Kenya Background Currently Currently not working characteristics working Worked in last 12 months Did not work in last 12 months Missing No. of Women Region Nyanza Bondo Siaya Western Busia Teso Wealth Rich Middle Poor Marital status Never married Married Monogamy Polygamy Divorced/Separated Education None Primary Secondary Age < Number of living children Overall

36 Employment Status of Partner Currently married women were asked whether their partner was currently employed, their main occupation, working patterns including if the partner works throughout the year, seasonally or occasionally, and type of earnings received categorized into either cash or in-kind. Table 11 presents distribution of the currently married women aged years according to current employment status and continuity of employment. Overall, 74 percent of married women had partners who were currently employed at the time of the study, 79 percent of whom were in Nyanza compared with 67 percent in Western. The survey data shows that married women with higher levels of education, higher wealth category, in the age category, and with fewer numbers of living children (0-2) were more likely to have their partners currently employed. Seventy one percent of married women had their partners working all year round, 22 percent had partners working during some time of the year, and 6 percent had partners who worked only once in the past 12 months preceding the survey. Most of married women from Busia (80 percent) had their partners categorized as working throughout the year compared to women from other districts. The survey results further indicate that 77 percent of married women had their partners paid in cash for their employment. Table 11: Employment Status of Partners Percent distribution of currently married women ages by the employment status of their partners, according to background characteristics, Western Kenya Background characteristics Partner Currently working Partner s nature of work in last 12 months Worked throughout year Seasonally/ part of the year Worked only once a while Missing Percent of women whose partners are paid cash for work No. of partners Region Nyanza Bondo Siaya Western Busia Teso Wealth Rich Middle Poor Education None Primary Secondary

37 Age < Number of living children Overall ,240 Women s Control over Earnings Currently married women who earned cash for their work were asked to state who the main decision maker was with regard to the use of their earnings. Married women with partners who earn cash for work were asked to state the main decision maker on how their partner s earnings are spent. This information provides insight into women s empowerment within the family and the extent of their control over decision-making in the household. These measures of empowerment have a bearing to women control and choice of number of children to have in a life time. Table 12 shows details of currently married respondents who were employed in the year preceding the survey with cash earnings according to person who controls how the woman s earnings are spent. The table also shows the distribution of married women whose partners earn cash according to the main person who controls how the partner s earnings are spent. Of married women earning cash, 65 percent made the decision on how to spend their earnings compared to 28 percent whose decision was jointly made with their partner. Only 6 percent of married women earning cash said that it was the partner who mainly made the decision on how to spend their earnings. More of married women in Nyanza (70 percent) decided how the money they earn would be used compared to 60 percent of women in Western. Women from poorer households, those with no formal education and those with more than two children were more likely to report that they have control on how to use the money they earn compared to other women. More than one-half of married women (57 percent) whose partners earn cash for employment reported that it is the partner (man) who decides how to spend their earnings. Less than ten percent of married women (9 percent) whose partners are paid in cash for employment have control over the partner s earnings while one-third of women said that they jointly make decisions with their partners on how to spend the partner s cash pay. 23

38 Table 12: Control Over Women s and Partner s Cash Earnings Percent distribution of currently married women aged years with cash earnings by person who decides how the woman s and partner s cash earnings are used: Western Kenya 2010 Background characteristics Mainly Respondent Respondent s earnings Jointly Mainly partner No. of Women Mainly Partner Partner s earnings Jointly Mainly Respondent No. of Women Region Nyanza Bondo Siaya Western Busia Teso Wealth Rich Middle Poor Education None Primary Secondary Age < No of living children Overall Women s Participation in Decision Making In addition to proxy indicators of women empowerment such as educational attainment, employment status, and control over earnings, the baseline survey collected information on some direct measures of women s autonomy. Specifically, women were asked about their perceptions on whom, between the woman and the partner, should have a greater say on the following: Making large household purchases; making small daily household purchases; when 24

39 to visit family, friends or relatives; and when and where to seek medical care. Table 13 shows the percent of women age who think that women or together with their husbands have a greater say on the critical decisions listed. Table 13: Women s Participation in Decision-making Percentage of women aged years who think that women alone or jointly with their husbands should have a greater say in specific decisions by selected background characteristics, Western Kenya 2010 Background characteristic Making large daily purchases Making small daily purchases Visits to family, friends or relatives Deciding when and where to seek medical care No. of women Region Nyanza Bondo Siaya Western ,010 Busia Teso Wealth Rich Middle Poor Marital status Never married Married ,240 Monogamy Polygamy Divorced/Separated Education None Primary ,435 Secondary Age < Employment Status Gainfully employed in the past 7 days Overall ,997 25

