Background
In recent years, the global family planning (FP) community has galvanized around ensuring accessible, high quality FP care for adolescents and youth, including access to a full range of contraceptive methods [
1,
2]. A well-established literature base shows that a range of factors influence contraceptive use among young women. These include demand-side factors related to their social environment [
3‐
5]; knowledge and awareness of specific methods [
6‐
9]; attitudes towards FP of the young person and her peers, partner or family [
7,
9,
10]; and women’s own fertility and FP intentions [
7,
10], amongst others. Yet, when young women make the decision to avoid a pregnancy, there are at least two critical choices that must be made: which contraceptive method to use and where to obtain it. In this paper, we are interested in exploring these two decisions—method choice and source choice—and if and when one decision takes priority and then subsequently influences the other decision.
Various features of sources or service delivery points (SDPs) have been identified as influential on where young women seek contraceptive methods. Some of these supply-side factors include concerns about privacy and confidentiality [
9,
11,
12]; geographic accessibility of the SDP and the flexibility of its operating hours [
7,
9,
13]; cost [
9,
11]; method availability and stock-outs, which are closely tied to the type of facility selected [
9,
14]; and quality of care and expectations for provider interactions [
15‐
18]. Several of these factors may drive young people to seek FP services at a specific type of source that is more convenient, more discreet, or less costly (e.g., a pharmacy, drug shop, or a public sector facility), though less is known about young people’s decision-making around sourcing contraception from pharmacies. Young people’s choice of a method is then limited to the methods available at the selected site.
Radovich and colleagues analyzed Demographic and Health Surveys between 2000 and 2016 from 33 sub-Saharan African nations and noted the link between type of contraceptive method that young women used and source type; they found that 80% of male condom users reported procuring their method from a drug shop or informal provider, while young women who used IUDs and implants overwhelmingly sourced them from public health facilities [
19]. While there appears to be clear patterns for obtaining certain types of methods from specific sources, there is more to be learned regarding the process for and influences on the sequencing of these decisions. This includes better understanding of whether method choice or source choice is prioritized; that is, whether young women first select the method they want and then decide where to obtain it or whether they initially determine where they will seek FP services and subsequently choose a method among those available at that site.
Research on how and if young women prioritize decision-making about method choice and source choice is limited. Prior studies from Nigeria and Ghana using exit interviews with FP clients of all ages found that the majority of women seeking a FP method for the first time had a preference for a particular method before coming to the SDP [
20,
21]. However, these studies exclude users who went to pharmacies or shops, frequently for male condoms or emergency contraceptives (EC), and often do not examine whether women go to a specific SDP and choose among the methods available or if they know what method they want and choose the SDP accordingly. A study by Jarvis and colleagues in the Democratic Republic of Congo showed that a higher percentage of clients reported a pre-existing preference for implants and IUDs among those who sought care at outreach events or special FP days as compared to those who sought care at a facility; the authors suggest this may be due to clients knowing that these methods would be available at such events and therefore decided to attend [
22]. These few studies focus on women of all ages, without a specific focus on young women under age 25, and do not attempt to determine how and when source factors into the choice of method.
The objectives of this study are to understand whether young women prioritize their choice of contraceptive method or method source and how one choice influences the other in the contraceptive decision-making process in Kenya. Given that the choice of method to use and where to source a method are not completely independent, we are interested in the intersection of these decisions and whether one of these decisions takes priority over the other for young women who want to delay or avoid pregnancy. Better understanding of this decision-making process among young women will help in the development of new program strategies, including those which focus on increasing knowledge about and access to a range of contraceptive methods among young people.
Context
In Kenya, the site of this study, more than 60% of the population is under 24 years of age [
23]. Over the last several years, adolescent pregnancy has been a pressing public concern in Kenya with increasing attention during the COVID-19 pandemic [
24,
25]. According to the 2022 Kenya Demographic and Health Survey, 15% of young women ages 15–19 had ever been pregnant and an additional 3% were currently pregnant [
26]. In 2020, 11.7% of female adolescents ages 15–19 and 45.8% of women ages 20–24 years reported current use of a modern contraceptive method [
23]. Despite different levels of use, contraceptive method mix was similar among these two age groups with implants, injectables and male condoms being the most commonly used methods. Notably, method mix varies considerably by marital status with unmarried women ages 15–24 reporting highest use of male condoms (15.2%) and married women ages 15–24 reporting highest use of implants and injectables (25.5% and 23.4%, respectively) [
23].
