Trends and factors associated with long-acting reversible contraception in Kenya

Introduction

Family planning is a critical component of Kenya’s development agenda and it is addressed in the Vision 2030 social pillar on provision of reproductive health for the poor and vulnerable population. Kenya is a model of fertility transition, having moved from a very high level of fertility of over eight children in the 1970s to about four children in 2014, with a contraceptive prevalence (CPR) of 58%. A major recent growth in CPR was especially evident in the use of modern methods between 2003 and 2014. CPR increased by 17% between 2003 and 2014, while use of modern methods, which has driven the CPR up, increased by 21% over the decade^1,2. The increased demand for contraception was generated by robust campaigns that were initiated with the repositioning of the family planning program. The agenda of family planning is also central in the International Conference on Population and Development after 25 years (ICPD25) Commitments as well as in Sustainable Development Goal (SDG) 3.7³.

Investing in family planning is highly cost-effective and can lower healthcare costs and cascade benefits to Kenya in an unrivalled manner. As of 2015, Kenya had saved US$4.48 directly in healthcare costs for every US$1 that was spent on family planning. If county governments accelerated demand and hence uptake of modern contraceptive methods, the savings would rise to US$5.46 for every US$1 used in family planning and result in a direct total saving of US$80 million by 2020⁴.

Long acting reversible contraception (LARC) refers to contraceptive methods that can be used beyond one year upon insertion and comprises the implant and intrauterine devices (IUDs). Evidence from the 2014 Kenya Demographic and Health Survey (KDHS) shows increased use of LARC in comparison to other modern contraceptive methods, with the implant becoming the second most popular method after injection¹. The reproductive behavior of the 12 million female adolescents and youths aged 10–34 years⁵ will determine the growth and size of the population of Kenya for the next decade.

The anticipated momentum of births from the huge female population can be slowed by use of LARC as these methods are longer acting, reversible, more effective, need no user adherence and hence have no risk of incorrect or inconsistent use common to young contraceptive users and have lower rates of discontinuation⁶. They are also credited with higher user acceptability/satisfaction, fewer side effects and user contraindications as well as little partner involvement. They are estrogen free, hence pose fewer risks to a woman’s health, and involve less visits to health facilities, hence less strain on the health system^7,8. Despite these great health and social benefits, LARC is underutilized because potential users are not comprehensively counselled about them and additionally, the methods are initially expensive. Evidence on cost has, however, shown they are cost effective in the long-term and can result in savings of $12,000 in five years⁹. In concurrence, Trussel et al.¹⁰ found cost savings can be realized from LARC use within three years whether or not the methods are used to the end of their efficacy period. They arrived at costs of $304 for the IUD and $308 for the implant per woman, per annum in the United States.

Evidence has shown that unintended pregnancies and induced abortions could be considerably reduced by as much as 25% if women used more effective methods and specifically LARC¹¹. Using KDHS 2003 data, the study found a 0.4% failure rate for long acting methods against 2.7% for short acting methods and 15.8% for traditional methods. Total unintended births were 44%, out of which 5% were terminated. The number of unintended births that could be averted was estimated at 11% (69,000) out of the 44%. The expansion of access to LARC is critical in family planning programs that aim to address high rates of unintended pregnancy and curb high unmet need for family planning¹².

The current Kenya Family Planning Costed Implementation Plan (FP CIP) has several targets towards rights-based family planning and improved maternal and child health outcomes for the period 2016 to 2020. The targets are; increasing implant use from 12% to 16%; increasing IUD use from 5% to 7%; avert 2 million unintended pregnancies, 62,500 unsafe abortions, 4700 maternal deaths and reduce unmet need from 15% to 13%. An underlying target is to increase modern contraceptive prevalence (mCPR) from 54% to 58%, accompanied by high quality information and contraceptive services¹³.

A challenge in the access to contraceptive commodities is that the method mix in Kenya is dominated by the injection, and increasing the share of LARC can reduce this domination as well as expand the method mix. Method mix heavily influences rates of method failure because short acting methods have higher failure rates as they are less effective. Evidence has shown that women are more likely to choose more effective methods if exposed to information and services about them^14,15.

In contraceptive use dynamics, the role of method choice is critical in gauging the quality of services because client satisfaction, acceptance of a method and its continuation depend on it¹⁴. The convenience, effectiveness and availability of contraception methods vary, hence the side effects likely to be experienced by different users and resultant discontinuation rates vary by method and also by user characteristics. It is therefore crucial for managers of family planning programs to ensure clients use the most suitable method to enhance continuity.

LARC use has only picked up in the last decade and there is still a paucity of data and a lot of barriers to its uptake. Evidence on predictors of its use is critical in the next decade of promotion of LARC methods to overcome the challenges that hinder women from enjoying the many benefits of LARC.