40 In general, women or at least together with their partners, were more likely to be the main decision makers for purchases of small daily household items and services; when and where to seek medical care; and when to visit family, friends or relatives. Decisions around making large household purchases were more often than not made by the partner. Sixty four percent of women thought that they or jointly with partners, should make decisions on when and where to seek medical care, a perception that was more common in Western (67 percent ) as compared with Nyanza (61 percent); among women in higher wealth index (68 percent) compared with those in middle and lowest wealth index (62 percent) and among women with secondary or higher levels of education (73 percent) compared to those with no education (56 percent), or those with just primary level of education (63 percent). Freedom of Women in Decision Making Currently married women were asked whether their partners prohibit them from performing the following five activities: Working outside the home; receiving visitors; visiting her friends; visiting her family; and using a mobile phone. The results presented in Table 14 show that 63 percent of married women were not prohibited by their partners from performing any of the five activities. About one-third of women were prohibited by their partners from working away from home; 16 percent were prohibited from visiting friends, and about 13 percent were prohibited from receiving visitors at home, and 12 percent from visiting their families. Table 14: Freedom among Women to Make Certain Decisions Percentage of currently married women aged years who report that their husband prohibits them from doing the following things by selected background characteristics, Western Kenya, Background characteristics Visits to friends Visits to family None No. of women Working outside home Having visits from people Using a mobile phone Region Nyanza Bondo Siaya Western Busia Teso Wealth Rich Middle Poor Education None Primary Secondary

41 Age < Employed in the past 7 days Overall ,240 Perceptions about Family Planning and Child Bearing All women were asked to respond to series of statements assessing their perceptions on family planning and child bearing. Respondents were provided with a four point scale to rate their level of agreement or disagreement for each of the statements. Table 15 presents mean scores for each of the statements. Table 15: Women s Perceptions on Family Planning and Child Bearing Mean score of statements measuring women attitudes toward family planning practices on a scale of 1-4 (1=strongly disagree, 2=disagree, 3=agree, 4=strongly agree) by region Western Kenya 2010 Statements on scale of 1-5 Nyanza Western 1. The husband should be the one to decide whether the couple should use a family planning method Couples who practice family planning have a better quality of life than those who do not Husbands and wives should discuss family planning Men should not allow their wives to use family planning A woman who uses family planning without her husband s knowledge should be punished A woman who has no children is not complete/fulfilled A man who has no children is not complete/fulfilled It is good to have many children because one is not sure who among them will survive to care of the parents at old age The number of children a couple will have is for God only to decide A woman should continue bearing children until she has at least one son A woman should continue bearing children until she has at least one daughter Overall, women tended to agree more with the statement that couples who practice FP have a better quality of life (mean sore of 3.4) and that couples should discuss use of FP (mean score of 3.5 in Nyanza and 3.6 in Western). Women also strongly disagreed with statement that men should not allow their partners use FP (mean score of 1.7). 27

42 CHAPTER 3 Fertility Preferences Information on fertility preferences is important to family planning programs because it allows policy makers and designers of FP interventions to estimate the demand for contraception for spacing or limiting, as well as estimate the extent of unwanted and unintended pregnancies. Birth Intervals The length of intervals between births provides insight into birth patterns and maternal and child health. A woman who gives birth in an interval of less than 24 months after a previous birth exposes her child to a greater risk of poor health which also threatens health of the mother. Table 16 shows the percentage distribution of non-first births in the three years preceding the survey by the number of months since the preceding birth. The overall median birth interval was 30 months which is slightly lower that the estimated median birth interval for rural populations which is 32.4 months according to the Demographic Health Survey (KNBS, 2010). The most common birth interval category was months (35 percent) and the least common was 7-17 months (11 percent). The median birth interval was relatively shorter for children born to young women age 15-29; children whose preceding sibling died; children born to women in Busia and Siaya districts; and children born to women in middle and lowest wealth status. Table 16: Birth Intervals Percent distribution of non-first births in the last three years preceding the survey, by number of months since preceding birth according to background characteristics, Western Kenya 2010 Background characteristics No. of nonfirst births* Median no. of months since preceding birth Region Nyanza Bondo Siaya Western Busia Teso Wealth Rich Middle Poor Education None Primary ,

43 Secondary Age < Sex of the preceding birth Males Females Survival of the preceding birth Alive , Dead Overall , * N s in some variables are less than 1428 due to missing data Age at First Birth The onset of childbearing has a direct effect on fertility. Early initiation into childbearing lengthens the reproductive period and subsequently increases fertility. Table 17 shows the median age at first birth and teenage pregnancy. The median age at first birth was the same in Nyanza and Western provinces (18.2 years) with minimal difference observed between the districts. The median age at first birth was lowest among poor women (17.9 years) and was positively related to women s level of education. Women with at least some secondary level of education began child bearing about three years after women with no education (20.2 years compared to 17 years). Table 17: Median Age at First Birth Median age at first birth among women aged years according to background characteristics in four districts, Western Kenya 2010 Women Background characteristic Median age at first birth No. of respondents* Region Nyanza Bondo Siaya Western Busia Teso Wealth Rich Middle