Kenya has a six-tier pyramidal health system with community facilities at the lowest level, followed by dispensaries, health centers, county hospitals, county referral hospitals, and national referral hospitals being the highest tier. The Government of Kenya provides all methods of contraception free of charge at public facilities, yet a study by Radovich et al. found that nearly half of modern contraceptive users paid user fees when seeking FP from a public facility [
27]. More than 80% of public facilities in Kenya reported having oral contraceptives, injectables, male condoms, IUDs and implants available, yet 23% reported stock-outs of these commodities for an average of six days per month [
28]. A policy change in 2018 permitted injectables to be provided pharmacies [
29]. Approximately 60% of women under 25 years of age source their contraceptive method from the public sector and 40% from the private sector, which includes private facilities, and pharmacies (locally referred to as chemists) [
30]. Pharmacies are common sources for male condoms, oral pills and emergency contraception, though these methods are also available from the public sector [
23].
Methods
Study design
This paper uses data collected as part of a cross-sectional qualitative study for the Full Access, Full Choice project in Kenya, which was implemented by the Carolina Population Center at the University of North Carolina at Chapel Hill (UNC) and the African Institute for Development Policy (AFIDEP). The aim of the Full Access, Full Choice project is to generate evidence on expanded contraceptive method choice among young people.
The overall study aimed to understand influences on young women’s contraceptive use decisions and behaviors from the time they first used a contraceptive method until the time of interview. A detailed description of the Full Access, Full Choice (FAFC) project, the study design and additional findings from this study can be found elsewhere [
31]. The FAFC project team was comprised of American and Kenyan researchers, all of whom were knowledgeable and experienced in sexual and reproductive health research in Kenya; differing perspectives of the study team may have affected our overall ability to objectively design, analyze and report study findings. Power differentials and dynamics within the study team were discussed and addressed throughout the course of the project, with emphasis on understanding and valuing individual types of knowledge and experience that team members brought. The overall study had an external advisory group that employed a transdisciplinary approach whereby strategies were used to ensure a range of voices, including Kenyan youth, contributed to all stages of the study process, thus shifting traditional power dynamics in research across countries, populations and individual characteristics. This paper utilizes in-depth interviews (IDIs) which were undertaken with 30 women ages 18–24 years in three Kenyan counties (Nairobi, Mombasa and Migori) to explore decision-making about contraceptive method choice and source choice.
Sampling and recruitment
The FAFC project works in five focal counties which were selected based on levels of contraceptive use among youth, presence of FP implementing partners and advocacy partners to partner with, regional representation and political commitment to ensuring FP access for youth people. Selection was completed in collaboration with the Kenya Ministry of Health and the National Council for Population and Development. Compared to the two FAFC focal countries (Wajir and West Pokot) not selected for this qualitative study, the selected three counties—Nairobi, Mombasa, and Migori—have higher contraceptive use, an important factor for study eligibility criteria. Nairobi county is the capital of Kenya, is urban, and largest in terms of population at 4.4 million according to the 2019 national census [
23]. Mombasa county is situated on the coast of Kenya along the Indian Ocean, is urban, and has a 2019 population of approximately 1.2 million [
23]. Migori county is in the western part of the country, is predominantly rural, and borders Lake Victoria and Tanzania. Based on the 2022 Kenya Demographic Health Survey, adolescent pregnancy varies by county, with 8.4% of adolescent girls ever having been pregnant in Nairobi, 10.8% in Mombasa, and 23% in Migori county [
26].
Public and private sector SDPs in the three target counties served as the recruitment sites for study participants. Target SDPs were chosen using data from the Kenya Health Information System in order to identify facilities with high client loads. The Ministry of Health’s county reproductive health coordinators provided additional input and support in order to ensure inclusion of facilities and pharmacies which also had high client loads, particularly for adolescent and youth clients. Two to three public facilities, two private facilities [types included private clinics (n = 3), nursing homes (n = 2), and a faith-based dispensary (n = 1)], and one privately owned pharmacy were purposively selected in each county. The type of public facility varied by county and included: two public health centers in Nairobi, a public dispensary and health center in Mombasa, and three public hospitals in Migori. In total, 16 SDPs served as recruitment sites for study participants. Prior to the start of data collection, permission was sought from health facility managers and pharmacy owners.
