Trends and determinants of contraceptive method choice among women aged 15-24 years in Kenya

Introduction

Kenya has invested considerable resources towards improving adolescent sexual reproductive health (ASRH) and has in place the 2015 National Adolescent Sexual Reproductive Health (NASRH) Policy; however, the rates of teenage pregnancies do not reflect these heavy investments and are a matter of public health and social concern. Teenage pregnancy rates have plateaued for over a decade and have persisted at 20% between 2003 and 2014^1–3.

More than 10,000 Kenyan girls quit school every year due to unintended pregnancies and more than 10 percent of births in Kenya occur to girls aged 15–19 years⁴. Unintended pregnancies among teenagers are linked to poor health outcomes, which include sexually transmitted infections, unsafe abortion, miscarriages, stillbirths and complications during births that can lead to infant and/or maternal deaths. There is also rapid-repeat pregnancy, which is linked to greater risks of morbidity and mortality in mothers and new-borns as well as poor mental health⁵.

The Kenya Demographic and Health Survey (KDHS) 2014 revealed critical facts about adolescents in Kenya. One out of every three (30%) adolescent girls reported having had sex while the average age at which adolescent girls had their first child was 17 years and 12% of the girls were already in a relationship. Most sexually active 15–19-year-olds do not use contraception and only about 50% of those on contraception use it consistently with 14% of them being ambivalent about pregnancy. As many as 90% of unmarried sexually active adolescent girls reported not wanting to get pregnant in the next two years but only 43 percent were using a method to prevent pregnancy. Average unmet need for family planning for the group was 21% against the national average of 18%^1,6. Several interventions to address ASRH needs have been put in place but the median age at first birth continues to decrease.

Kenya has a very youthful population with the 15–24-year-old age cohort constituting about 30% of the population of 47 million⁷. The 15–24-year-old young women take about 15% which comes to 7 million. With the economic growth far below the desired 10% per annum, this group is critical to economic development but for them to be substantially productive the problems surrounding them have to be comprehensively addressed⁸.

Demographic dividend has been proposed as a viable solution to economic challenges faced by developing countries. Kenya’s demographic window is expected to open in 2038 and it could achieve demographic dividend by 2050 if it invests in the huge youth population and especially the adolescents. Demographic dividend modelling shows Kenya can attain $4,595 in GDP per capita by 2050 if it makes strategic investments against $896 if it maintains the status quo. This would mean a staggering fivefold economic growth whose achievement, family planning can accelerate^9,10.

Also, improved access to reproductive health has been identified as critical in the process of development in Sustainable Development Goal (SDG) 3.7¹¹. Adolescent and young women childbearing is linked with lower educational achievement and could lead to a cycle of poverty and hinder achievement of demographic dividend. Meeting the contraception needs of adolescent and youth to prevent unintended pregnancies should thus be a priority¹².

The Health Act of 2017 and constitution of Kenya have enshrined the right of every woman to safe, affordable, effective, and acceptable contraception services¹³. FP2020 has issued the Global Consensus Statement to expand contraceptive options for adolescents and youth and set higher family planning targets¹⁴. Family planning documents in Kenya advocate for promotion of long acting reversible contraception (implants and IUD) as safe, convenient and highly effective methods.

KDHS data shows the 15–24 age group taking a sizeable share of the modern method mix in Kenya among all users of reproductive age with 15% pill users, 8% of IUD use, 18% implants use and 24% injection use¹. It also shows shifting popularity from injections to implants for the young women, but correct and consistent use remains a challenge and unintended pregnancies prevail⁵. Data is constantly needed to monitor the success of the many policy and program efforts towards effective reproductive health programs for youth.

Poverty is a major contributing factor to teenage pregnancies with girls from poor households more exposed to the risk of early childbearing⁸. Evidence has shown that without contraception, more than 90% sexually active young women get pregnant within a year¹⁵. The leading reason for adolescents’ delay or for not obtaining contraceptive services is apprehension on confidentiality and side effects.

In Kenya, 22% of unintended pregnancies end up in dangerous abortions for adolescents because they mostly abort during the second trimester after late discoveries of the pregnancies. Adolescents below 19 years make up 20% of women seeking post-abortion care services in health facilities and 50% admissions from severe complications^16,17. There is urgent need to expand access to safe and affordable reproductive health care and options especially for the more vulnerable young women of lower education and economic status who procure unsafe abortions more¹⁸.