44 Poor Education None Primary Secondary Overall Teenage Pregnancy Forty four percent of women age had begun child bearing, an estimate that was highest in Bondo (71 percent), and lowest in Teso (30 percent) as shown in Table 18. One-half of women aged years in the lowest wealth status had begun child bearing. Table 18: Teenage Motherhood Percentage of women aged years who have begun child bearing, by background characteristics, Western Kenya 2010 Background characteristic Percentage who have begun child bearing Number of women* Region Nyanza Bondo Siaya Western Busia Teso Wealth Rich Middle Poor Education None Primary Secondary Overall * N s in some variables are less than 429 for teenagers aged years due to missing data Desire for More Children Information on desire for children indicates the future fertility intentions and preferences. Table 19 presents the distribution of currently married women by the desire for more children and according to the number of living children. Overall, there was widespread desire to have children. More than half (54 percent) of the women desired to have between 3-4 children and a quarter 30

45 desired to have five or more children. Younger women aged years, and those with higher educational status were more likely report wanting 3 or 4 children. There were minor differences in desire for children across regions and wealth status. Currently married women were asked to state the level of desire for more children among their spouses. The results are summarized in Table 20. Overall, 44 percent of the men wanted the same number of children as their spouses. Almost a quarter (23 percent) of the men wanted more children than their spouse and 4 percent wanted fewer children than their spouse. One half of the men in Western region wanted the same number of children as their wives compared to 37 percent in Nyanza. Men were more likely to want the same number of children as their spouses if they were from a wealthier household, were in a monogamous marriage, had more than primary education and were aged below 20. Table 19: Desire for More Children Percent distribution of currently married women by background characteristics, according to desire for more children, Western Kenya 2010 Number of children respondents desire to have Background characteristics Have another child (Any number/non numeric response)* Region Nyanza Bondo Siaya Western Busia Teso Wealth Rich Middle Poor Education None Primary Secondary Age < Overall No. of respondents Note: Sterilized women are excluded. Number of living children does not include current pregnancy 31

46 Table 20: Desire for More Children among Spouses of Currently Married Women Percentage distribution of currently married women by background characteristics, according to spouse s desire for more children, Western Kenya 2010 Responses of the spouse Background characteristics Missing Same Number More Children Fewer Children D/K partner s desires/ can t get pregnant Have another child (any number) Region Nyanza Bondo Siaya Western Busia Teso Wealth Rich Middle Poor Marital status Married Monogamy Polygamy Education None Primary Secondary Age < Overall No. of respondents Note: Sterilized women are excluded Mean Ideal Number of Children Table 21 shows the mean ideal number of children among women by five age groups according to background characteristics. Women were asked about the number of children they would choose to have if they could start afresh. The mean ideal number of children was higher in Western (4.0) compared to Nyanza (3.6). Generally the ideal number of children was higher among older respondents in both regions 32

47 Table 21: Mean Ideal Number of Children Mean ideal number of children among women by five age groups, and for all women, according to background characteristics, Western Kenya 2010 Background characteristic Age Mean ideal number of children All women Region Nyanza Bondo Siaya Western Busia Teso Wealth Rich Middle Poor Marital status Married Monogamy Polygamy Education None Primary Secondary Overall Fertility Planning Status The levels of unplanned and unwanted fertility was assessed in this study by asking women who had births during the three years before the survey whether the births were wanted at the time (planned), wanted but at a later time (mistimed), or not wanted at all (unwanted). For women who were pregnant at the time of the survey, the question was asked with reference to the current pregnancy. The results are summarized in Table 22 and Figure 4. Almost one-third of births in Western region were unwanted or were mistimed (wanted later). Births of a fourth child or more were least likely to have been planned. 33

48 Table 22: Fertility Planning Status Percent distribution of births in the last three years preceding the survey (including pregnancies), by fertility planning status according to birth order and region, Western Kenya 2010 Birth order Planning status Wanted then Wanted later Wanted no more Missing No. of births Region Nyanza Bondo Siaya Western Busia Teso Total No. of births Figure 4: Planning Status of Births 34

49 CHAPTER 4 Family Planning In Kenya, family planning is promoted as an entitlement for couples who seek access to reproductive health services. PWK project seeks to increase voluntary uptake of quality family planning services primarily among women of reproductive age. Knowledge of Contraceptive Methods Table 23 shows the level of knowledge of contraceptive methods among all women, currently married and sexually active women ages Almost all the women were aware of family planning methods. The awareness of contraceptives was generally higher among women from Nyanza compared to women from Western region. The least known modern method was the emergency contraceptive (EC) pill and male sterilization. Table 23: Knowledge of Contraceptive Methods Percentage of all women, currently married women, and sexually active unmarried women, age who know of any contraceptive method, by specific method, Western Kenya 2010 Method All women Nyanza Currently married women Unmarried sexually active All women Western Currently married women Unmarried Sexually active Any method Any modern method Female sterilization Males sterilization Pill IUD Injectables Implants Male Condom Female Condom Emergency pill Any traditional method Periodic Abstinence Withdrawal