The recruitment of study participants was stratified by county and parity (no children or 1 + child). The aim was to complete four IDIs among nulliparous women and four IDIs among women with one or more children per county, with the interviews spread across the SDP types within each county. Recruitment was undertaken at different types of SDP in order to identify women who visited various SDP types, but women did not need to be seeking FP services at the time of recruitment.
The eligibility criteria for participation in the in-depth interviews included being a woman between 18 and 24 years, and having ever used at least two modern contraceptive methods that could be obtained from an SDP (implant, IUD, injectable, oral pills, emergency contraception (EC), and male condoms). In this manuscript, we refer to male condoms as ‘condoms’. Of note, the respondents needed not be using a contraceptive method at the time of recruitment. This study included respondents aged 18 and older due to the desire to recruit women with more contraceptive experience.
Study procedures
A 10-day training of interviewers was held in August 2019 which included classroom-based sessions which covered ethics training, review of study methods, procedures and guides and mock interviews. The eight trained female interviewers were from the three counties and familiar with the local languages and customs. All interviewers had a first degree in social sciences and were experienced in qualitative research with youth on issues related to sexual and reproductive health. We also selected female interviewers under 30 years of age in an attempt to balance power dynamics between interviewers and participants.
A field-based pilot was conducted at two public health facilities in Nairobi which were not part of the facility list for the study. The pilot was undertaken by the trained interviewers in order to pre-test field procedures, including recruitment, screening and interview completion. Over the course of two days, eight IDIs were completed. Based on the successful pilot, the number of questions in the guide was reduced and one question was moved.
From August to September 2019, one or two interviewers per county rotated across the SDPs. All study participants were recruited outside of, or in the waiting areas of the selected SDPs. Approval to undertake the study at each SDP was sought from the SDP in-charge. The MOH supplied a letter of approval and support for the study which was presented to the SDP in-charge. The eligibility of potential participants was assessed using a short checklist to ascertain information about age, parity and past and present contraceptive use. Once a woman was confirmed to meet the eligibility criteria, was informed about the study and was interested in participating, she was asked by the interviewer to provide verbal consent to participate in the study in accordance with the regulations and requirements set forth by the IRB on record (AMREF Health Africa Ethics and Scientific Review Committee). The informed consent form was read verbatim to potential study subjects. Women were asked if they had any questions, and if so, the interviewer answered all and any questions. If the respondent freely and voluntarily agreed to participate in the study, the interviewer signed the consent form and gave the copy to the respondent. The informed consent process and interviews were conducted in a private setting outside of the recruitment site which frequently included seats in a shaded spot away from where anyone could overhear the conversation. Emphasis was placed on ensuring that respondents’ preferences around privacy and confidentiality were attended to. All interviews were digitally recorded and were conducted in English (n = 1), Kiswahili (n = 18), DhoLuo (n = 8) or Kuria (n = 3) based on the preference of the respondent. On average, interviews took about 75 min.
Data collection instrument
The guide followed a modified life history approach to understand adolescent girls’ and young women’s family planning use and decision-making processes from first use of contraception until the time of interview [
32]. The semi-structured IDI guide included questions about young women’s life circumstances as well as their decision-making processes around selecting contraceptive methods for every method ever used. For each method they adopted, we probed on whether women prioritized their choice of the contraceptive method, which then influenced where they sourced the method; or prioritized their choice of where they would obtain an FP method, and then decided on the type of method to use after going to the source. This last section also asked about features of service delivery points and providers that are attractive and important to adolescents and young women. The IDI guide was translated into Kiswahili, DhoLuo, and Kuria, and pre-tested before data collector training, and finalized after piloting.
Data analysis
The digitally-recorded IDIs were transcribed and translated from the local languages into English. Transcripts were uploaded into Dedoose software (v.8.3) for coding and analysis. A codebook was developed based on a priori codes which were based on the IDI guide. Five members of the research teams at AFIDEP and UNC reviewed the same two transcripts and coded them based on a priori codes; where needed, they identified and agreed upon additional emergent themes for coding. A third transcript was double-coded by the team members to assess intercoder reliability and to ensure the codes were being applied consistently. The team reviewed and resolved discrepancies in coding and adjusted the codebook as needed. The full codebook was reviewed by a wider group of team members from FAFC in order to ensure consistency in interpretation and understanding between those intimately involved in coding the data and the larger team. The remaining transcripts were divided among team members for coding. The team developed matrices to identify themes, connections, and patterns based on methods used and how young women prioritized choice of contraceptive method versus source, type of source, and relevant characteristics of SDP and providers that influenced decision-making. An independent check of coding was undertaken by a member of the larger team at the end of the coding process.