Evidence has shown increased use of contraception is a primary factor in reduction of adolescent fertility and births rates¹⁹. Comprehensive sexuality education (CSE) and integrated youth friendly services have also shown success when well implemented but youth centres and peer education have not been effective²⁰. Providing contraceptive information, counselling and services and the use Larcs has been found useful to encourage new acceptors of contraception among nulliparous young women. LARCs are 99% effective if correctly used and have several non-contraceptive benefits like reducing menstrual flow and pain and thus endometriosis.

To achieve demographic dividend, a country must undergo a demographic transition which brings about lower birth and death rates through investments in family planning. Significant declines in fertility can be reaped from a high contraceptive use momentum that young women can generate. A slower population growth can also be achieved if age at first birth is delayed for most of these women. A huge young population represents great economic potential and investments in their health and education can stimulate new economic opportunities²¹.

Previous studies in Kenya have identified socio economic factors such as education and wealth as significant on the use of contraception^22,23. Choice and continued use of a method is influenced by socio-economic factors hence the choice of explanatory variables²⁴. This study attempted to provide a current information base on how contraceptive use among 15–24 years old girls in Kenya has evolved from 2003 to 2014 with a view to providing evidence which could form a basis to increase modern contraceptive use among them.

The main objective of the study was to examine factors that influence the choice of contraceptive methods for young women 15 to 24 years old.

Methods

Results

Trends in contraceptive method choice

The section addresses the second objective, ‘to establish the trends in contraceptive method choice for young women’, 15–24 in Kenya from 2003 to 2014. Further analysis established shares of use for the Pill, Condom, Injection, IUD and Implants presented in the following figure.

As seen in Figure 1, the main method of contraception was injection with a share of 54–58% in the three data sets. Its share increased slightly between 2003 and 2008/09 from 56% to 58% then reduced to 54% in 2014. The pill was second most common in 2003 (23%) but declined to fourth (11%) in 2014.

Figure 1. Trends in Contraceptive Method Choice in Percentage for Women Aged 15–24, 2003–2014.

Source: KDHS Data.

Condom use increased from 17% in 2003 to the second largest share in 2008/09 at 24% but fell to third position in 2014, below implants. Implants were fourth between 2003 and 2008/09 with a 2–3% share but between 2008/09 and 2014, had a huge upsurge of 16 percentage points from 1.9% to 17.7% to move to second position after injection. The IUD had a very low share of between 0.4% and 2%.

Discussion

The study has shown use of modern methods among women aged 15–24 years has been increasing from 2003 but more so from 2008/09. Proportions using modern methods increased almost sixfold between 2008 and 2014. Use of modern methods has been increasing globally and in Kenya in recent years for all women of reproductive age, but more so among those aged 15–24 years, where there are huge numbers of sexually active youth who are initiating contraception. The findings are collaborated by the annual FP2020 reports for Kenya²⁵. Other studies had reported rising use of modern methods and more so injectables earlier^5,26.

Use of long-term methods increased by around four times between 2008/09 and 2014. This is not only a Kenyan phenomenon but a general trend in Sub-Saharan Africa, where successful LARC promotion campaigns and innovative youth sexual and reproductive health programs are increasing the numbers of new acceptors. Implants are now the fastest rising method of contraception among women 15–24, their use more than doubling from 10 to 21% between 2008/09 and 2014. Rapid increase in the use of implants has been reported recently for several countries, including Kenya, where scale up campaigns have been conducted^27,28. LARCs are more effective and cheaper in the long term than shorter-acting contraceptives, and are recommended for most women, including adolescents and nulliparous women²⁹.

The shift away from short-term methods resulted in declining use of pills and condoms, as shown in Figure 1 and in latter analysis, as declining use of short-term methods which were previously very popular with young women. Condoms are an important dual contraceptive method for prevention against pregnancy and also sexually transmitted infections and HIV/AIDS. They have been previously marketed aggressively to ensure demand creation but shifting priorities of HIV funding have led to fewer campaigns from 2007, which has probably led to their declining use³⁰.

As shown in the trend analysis for individual modern methods, implants are the new contraception frontier for women aged 15–24. Other studies have shown implants as increasing their acceptance among young women as efforts to promote them increase. A study in Kenya to promote LARCs among young women showed a major upsurge of implants between 2008 and 2014 with use doubling in the 15–19 age category and increasing by six times among the 20–24-year-old age group³¹.