50 Ever Use of Modern Contraceptives All women who said they have ever heard of a family planning method were asked whether they had ever used a specific method to delay pregnancy or to avoid getting pregnant. Table 24 and 25 shows the percentage of all women, currently married, and sexually active unmarried women in Nyanza and Western regions respectively who had ever used a specific method of family planning. Ever use of modern contraception methods was higher among sexually active unmarried women (77 percent in Nyanza and 71 percent in Western). The most commonly ever used method among all women and currently married women was injectable contraception. Slightly more women in Western (17 percent) had ever used a traditional method of family planning compared to women in Nyanza (12 percent). Periodic abstinence was the most commonly ever used traditional method. 36

51 Table 24: Ever Use of Contraception-Nyanza Percentage of all women, currently married women, and sexually active unmarried women, who have ever used contraceptive method, by specific method and age, Nyanza region Kenya 2010 Modern methods Traditional methods Age Any method Any modern method Female steriliz ation Male steriliz ation Pill IUD Injectable Implant Male Condom Female condom Emergency pill Any traditional method Periodic Abstin ence All women Total Currently married women Total Sexually active unmarried women Total Withdr awal No. of respon dents 37

52 Table 25: Ever Use of Contraception-Western Percentage of all women, currently married women, of sexually active unmarried women, who have ever used contraceptive method, by specific method and age, Western Kenya 2010 Modern methods Traditional methods Age Any method Any modern method Female steriliz ation Male steriliz ation Pill IUD Injectable Implant Male Condom Female Condom Emergency pill Any traditional method Periodic Abstin ence All women Total Currently married women Total Sexually active unmarried women Total Withdr awal No. of women 38

53 Current Use of Modern Contraceptives (CPR) Table 26 shows current use of contraceptive among all women and currently married women in Nyanza according to age. One-third of all women and currently married women in Nyanza were currently using a modern method of family planning. Overall, a higher number of women using modern contraceptives were in age category compared to other ages. Injectables and male condoms were the most commonly used methods of family planning. Table 26: Current Use of Contraception -Nyanza Percentage of all women, currently married women, of sexually active unmarried women, by contraceptive method currently used, according to age, Nyanza Kenya 2010 Age Modern methods Any method Any modern method steriliz ation Pill ICD Inject able Implant Traditional methods Male Condom Periodic Abstin ence No. of women All women Total Currently married women Total Table 27 shows current use of contraception among all women and currently married women in Western region according to age. One-third of all women and four fifths of currently married women were using a modern method of FP. Unlike in Nyanza, women in age category were currently using FP as much as women in age category Injectables and female sterilization were the most commonly used method. About 5 percent of women used traditional methods of FP. 39

54 Table 27: Current Use of Contraception-Western Percentage of all women, currently married women, of sexually active unmarried women, by contraceptive method currently used, according to age, Western province Kenya 2010 Any Age Modern methods Traditional methods Method Any modern method Steriliz ation Pill IUD Inject able Implant Male condom Periodic abstin ence No. of women All women Total Currently married women Total Figure 5 shows that use of a modern method of FP is related to wealth status and level of education. Women in highest wealth tertile and who have attained secondary or higher levels of education were more likely to use a modern method of family planning compared to women in lower wealth status or with primary or no education. 40

55 Figure 5: Current Use of Contraception among Married Women by Wealth and Level of Education Knowledge of Fertile Period Basic knowledge of the fertile period is useful particularly among women and couples using fertility awareness methods such as cycle beads or traditional methods. Only 18 percent of respondents understood that a woman is most likely to conceive halfway between her menstrual periods as shown in Table 28. One-third of respondents reported that they did not know of the timing of the fertility period in a woman while some 16 percent reported that fertile period begins just before the onset of menses. Table 28: Knowledge of Fertile Period Percentage distribution of women age by knowledge of the fertile period during the ovulatory cycle by region, Western Kenya 2010 Region Occurrence of the fertile period Just before her period begins During her period Right after her period ends Halfway between two periods Other Don t know Missing No. of women Nyanza Bondo Siaya Western ,010 Busia Teso Total ,997 41