Objective

The objective of the study was to establish the factors associated with LARC methods with a view to establishing potential for increasing demand for LARC.

Methods

Results

In an attempt to obtain the profile of the LARC user, cross tabulations were undertaken to show the share of LARC use against other modern contraceptives and examine any significant relationships between the socio demographic factors and use of modern methods categorized under LARC or ‘other modern’ for each year under study. Table 1 presents the results.

Table 1 shows low shares of LARC, ranging from 5% to 15% among modern contraception in 2003, reducing slightly in 2008/9, before a 2-6 fold increase across all socio demographic factors to reach 20–26% in 2014. Other modern contraception had huge shares of 85–95% in 2003 and 2008/09, which declined to 75–80% in 2014. For women with no children, LARC use was very low at 3% across the data sets. The emerging general profile of the LARC user was that of secondary educated, mostly married women of higher wealth, living in urban areas, with at least one child and aged 25 to 34. All the factors apart from region and desire for children exhibited significant relationships with use of modern methods.

Levels and trends in LARC use

To find out levels and trends in LARC use against other modern methods, descriptive analysis was done based on age and regions. Figure 1 to Figure 9 present the different results. Figure 1 complements Table 1 results on age.

Figure 1. Long-acting reversible contraception use by age in Kenya, 2003–2014.

Figure 2. Intrauterine device use by age, 2003–2014.

Figure 3. Implant use by age, 2003–2014.

Figure 4. Implant use by education, 2003–2014.

Figure 5. Intrauterine device use by education, 2003–2014.

Figure 6. Percentage use of the intrauterine device among modern contraceptives by region, 2003–2014.

Figure 7. Percentage use of implants among modern contraceptives by region, 2003–2014.

Figure 8. Percentage use of long-acting reversible contraception among modern contraceptives by region, 2014.

Figure 9. Trends in long-acting reversible contraception use by fertility desire, 2003–2014.

LARC use by age. Figure 1 shows LARC use in 2003 and 2008/09 was highest among women aged over 35 years, but in 2014 was highest among those aged 25–34. There was a decline in LARC use between 2003 and 2008/09, and then major surges between 2008/09 and 2014. Use among 25–34 and 35+ age groups each increased two-fold, while for the 15–24 group, the increase was seven-fold.

Further analysis (shown in Figure 2 and Figure 3) on age showed that for the IUD, the majority of users were in the 35–49 age group, while for the implant, the majority were in the 25–34 age group. The lowest use for both was among the 15–24 age group.

LARC use by education. Analysis by education (shown in Figure 4 and Figure 5) revealed that in 2014, the majority of users for both IUDs and implants, with a 50–60% share each, had primary level education, while the lowest use for both was among women with higher education.

IUD use by region. Figure 6 shows that the share of IUD use among modern contraceptive use in the Central region was highest in 2003 and 2014 at 13%, while its share in Nairobi was highest in 2008/09 at around 10%. The North Eastern region had 5% of its modern contraceptive users using the IUD in 2014. There was no data for the region in 2003 and there were no IUD users in 2008/09. The Eastern region showed consistent use, with 5% of its modern method users using the IUD, while the Western region showed a gradual rise in IUD use across the three data sets. Results between 2008/09 and 2014 show an increase in IUD use in all regions except for the North Eastern region, with the biggest change being in the Central region, where IUD share among modern methods increased two-fold from 3.2% to 6.3% in prevalence.

Implants use by region. Figure 7 shows the low share of implants among modern contraceptive users in 2003 and 2008/09, before a major rise in the share of implants across all regions in 2014. The Western region in 2014 led, with 27% of its modern method users using the implant, followed by Nyanza, Nairobi and Central, each with around 20% share.

LARC use in 2014. The status of LARC share among modern contraception in 2014 in all regions is shown in Figure 8.

Figure 8 shows the level of LARC use after the surge that occurred between 2008/09 and 2014, wherein the share of LARC among modern contraceptive use rose to comprise 20% to 30% of the share of modern contraceptive use in all regions apart from the Eastern region. The Western region, which earlier had very low shares of IUD and implant use, caught up with Nairobi and Central to reach a 30% share for LARC among modern contraceptive users.

Trends in LARC use by fertility desire. Another analysis done on LARC users was by fertility desire (whether one was spacing or limiting children) in an attempt to establish whether family planning clients were using the appropriate methods for their reproductive goals. The results are presented in Figure 9.

The results show that majority of LARC users are limiters in all the data sets but there is a sustained total decline of 12% from 71% in 2003 to 59% in 2014. Running counter to this is an equal increase among spacers from 29% in 2003 to 41% in 2014.