In the analysis, we defined a decision-making instance as each time a respondent initiated a new contraceptive method. We then examine the circumstances and influences around that decision. We categorize each contraceptive decision-making instance by the decision that was prioritized by the participant: the decision about which method to use or the decision about where to obtain a contraceptive method. In addition, a third category of decision-making arose whereby there was not a clear prioritization of either choice (method or source) and we refer to this group of decisions as “ambiguous decision-making”. An analytic matrix was created to be able to explore differences by characteristics including county, age, parity, education level, and urban/rural. No differences were found by these demographics and so results are presented jointly.
Ethics approval
All study materials, including guides and consent forms were approved by the AMREF Health Africa Ethics and Scientific Review Committee (P205/2019), National Commission for Science, Technology and Innovation in Kenya, and the University of North Carolina at Chapel Hill Institutional Review Board (19-1360). Additional approvals were obtained from each county’s Director of Health. The in-charge of each individual SDP provided approval for data to be collected at their site.
Discussion
This qualitative study utilized in-depth interviews with young women from three counties in Kenya who were experienced FP users to understand the prioritization and decision-making process for method selection and contraceptive source selection. Our study found that the vast majority of young women knew what contraceptive method they wanted to use and then subsequently made the decision of where to obtain it; this was true both for the first method ever used and subsequent contraceptive decisions. Of the smaller number of women who selected the source of their contraceptive method first, many were in the post-partum period or experiencing side effects so turned to a trusted health provider for contraceptive counseling.
Our findings are consistent with previous quantitative studies that show that women often have a method in mind when seeking family planning services [
21]. By utilizing qualitative data, our study was able to go beyond common quantitative questions and understand what factors influence method selection and explore why that choice was generally prioritized over source selection. Respondents were often unwavering and confident in their method choice, having made the decision based on receipt of information through a variety of sources including friends, partners, providers, and schools, as shown in earlier studies [
3‐
5,
9]. They then determined where to obtain the chosen method. This was particularly true for the first methods women used, most often male condoms and EC, where respondents cited limited knowledge of other contraceptive methods, dual protection and protection against pregnancy after unprotected sex [
33]. The confidence women exhibited regarding method selection for male condoms and EC also extended to other commonly used hormonal methods in Kenya, such as implants and injectables, where, similar to findings from other studies, women often expressed a desire for a method that was longer acting and did not require frequent follow-up at health facilities [
7,
9]. Our study expands on the Jarvis et al. study, which found that women frequently know what method they want before seeking services, by suggesting that the choice of a method may guide where it is sourced [
22]. Our study found that when considering which decision was prioritized, the default for women who decided to use contraception was to seek services after identifying the method they wanted; only in specific circumstances did women arrive at a SDP without having pre-determined their method of choice.
We found that for a smaller set of young women, after deciding to use contraception, the choice of a method was secondary to the decision about where to obtain the method. In most cases, this prioritization was applicable to young women who were farther along in their reproductive life course and had either recently had a pregnancy or birth or were experiencing side effects and required information and counseling from a provider in order to determine what contraceptive method to use. When explaining this prioritization, women cited their inability to decide on a method before seeking services, and instead prioritized returning to trusted health care staff or sources where they had received services in the past, primarily for some type of maternal, newborn or child health service.
Our study also highlighted that counseling during pregnancy and after childbirth is key in helping women make decisions about what method to use and where to seek contraception, regardless of which decision they prioritize. This includes women who selected their method before selecting the source but after receiving information about contraception during past antenatal or post-partum care visits. Despite most women having decided on a contraceptive method prior to visiting the facility, our study highlights the importance of provision of high-quality information and services, including ensuring comprehensive counseling on a full range of methods when a woman comes to a facility to seek antenatal, postnatal, child health visits, and contraceptive services [
34], as it may influence future contraceptive decision-making. Additionally, women who return to the SDP where they gave birth for FP counseling and contraception benefit from these sites offering a broader range of methods as compared to pharmacies, and therefore these sites have the ability to provide them with their chosen method.