56 Source of Modern Contraceptives Data on where people obtain contraceptives is important for planning of logistics for FP commodities. Women reporting currently using modern methods of FP were asked to provide information about the source from which they last acquired the method. The results are presented in Table 29 which shows that most of the women from Nyanza and Western region obtained FP from the public sector (77 percent). More women from Western region obtained contraceptives from the private sector (11 percent) compared to women from Nyanza (5 percent). About 20 percent of women reported obtaining pills from a pharmacy, chemist or a drug store. In the Western region, private sector facilities were a common source of female sterilization (27 percent) and IUD (34 percent). Table 29: Source of Modern Contraception Methods Percentage distribution of current users of modern contraceptives methods, by most recent source of method, according to specific modern method, Western Kenya 2010 Source Female sterilization Pill IUD Injectable Implant Male condom Nyanza Public sector Private sector Pharmacy/Chemist/Duka la dawa Other source Missing Western Public sector Private sector Pharmacy/Chemist/Duka la dawa Other source Missing Total Challenges in Obtaining Contraceptives Women currently using a hormonal method or condom and who reported facing challenges in obtaining the method were asked to state the most common challenges they faced. The results are summarized in Figure 6. Most commonly cited challenges were high cost of transportation to the facility or source (84 percent), periodic stock-outs of the method at the source (64 percent), and waiting for a long time to receive the method at the source (42 percent). Other barriers cited included fear of partner knowing about use of method (38 percent), lack of time to be way from work or household chores to obtain a method (31 percent) and the cost of service (23 percent). 42

57 Figure 6: Common Challenges Faced when Obtaining Hormonal Methods and Condoms Women Acceptance of Contraceptives from Community Health Workers PWK project plans to expand access of contraceptives among needy population through use of community led distribution channels. In the past three years, the Ministry of Health has been piloting the feasibility of provision of injectables to women through community health strategy. The baseline study sought to find out the preparedness of the community for a large scale community-based contraceptive distribution system. Respondents were asked if they would accept a daily pill, injectable or emergency contraceptive pill from a community health worker. Table 30 shows that approximately one -third of the study population were willing to receive all of the three methods of family planning (daily pill, injectable and emergency contraceptive) from a community health worker. Women from Bondo are more receptive to community health workers as sources of the short-acting methods compared to women from other districts, as shown in Figure 7. Table 30: Acceptance of Contraceptive Methods from Community Health Workers Percentage of women aged years, who know any method of contraception by type of contraception they would accept from community health workers (CHW), according background characteristics, Western Kenya 2010 Background characteristics Region All the three methods Oral pill Emergency contraceptive Injectable None No. of women Nyanza Bondo Siaya Western Busia Teso Wealth Rich

58 Middle Poor Marital status Never married Married ,220 Age < Total ,893 Figure 7: Acceptance of Selected Types of Contraceptives from Community Health Workers Informed Choice Current users of modern methods who are well informed about side effects, what to do to manage the side effects and alternative range of contraceptives are better informed about which method they would like to use. Table 31 shows percent of users of selected modern contraceptive who have ever been informed by a heath provider of side effects, informed of what to do to manage the side effects, and informed by a health worker about alternative methods of family planning available, according background characteristics. One-half of the current users of FP had ever been informed of the side effects of their current method. A majority of women (87 percent) had ever been informed by a health provider of what to do in the event of experiencing side effects from their current method. Sixty two percent of women had ever been informed by a health provider about alternative method of family planning. Women currently using pills were least likely to report having ever received information from a health worker about the possible side effects, how to manage those side effects or about alternative methods to pills. 44

59 Table 31: Informed Choice Among current users of modern contraceptives, percentage who were informed of side effects, what to do if they experienced the side effects or were also informed of other available alternatives methods of FP, according to district, Western Kenya 2010 Current method/district Method Female Sterilization Informed by health worker of side effects Informed what to do in the event of side effects Informed by health worker of alternative methods No. of respondents* Pill IUD Injectable Implant Region Bondo Siaya Busia Teso Overall Reasons for Non-Use of Family Planning Couples can realize their reproductive health goals through consistence use of contraceptives. Understanding reasons why women choose not to use a method of family planning despite risk of unwanted and mistimed pregnancies is important for family planning programs. Figure 8 shows the reasons cited by all women who were not using a method of family planning at the time of the survey. Figure 8: Reasons Given for Non- Use of FP among Women not currently using a Method 45

60 Fertility related reasons including infrequent sex, distance from spouse, trying to get pregnant and breastfeeding were most commonly cited (72 percent) factors for not using contraceptives. One third of women not currently using a method of family planning cited method related reasons such as health concerns, fear of side effects, lack of access of the method, unaffordability of the method and inconvenience of use. These factors among other less popular ones such as lack of knowledge about the method, opposition to use from friends, spouse and religious leaders were the drivers of the low uptake of contraceptives and led to high levels of discontinuation among ever users. Future Intentions to Use Contraceptives In order to understand the changing demand for family planning, information on the intentions to use FP among non users is critical. Table 32 shows that 46 percent of non-users wanted to use FP in future. The largest percentage of prospective users had one or two children (58 percent). Women with no children were the most unsure about using contraceptives in the future (44 percent). Women in Nyanza not currently using a method of FP were more likely to use contraceptives in the future (54 percent) compared to those from Western region (37 percent). Women who had at least primary school education and those aged years were more likely to use contraceptives in future. Table 32: Future Use of Contraception Percent distribution of women age who are not using contraception by intention to use in the future, according to background characteristics, Western Kenya 2010 Intends to use Unsure Does not intend to use Missing No. of women No. of living children Region Nyanza Bondo Siaya Western Busia Teso Wealth Rich Middle Poor Education None Primary Secondary