Discussion

The study shows LARC having very low usage initially, before a big shift in use from other modern towards LARC between 2008/09 and 2014. The period of increased use coincided with LARC promotion campaigns that were conducted in Kenya and several African countries, which generated great demand by advancing LARC as the longer lasting, safer and more effective methods. The demand created was met by a steady supply of the methods. The implant has had higher uptake than the IUD, suggesting higher acceptability of the method, which may be due to ease and method of insertion, length of efficacy or preference for hormonal methods⁷. The increase in LARC use was seen in many sub-Saharan African countries but the uptake of the implant in Kenya was the highest in the world at 18% prevalence as of 2017¹⁹.

The network of Tunza clinics in Kenya also had a project to increase LARC uptake through demand generation between 2009 and 2014. The project increased implant uptake by around 12% and IUD uptake by 5% within Tunza clinics²⁰. The Tupange project also scaled up use of implants in five urban centers over a five-year period²¹. Overall, the relaunch of the Kenyan family planning program and launch of FP2020 in 2011, as well as the development of FP CIP 2012–2016²², aided the increase in LARC nationally.

The uptake of the IUD is low in Kenya in spite of the aggressive LARC campaigns, mostly because of rumors and misconception about their convenience and effectiveness as well as provider attitudes and bias²³. Of concern is its suitability for certain populations; for example, young women and women with a tendency towards multiple partners. The situation was different in the 1980s and it commanded a good share of the method mix in Kenya at 31% but thereafter started declining and is currently heavily underutilized²³.

Influence of age on LARC use was seen in all the data sets. LARC use was initially seen to be more common among women of at least 35 years, who are traditionally limiters as they have mostly attained their desired number of children and do not want more children. However, globally LARC was recommended for adolescents and young women²⁴ and those who were spacing, as fertility returned soon after the method was discontinued²⁵. Other studies have also associated age with LARC use²⁶, while others have found it insignificant²⁷.

As of 2014 in Kenya, a shift had occurred such that the leading users of LARC were now 25–34-year-olds, who are also the majority users of modern contraception, fulfilling the huge demand for spacing births. However, IUD use in Kenya shows dominance by the over 35s, who are limiting births. As expected, low LARC use was seen among the 15–24-year-olds and the reason for this may be their general lower use of modern contraception and their tendency towards short term methods because they are cautious about using methods that may interfere with their future fertility intentions²⁸. The group showed major increases in LARC use from 3% in 2008/09 to 20% in 2014^1,29.

This study showed LARC use was more prominent among women of higher socio-economic status, perhaps because of their better exposure and access to contraceptive information and services. Other studies have found LARC to increase with education²⁶ and wealth^30,31, while others did not find any effects from education²⁷. LARC methods are generally more available in urban areas and a contributing factor is the lack of trained providers in rural and low-income areas to handle insertions and removal²⁷. For the IUD, the issue of insertion is sensitive and must be done correctly for a user to be satisfied and continue using it for the intended period. This contributes to high discontinuation rates for the IUD³².

Analysis based on region showed that the Central region and Nairobi had the biggest shares of LARC against other modern methods. However, between 2008/09 and 2014, a shift was seen with regions with previously low contraception rates registering big surges in LARC uptake and some even overtaking the previous high contraception rate regions. The Western region was seen to overtake Central and Nairobi to have the biggest share of implant use among modern method usage. The North Eastern region, the region with the lowest contraceptive prevalence in Kenya, is also seen to be making good strides in terms of its proportion of LARC against other modern methods.

The reproductive goals of a woman are about the number and timing of the children she desires to have and the method she chooses is supposed to enhance the goal of either spacing or limiting births. This was emphasized by the strong influence seen from the number of living children, with LARC use increasing with the number of children. A possible explanation is that higher parity may expose a woman to a lot of information and experience about contraception during prenatal and postnatal clinics^31,33.

Levels of LARC use seen in the study are low when viewed against its many contraceptive and non-contraceptive benefits. One barrier to LARC uptake is myths and fears of side effects. Qualitative studies reveal that among the believed side effects for the IUD is that it causes cancer, while other women think LARC will interfere with their future fertility, hence do not opt for them until they have attained their desired number of children²⁷. This study complements this view as analysis on fertility desire showed most LARC users are limiters.

Conclusions

The study has compared use of LARC to that of other modern contraception and documented how it has evolved from very low to significant shares in modern contraceptive use and the factors that have influenced its use over different time settings. It has established huge unexploited potential for more LARC uptake based on the identified predictors of its use. The data will be useful to inform strategies to improve LARC use and help Kenya increase mCPR and reduce unwanted fertility, unsafe abortions and unmet need for contraception.

Scaling up of LARC uptake is critical to deal with issues of poor user adherence, incorrect and inconsistent use and method failure that characterize short acting contraception, resulting in increased unintended pregnancies, incidences of unsafe abortions and maternal and infant mortality. Strategies are needed to provide accurate information to counteract rumors and misconceptions surrounding the IUD to increase its uptake.

Data availability