Regions of lower contraceptive use are surpassing regions of high contraception and are showing potential for major increases in use of modern contraceptives for women aged 15–24 and it is collaborated by FP2020 progress reports. This presents evidence of potential for scaling up modern CPR and achieving the FP2020 targets²⁵.

Region was a socio-economic predictor of contraceptive choice in this study in 2008/09 and 2014. However, the classification of regions in terms of contraceptive use, as performed here, has been changing as seen from KDHS 2014 such that regions which previously had lower contraceptive uptake like Western are recording very high uptake of modern contraception especially for LARCs. This is possibly an outcome of high-level campaigns to promote long-term methods in the whole country but more so in the regions of lower contraceptive use.

On residence, no distinct variations in method choice are seen in rural or urban areas, suggesting good progress towards equity in accessing methods in both types of residence. Previous studies in Kenya had revealed distinct regional differentials showing the likelihood of using a modern method, more so long-term ones, being higher in urban than rural areas and also higher in regions of high contraception uptake than in regions of lower contraception²². In another study in Kenya, residence was also found to influence variations in contraceptive choice⁵.

The findings on the significance of education and wealth status are in line with earlier studies in Kenya that found education and wealth had significant influence on the use of contraception^22,23. A study in Uganda found similar results²⁴. In contrast, other studies on Kenya have not found education and household wealth to be significantly associated to contraceptive use^32,33.

Results have shown that users of modern contraception methods are exhibiting higher education levels in recent years. This is probably a reflection of the heavy investments in education Kenya is making to ensure all children complete primary school and transit to secondary school, and also introducing free primary and secondary education. However, the results of regression with education showed an inverse relationship between education and choice of long-term contraceptive methods in all the data sets. Women with secondary education were 40–70% less likely to choose long-term methods than those with primary education. The results tally with surprising recent findings in Ghana that women with secondary education were using less effective, short-term and periodic contraception more than effective, long-term, modern methods^33,34. Questions arise whether they are experimenting with methods, are wary of side effects or are intending to get pregnant.

An interesting finding is that users of more modern contraception were in the lower wealth brackets in 2008/09 and 2014 and users of long-term methods were more in rural areas. This could imply success of family planning campaigns in rural and low-income areas or improved access for women of lower wealth status. Community health workers (CHWs) whose role in expanding contraceptive access has been revitalized work in some of these rural and hard to reach areas where most households are of lower wealth.

As observed in the study results, 15–24-year-old users of modern methods are shifting away from short-term contraceptives towards LARCs, which are more efficient, convenient and offer greater user satisfaction³⁵. The shift is more pronounced among women with primary education, from rural areas, lower-wealth households and regions of low contraceptive use. Implants may overtake the injection as the most popular method for this group if the surge in popularity continues.

Conclusions

Results from the study have provided a useful profile of young modern contraceptive users and established a general pattern of their contraceptive use. The study has identified the predictors of contraceptive use among young girls as age, education, household wealth and type of region, and detailed how these factors are changing with time. This information is useful for managers of youth reproductive health programs and could guide interventions to help reduce unintended pregnancies among young girls in Kenya so that girls can stay in school longer and complete their education to desired levels.

The results for the young women, 15–24 years of age, conform to the general shift towards long-term methods for all women of reproductive age, as seen in the recent studies^35,36. Kenya is an example of family planning policy success but the journey towards replacement level fertility cannot be complete if the 15–24 age group is left behind. More investment towards successful adolescent and youth reproductive health are needed to ensure Kenya takes advantage of the opening of the demographic window and reaps the demographic dividend. Young women aged 15–24 are at the centre of these efforts; family planning policy and program managers must ensure they take control of their reproductive health and use contraceptive information and services to their advantage.

Contraception allows young women to make informed choices concerning their reproductive and sexual health, stay in school longer, complete higher levels of education and transition to colleges for labour relevant skills that will enable them optimally contribute to the economy and lead Kenya to achieving the much desired demographic dividend. LARC has potential advantages for these women who wish to delay pregnancy for several years.

To improve the environment for reproductive health and modern contraception for women 15 to 24 years with a view to minimising unintended pregnancies, several interventions can be put in place: 1) Implement fully the National Adolescent Sexual and Reproductive Health Policy, 2015; 2) Initiate age appropriate Life Skills Education (LSE) in all schools; 3) Mainstream youth friendly services into regular services at all health facilities; 4) Expand the range of available method mix for married and unmarried young women and especially the LARCs; and 5) Ensure commodity security by reducing stock outs of commodities.

Data availability