61 Age < Overall Table 33 presents data on the preferred method of contraception for future use for all women who are not using but say that they intend to use in future. The largest percentage of prospective users reported injectables as their preferred method (63 percent), 12 percent preferred daily pills, and 7 percent were in favor of male condoms. Short-acting methods were therefore more preferred in the study areas. Older women preferred female sterilization compared to younger women. The preference of methods does not vary much by wealth status or district. 47

62 Table 33: Preferred Method for Future Use Percentage distribution of women aged years who are not currently using contraception and intend to use a method in the next 12 months by preferred method, according to selected background characteristics, Western Kenya 2010 Daily pill Emergency pill Male condom Female condom Injectable Implant IUD Natural methods Female sterilization No. of Other Don t know women Region Nyanza Bondo Siaya Western Busia Teso Wealth Rich Middle Poor Age < Overall

63 Discussions of Family Planning with Spouse Information on level and frequency of spousal communication on family planning is critical to family planning programs in order to understand the level of support women receive from their spouses to space or limit births. Table 34 shows the percentage of married women who have ever discussed with their husband about parity by number of times they have discussed in the past six months according to background characteristics. The results indicate that in the past six months, 40 percent of women never discussed with their spouses about the number of children they wanted to have. The largest proportion of this group of women were in Nyanza (51 percent) compared to Western (28 percent). Some 39 percent of women reported that they had, in the past six months, discussed once or twice with their spouses about the number of children to have. Women, who cited discussing children with their husband three or more times were most likely from Western, had higher socio-economic status, had at least secondary school education and were of aged years. Table 34: Discussion About the Number of Children to Have Percentage distribution of currently married women aged years who have ever discussed with their husband about parity by number of times by the number of times they have discussed in the past six months, according to background characteristics, Western Kenya 2010 Frequency of discussion Never Once or twice Three or more times No. of women Region Nyanza Bondo Siaya Western Busia Teso Wealth Rich Middle Poor Education None Primary Secondary Age < Overall ,240 49

64 Other than spousal communications, family planning programs are interested with other sources of influence for women to use FP in the community. All currently married women were asked to state persons other than partners who influence their use of contraceptives and the results are presented in Table 35. Approximately three-quarters of married women were not influenced by anyone else (excluding their husbands) to use contraception. The mother (9 percent), friends (7 percent) and health care workers (7 percent) were some of the persons with the greatest influence on women in using contraception. As expected, younger women were likely than older women to be influenced by their mothers. Table 35: Women s Source of Influence to Use Contraception Percentage distribution of currently married women according to their source of influence other than husband to use contraception by background characteristics, Western Kenya 2010 Source of influence to use Mother Health worker Friend Other None No. of women Region Nyanza Bondo Siaya Western Busia Teso Wealth Rich Middle Poor Education None Primary Secondary Age < Overall ,240 Family planning programs require support from government and religious leaders for them to be successful at the community level. The baseline survey collected data from women about whether they had heard a government officer or a religious leader talk for or against use of family planning in the past one year. The results are summarized in Table 36. Only about one-half of women (54 percent) had heard a government official talk in favor of family planning. Women in Nyanza were more likely (60 percent) to have heard of a government official talk in favor of FP 50

65 compared to women from Western (51 percent). Only a small percentage (6 percent) of women had ever heard in the past one year a government official talk negatively about FP. Twenty-seven percent of respondents reported that in the past one year they heard a religious leader talk in favor of FP while some one-third of respondents said they had heard some religious leaders talk against FP. Women from Western were more likely (33 percent) to report about hearing of a religious leader talk positively about family planning compared to women in Nyanza (25 percent). Table 36: Support of FP from Religious and Government Leaders Percentage distribution of women that heard in the past one year of a government or a religious leader talk in favor or against use of contraception by region, Western Kenya 2010 Government official Religious leader Region For Against For Against No. of women Nyanza Bondo Siaya Western ,010 Busia Teso Overall ,997 Self-efficacy in Use of Family Planning Women s ability to convince their partners to accept use of contraception, their own self conviction to obtain and use contraception, and ability to tolerate side effects of contraceptives are important factors in sustaining demand and use of family planning. All women aged years were asked to rate their level of agreement or disagreement on a scale of one to four with statements written to measure perceptions of self-efficacy. The mean scores for each of the statement was calculated and presented in Table 37 by background characteristics. 51