Additionally, despite few examples of ambiguous decision-making around method or source prioritization, the examples highlight the value and strength of qualitative data to uncover and explore the nuances of contraceptive decision-making. At least two of the experiences that young women shared highlight issues around power and abuse, whereby these young women were not able to make a free and informed choice about contraceptive use. These examples point to complexities around contraceptive use and decision-making among young women, which are important for health care providers to be sensitive to.
Regardless of which decision—the method or the source—was prioritized, many of the desired features of service delivery points were similar for the source where women ultimately received their method. As found in other studies, young women preferred sources that were proximate to their home and were perceived to offer privacy and confidentiality [
7,
9,
13]. As women transitioned to having children or being married, new preferred features emerged such as a facility with which they were familiar and where they could receive all of their care or that they had received FP information from the facility in the past.
This study has several strengths and limitations. First, in using in-depth interviews we were able to ask complex questions that went beyond common quantitative questions in order to understand the factors that influence prioritization of contraceptive decision-making and sourcing, and how these two choices were related. To the best of our knowledge, this is the first study to address this research topic particularly with the unique population of adolescents and youth. Additionally, our study included FP users who were using clinical methods as well as those who had received non-clinical methods from pharmacies and shops, a segment of the population that is often missed through client exit interviews. Finally, by asking participants to discuss all contraceptive methods they had ever used, we were able to explore multiple decisions about method and source made at different points in a young woman’s life.
Despite the strengths of our study, collection of retrospective data introduces recall bias. Respondents may have had challenges recalling important details about their past decisions. Given that this research topic focuses on nuances in decision-making, it is possible that some respondents may not have been able to accurately recall how and why they made particular decisions. Further, knowledge gained and decisions made later in their lives may have biased their recall of earlier decisions. In addition, the study population of focus is young women who had previously used two or more methods of contraception, including clinical methods. These “experienced” users may be different than women who have not used multiple methods.
Finally, for a small number of respondents, the reason for prioritizing one choice over the other was ambiguous and even with probing, respondents often had difficulty differentiating which decision was prioritized. Respondents typically resorted to explanations about the features of the methods or the source that they preferred or liked, but sometimes did not clearly articulate why they would prioritize one decision over the other. Additionally, male condoms are often procured by male partners and are easily accessible at multiple sources, thus making the decision-making priority less relevant [
9,
33]. Relatedly, some respondents indicated that decisions regarding method and source appeared to occur jointly. It may be that women have an innate association in their minds, for example, that certain methods are obtained from certain sources, such as male condoms from pharmacies [
35]. They may also attribute specific features of sources to a particular type of source, such as that methods are free at public facilities or that quality of care is higher at private facilities, and these characteristics may be closely related to method selection.
Conclusion
Our findings highlight that the choice of method among women at the beginning of their contraceptive life course is primarily limited to male condoms, being the main method they know about. Programs should develop targeted information campaigns either through the mass media, through community-based programming, or in schools for adolescents and youth that focus on increasing knowledge about contraceptive options, including information on the features of methods, the importance of male condoms for dual protection, side effects of different methods, while also dispelling myths and misconceptions about methods and method use among young people. Broadening young people’s knowledge base on contraceptive methods and where to source them will ensure that they are able to select the method that best suits their life circumstances, even if in the future.
This study also points to the need to provide young women with information about contraceptive options at all points along the reproductive health continuum of care. Several respondents in our study made decisions about which type of contraceptive to use based on family planning counseling during antenatal care, childbirth care, postnatal care or a well child visit. Where possible, programs should include comprehensive counseling on family planning during each of these contacts with the health system and consider other opportunities for integration, with a particular focus on reaching sexually active young adults with information on the range of family planning methods available as it may inform future contraceptive decision-making.
With the recent roll-out of the 2018 policy now allowing pharmacies to sell and administer injectables [
29], a commonly used method that has been primarily and historically sourced from public facilities in Kenya [
23], future work should explore how and if this broadens method mix among the youngest clients as well as if this shifts the decision-making process regarding source and method prioritization. Expanding source options for hormonal methods may help to address some of the barriers that women face seeking contraception, particularly young women.
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