Fertility intentions and the adoption of long-acting and permanent contraception (LAPM) among women: evidence from Western Kenya

Data were extracted from a family planning intervention conducted in two predominantly rural counties in Western Kenya, Busia and Siaya. Busia County is predominantly a Luhya community forms about 14.3% of the Kenyan population [21]. In Luhya custom, the extended family and clan units are very strong cultural institutions, demanding significant commitment from members. Although modernity has brought a lot of cultural shifts, men are still expected to pay in the form of cattle, sheep or goats or monetary equivalent for taking a wife. Intra-clan marriage still remains a taboo [22]. Siaya County on the other hand forms part of the larger Nyanza region with the Luo as the predominant ethnic group – about 12% of the Kenyan population [21]. While family formation begins late among men, it starts early for women; they are pro-natal and children born “belong” to the male partner in the Luo communities [23‐25]. Patriarchy is a dominant aspect of social life in both communities, with men serving as ‘de facto’ depositories of social and cultural power. These counties have an average total fertility rate of 5.5 despite a reasonably good level of modern contraceptive use overall (around 32% as at 2008 (the 2008 data is not disaggregated by county as was done in 2014 KDHS) and currently at 58% and 55% for Busia and Siaya counties) [1, 26]. In these areas, the injectable is the most commonly used contraceptive method (20% for Busia and 19% for Siaya respectively).

Data for this study were extracted from a larger study on family planning intervention implemented in Busia and Siaya counties, Kenya. The full description of the project is detailed elsewhere (see, [27]). Briefly, from 2012 to 2014 the African Population and Health Research Center (APHRC) in partnership with the Ministry of Health, Kenya collaborated with five community organizations (Family Health Options-Kenya, Marie-Stopes, Kenya, Center for Study of Adolescence, Forum for African Women Educationalist, Christian Health Association of Kenya and Great Lakes University of Kisumu) to increase routine use of modern contraceptive methods among women of reproductive age. The intervention included deliberate efforts to influence women to switch from short-acting contraceptive methods (SACs) to long-acting reversible contraceptive methods (LAPM) or sterilization. Approximately 600 community health volunteers (CHVs) were recruited/engaged to distribute short-acting contraceptive methods, counseling of women, and referral of women for LAPM or sterilization services.

This was a descriptive observational study – drawing data from routine service statistics. CHVs and service providers collected the data, using structured data collection tools as part of the monitoring processes at health facilities.

The dependent variable was the contraceptive method the respondent was using during the reference year. This variable was recoded into a dichotomous variable: “1” if the respondent was using a LAPM (injectable, implant and IUD or opted for sterilization); and “0” if the respondent was on any other method other than LAPM. The primary independent variable was fertility intention, defined as whether or when a person wants to or not to have a child or children [28]. Studying fertility intentions enhances understanding of fertility behavior and improves reliability of fertility predictions [29]. In addition, we included several other variables known to be associated with contraceptive use such as: age, number of children, county (place of residence), and type of service delivery model (whether through mobile or stationary clinics), level of education, family planning counseling and project status. All these variables were reported by women at the point of care.

The analyses focused on 28, 515 women aged 15–49 years who received FP and related services as part of the intervention between 2013 and 2015. At first visit, women were given a unique identifier so that regardless of the number of times they visited a facility, their primary records (e.g. age, parity etc.) remained unchanged. The exclusive identifiers helped to avoid double counting. Data analyses were conducted using STATA 13.0 (College Station, Texas 77,845 USA). Frequencies, cross-tabulations and logistic regression analyses were performed. Bivariate regression models were used to assess the crude association between each independent variable in influencing likelihood of using LAPM among service users. The main outcome variable was whether a woman received a LAPM on the current visit to a clinic or not. Exponential β (odds ratios) are used to depict the likelihood of receiving a LAPM compared to any other method of family planning. A ratio greater than 1 means greater likelihood of using LAPM than the reference category; a ratio less than 1 means lower likelihood of using LAPM than the reference category; and a ratio of 1 means same likelihood of using LAPM as the reference category. STATA version 13 was used to conduct the data analysis.

The project received ethics approval from the Kenya Medical Research Institute (KEMRI). Consent of individual women was waived given that the primary project was implemented in the form of service delivery rather than primary research.

Table 1 shows the characteristics of 28,515 who received FP services from the project between 2013 and 2015. Half of the women (50%) were aged 25–39 years while 4 % were aged 40+ years. Twelve percent of the women had secondary or higher education, 41% had only some primary education, and 5 % had never attended school. Most (67%) of the women were from Siaya County and had not begun childbearing (53%). Over half (55%) of the women received FP from mobile health service providers. Under half (43%) of the women were new FP users through the project. Almost all (96%) the clients were counseled on FP before deciding on a method of contraception. More than half of the women reported using a long-acting method of contraception.

Table 2 shows the percent distribution of adoption of LAPM by background characteristics. In term of fertility intentions, most women who wanted no more children (85%) and wanted another child within two years (53%) and after two years (83%) often adopted LAPM. However, more than half of women who were uncertain – usually indicating “it’s up to God” or “can’t tell” tended to use injectable contraceptives (55%) more than any other method. Parity had differing association with the type of FP women chose – nulliparous (never had a child) women for instance utilized injectable (51%) more than LAPM (31%). On the contrary, almost all multiparous (5+ children) opted more for LAPM (90%). The FP service delivery model – facility-based or mobile showed differing pattern with whether LAPM or a short-acting method was adopted. For women who received services from facilities, injectable was prevalent (62%) while women served through mobile service usually chose a LAPM (79%). The majority (58%) of women who were counseled before a method preferred a long-acting method while the majority of the few (1294) who did not receive counseling chose injectable (65%).

Table 3 contains three models used to clarify how fertility intentions affect the adoption of LAPM. Model 0 is the unadjusted estimates showing crude effects of each independent variable on the outcome variable. At least, one category of each of the independent factors showed significant association with the use of LAPM except fertility intentions. Despite that, the propensity to adopt a LAPM was higher among women who wanted their next child after two years in contrast to the reference category – wants no more children. In Model 1 where all the predictors, excluding fertility intentions were fitted into the equation, the signs for some variables turned negative. Particularly, increasing age and education reduced the likelihood of women using a LAPM (Table 3 Model 1). For instance, women who reported secondary or higher education were 0.21 (95% CI = 0.18–0.24) less likely to use a long-acting reversible method compared to their counterparts with no education. Also, the chances of using a LAPM among those 40+ years was around 34% lower than the 15–24 years group.

The final model (2) presents the association between fertility intentions and adoption of LAPM net of the other independent factors. The model shows that having no intentions for more children has a strong significant influence on the use of LAPM. That is, wanting another child within or after two years considerably reduced the odds of using a LAPM by around 70 and 22% respectively. Similarly, women with uncertain intentions were 38% less likely to use a LAPM.

Model 2 further demonstrates that the project had higher influence on LAPM use. Compared to women who were newly introduced to FP use by the project, existing FP users and utilizing the project for FP were less inclined to use a LAPM. For the three years we collected data, utilization rates for LAPM were 61% higher in 2014 than in 2013.