66 Table 37: Women s Self Efficacy in Contraceptive Use Mean score distributions on scale items measuring perceived self-efficacy to use contraception among women aged years, according to background characteristics, Western Kenya Background characteristics You can start a conversation with your partner about FP You can convince your partner that you should use FP You can get to a place where FP is sold/ offered if you decided to use one. You can obtain a FP method if you decided to use one. You can use a method of FP even if your partner doesn t want you to. You can use a method of FP even if none of your friends or neighbors uses one. You can use FP even if a religious leader did not think you should use one. You can continue to use a FP, even if you experienced some side effects. Region Nyanza Bondo Siaya Western ,010 Busia Teso Wealth Rich Middle Poor Education None Primary ,435 Secondary Age < Overall ,997 No. of women 52

67 Generally, women have favorable perceptions around abilities to use or convince a partner to approve use of FP or overcome negative pressures around use of contraceptives. For example, for the statement that You can obtain a FP method if you decided to use one, women from Busia, those with secondary or higher level of education and those in age category years scored a mean of 3.5. For the statement, You can continue to use a FP method even if you experienced some side effects, women on average scored a mean of 1.7 meaning that they have favorable perceptions to use family planning irrespective of the side effects. Locus of Control in Contraceptive Use Sustaining demand for family planning despite internal and external factors is a critical in enabling women to using family planning. Table 38 shows the percentage distribution of women aged who agree that a woman can use contraceptives without her husband s or partner s knowledge given specific circumstances, according to background characteristics, as a measure of the level of perceived internal locus of control. Table 38: Locus of Control in Contraceptive Use Percentage distribution of women aged years who agrees that a woman can use contraceptives without her husband s or partner s knowledge given specific circumstances, according to background characteristics, Western Kenya It s OK to use FP without husband s knowledge if Background characteristics He is against contraceptive use but she wants to use it They have a lot of children Husband is violent towards her and/or the children Couple does not have enough money for any more children No. of women Region Nyanza Bondo Siaya Western ,010 Busia Teso Marital status Never married Married ,240 Education None Primary ,435 Secondary Age < Overall ,997 53

68 Overall, 64 percent of women said they would continue to use contraceptives even when their husband was against it, 82 percent would use FP even when the husband was violent towards her or children, and 87 percent would continue to use a method of FP when the couple had many children or did not have enough money to bring up more children. Fewer unmarried women (58 percent) compared to married (69 percent) would use FP if their husbands were against contraceptives. Younger women were less likely to use contraceptives without their husband s knowledge. 54

69 CHAPTER 5 Other Proximate Determinants of Fertility Current Marital Status Marriage is the primary indication of the regular exposure of women to the risk of pregnancy. Populations with low age at first marriage tend to experience early child bearing and high fertility. Table 39 shows the percent distribution of women by marital status by region and age. One in every five women aged years who have never been married, one-half is in a monogamous relationship, 12 percent are in a polygamous union, 9 percent are widowed, 1 percent are divorced and 4 percent are separated. The distribution of women by marital status was almost same across regions. Twenty two percent of women aged years were either in polygamous marriage or were widowed. More women in Nyanza were married compared to women in Western. Table 39: Current Marital Status Percent distribution of women by marital status, according to background characteristics, Western Kenya 2010 Background characteristics Never married Married Others No. of women Monogamy Polygamy Widowed Divorced Separated Region Nyanza Bondo Siaya Western ,010 Busia Teso Age < Overall ,997 55

70 Age at First Marriage Marriage is a primary indication of the regular exposure of women to risk of pregnancy. Table 40 shows the percentage of women who have married by specific ages, according to current age group. The proportion of women first marrying by the age of 15 years was highest among youngest women in age category (30 percent) and older women age (31 percent). The 2010 Constitution of Kenya defines a child as a person who has not attained age of 18. The data therefore shows that early and child marriages were common in the study area. The median age of first marriage was 17 years in all districts. Table 40: Age at First Marriage Percentage of women aged years who were first married by specific exact ages and median age at first marriage, according to background characteristics, Western Kenya, 2010 Percent first married by exact age Never married Median age at first marriage (15-49) No. of women Age < na na na Overall ,997 Age at First Sexual Intercourse In the 2010 baseline survey, women were asked how old they were when they first had sexual intercourse. The percentage of women who had sexual intercourse is given by exact ages in Table 41. Among those who had experienced a sexual encounter, the median age at first sexual intercourse was 15 years. Only 10 percent of women aged years had never had sex at the time of the survey. Sexual intercourse at an early age (below 18 years) exposes girls to teenage pregnancy and motherhood and contributes to low girl-child retention in schools. 56

71 Table 41: Age at First Sexual Intercourse Percentage of women aged years who had first sexual intercourse by exact ages, percentage who never had sexual intercourse, and median age at first intercourse, according to region and current age, Western Kenya 2010 Percent first intercourse by exact age Never had sex Median age at first intercourse (15-49) No. of women Region Nyanza Bondo Siaya Western ,010 Busia Teso Age < na na na Overall ,997 Recent Sexual Activity Information on sexual activity is used to understand risks of exposure to pregnancy. Table 42 shows recent sexual activity amongst women aged years. Thirty percent of women reported that their last sexual encounter took place the week preceding the survey, compared to 20 percent who had sex within the previous four weeks. Recent sexual activity was more common among the married and those aged over 20 years. Marked differences were seen among those who were married (45 percent) compared to those who were not married (7 percent). A higher proportion of those who had at least primary level of education (33 percent) or secondary education (35 percent), reported sexual activity in the previous week compared to women with no education at all (23 percent). 57

72 Table 42: Recent Sexual Activity Percentage distribution of women aged years by timing of last sexual intercourse, according to background characteristics, Western Kenya 2010 Background characteristics Timing of last sexual intercourse Within last 1 week Within last 4 weeks* Within 1 year One or more than a year Never had sexual intercourse Mean weeks since last sexual episode No. of women Region Nyanza Bondo Siaya Western ,010 Busia Teso Wealth Rich Middle Poor Marital status Never married Married ,240 Monogamy Polygamy Divorced/ separate Education None Primary ,435 Secondary Age < Overall ,997 * Within last 4 weeks excludes within the last 1 week 58

73 CHAPTER 6 Integration of FP with Maternal Child Health Services Delivery of integrated health services is the most effective way of increasing utilization of health services in a population and increasing access of certain services to the most vulnerable and needy populations. The 2010 baseline survey gathered information about place of delivery, assistance during birth, and exposure to family planning information or counseling at time of delivery, child and maternal health services. Place of Delivery Interviewers asked each woman to give the type of facility where she gave birth most recently. Table 43 shows the percent distribution of most recent live births since 2007 by place of delivery, according to background characteristics. The survey results indicated that one-half of births in Western Kenya were delivered at home and 48 percent of births were delivered in a health facility. Births among older women, births among women from Busia and Teso district, births among poor women or women with no education or primary level of education were more likely to occur at home. More of the births occurred in public health facilities (38 percent) compared to private health facilities (5 percent) and faith based health facility (2 percent). Assistance during Delivery Assistance during child birth is an important factor that influences the outcome of births. Table 44 shows the percent distribution of recent live births since 2007 by person providing assistance during delivery, according to background characteristics. One half of births in Western Kenya were delivered under supervision of a skilled birth attendant, usually nurse or a doctor. Traditional birth attendants assisted 23 percent of births in the study area. Relatives and friends assisted 9 percent of births while community health workers assisted in 3 percent of births. In about onetenth of births (13 percent), mothers did not receive any form of assistance. Births among older women (24 percent) and births among women from Busia and Teso were likely to be occur without any assistance or were attended to by traditional birth attendants. Births among more educated mothers were likely to be assisted by skilled personnel. 59

74 Table 43: Place of Delivery Percentage distribution of live births since 2007 by place of delivery, according to background characteristics, Western Kenya 2010 Public Private FBO Home Other Missing Total No. of births since 2007 Background Characteristic Mother s age at birth < Region Nyanza Bondo Siaya Western Busia Teso Wealth Rich Middle Poor Missing Education (Mother s current) None Primary Secondary Overall No. of births since

75 Table 44: Assistance During Delivery Percentage distribution of recent live births since 2007 by person providing assistance during delivery, according to background characteristics, Western Kenya 2010* Doctor/ Clinical Officer Nurse/ Midwife TBA CHW Friend/ Relative Other None Missing Total No. of births** Background Characteristic Mother s age at birth < Region Nyanza Bondo Siaya Western Busia Teso Wealth Rich Middle Poor Education (Mother s current) None Primary Secondary Overall No. of respondents * Where multiple healthcare providers were mentioned, the most qualified of all was used. Reasons for Not Delivering in a Health Facility Figure 9 shows reasons for not delivering at health facility among women who had live births since The most common reasons cited for not delivering at a health facility were that it s not a priority (54 percent), distance or transport to the facility (34 percent), and cost related barriers (25 percent). 61

76 Figure 9: Reasons for not Delivering in a Health Facility Exposure of Family Planning Interventions to Maternal and Child Health Clients Women who gave birth in a health facility since 2007 were asked about their exposure to FP information and counseling at the time of last delivery. Forty four percent of women who delivered in a health facility received some information or counseling about use of FP as shown in Figure 10. Women with at least one living child were asked whether they had gone to a health facility for child health services in the past three months. About one quarter (26 percent) received information or counseling on FP as shown in Figure 10. During the survey, respondents were asked whether they had gone to a health facility in the past one year for any maternal health services such as prenatal or post-partum. Those who had sought maternal health services were asked to state if they received FP counseling or information during the last visit and the results are shown in Figure 10. Two in every five women received FP information or counseling during their last visit in search of maternal health services. 62

77 Figure 10: Exposure to FP Information or Counseling During Delivery, Child Health and Maternal Health Visits 63