Too many, too soon, too close

Challenges of family planning in Sub-Saharan Africa

Suvi Tuominen

PREFACE

Population growth is one of the most serious problems of the human kind. It affects all the sectors and levels of the human life: from economy, to environment, from education to health, from household level to all the way up to carrying capacity of the whole globe. Why then, the population growth is not the centerpiece of every important debate of the policy-makers and civil society? Maybe because population growth, being altogether something abstract, is not seen as something urgent? Maybe it is because the challenge is so huge one does not even know where to start? Maybe it is because at the end of the day, population growth is about sex and for some, this topic is something uncomfortable? Whatever the reasons behind the inaction lie, the truth is that we are too much. When discussing about population growth, where it comes down at the end of the day, are the individuals. They are the ones giving birth to babies and they are the ones using family planning to manage these births. These individuals are also the centerpiece of this study. However, these individuals are dependent on the active policy level that addresses funds to family planning programs and functional service level that cares for the patients and has the tools and the attitude to address their needs and concerns properly. Having active policy level and functional client-oriented service level are still not enough. There are also traditions and old customs and norms that affect the individual decisions about family planning. Actually, many of the challenges of family planning relate to deep rooted socio-cultural factor that have existed in the society for decades or even for centuries. Having large families has for long been a tradition in Sub-Saharan Africa that has gradually started to change as a reaction to modern realities. Still, family sizes tend to be much larger than for example in the Europe. This is not a problem per se: everyone should have the right to choose how many children they want, whether it is many or few. The ability to choose, the ability to have an option, is thus the core issue of family planning and family planning is a means to having an option. A means to deciding, not only how many children to have, but when and with which spacing. This seems to be something very obvious. In Sub-Saharan Africa it is not. Having options requires that one is aware of this option. This is not the case with every mother and father of Africa. If you have no idea about a possibility to manage the number of children much less the methods available for doing this, there is no option. One mama, living in one of the largest slums in Sub-Saharan Africa, Kibera, had heard about family planning from her neighbors only after giving birth to her 7th child. If only she had known, she would have wanted to have 4 children. Giving information to people like this mama, means giving them options. Having information, however, is not always by itself, enough. Fulfilling the preferences can be hindered by the decision-making power by someone else, in this case usually the husband. One may know his/her option but it not able to actualize it because of someone else. Thus in addition to purely providing information, also empowerment to utilize this information is needed. What do you do with the information, if you are not able to use it? Thus empowering people, also means giving them options. In addition to the closest family members, family planning faces obstacles from the surrounding society. Media, religion and even the ethnic group can affect ones decision as individuals do not live in a bubble that acts as a shield against the outside society. It takes a lot of courage to stand against the negative perceptions, like another young mama from Kibera who has decided to have two children, two children only, even though she faces mocking from her neighbors who tell her to give birth until all eggs in stomach 2

are finished and threaten her with stories that she wont go to heaven as she is using family planning and thus killing her kids. Challenges of family planning are many in the Sub-Saharan Africa. The lucky ones dont have any challenges, but there are many, that have. These people, in order to use family planning, have overcome obstacles from service level that is usually dependent on the policy level and the challenges coming from the surrounding society as well as the community not to mention the people close to you. The lucky ones and the not so lucky ones were both interviewed for this study. There is no one solution to managing the ever growing population of this world. Addressing the challenges of family planning, is however, a good place to start. As everyone deserves an option. Even the mamas living in the slums like Kibera.

EXCECUTIVE SUMMARY

The results of this report can be summarized as follows: Population growth Population growth is one of the most challenging problems of today with serious consequences to economy, environment, health, infrastructure and quality of life, carried mainly by the developing countries When it comes to Sub-Saharan Africa, the consequences of population growth have even more serious effects to continent than in developed countries, as the ability to cope with these consequences due to, for example, bad governance, weak institutions and infrastructure, widespread poverty and even armed conflicts, are not very good Family planning has been introduced as a mean to manage this growth. Despite of this, the fertility rate of 5,3 births/woman in Sub-Saharan Africa is the highest in the world

High-level challenges of family planning: One of the main challenges with family planning seems to be that it is not seen as something urgent. This has effects on all levels from policymakers to grassroots level. One of the biggest challenges of the past decade for stakeholders involved in family planning has been the lack of funding due to Mexico-city policy and HIV/AIDS crisis taking over Africa. This shift of funding has left a gap in family planning programs in Kenya.

Challenges of family planning at the service level Public family planning programs face challenges with commodity availability and weak healthcare infrastructure that has effects in the lack of man power in family planning clinics and bad quality of services Public family planning services are supposed to be free. However, this is not the case as in order to sustain, facilities have decided to levy of provision of certain services. As this may not be problem for all as the fees are still low, it certainly can act as a barrier to the poor people

General perceptions about family planning: Family planning is seen mainly as womans issue instead of being a mutual thing concerning the couple together It is not self-evident that family planning is discussed with the partner Use of family planning, in many cases, is not a mutual decision Having large number of children is commonly not something that was planned but more of something that just happened

Socio-cultural and economic factors supporting large families Large family can be seen to contribute to the economic situation of the family by helping it financially, acting as a labor force and supporting the parents when they get old However, in general the economic restrains of having a large are well understood but it may not have effect in practice 4

Myths and misconceptions about family planning in general and especially on the side-effects are widely present in the every level of the society and affect the use of family planning negatively. The access to contraceptives is not enough if they are seen as something harmful and because of that, not used There is still a clearly a preference for boys over girls. This can contribute to having large families as couples have many children because they try to seek for a boy The traditions seem to be in conflict with modern reality: The economic restraints of having large families are well understood yet family sizes are large

Outside influence There is a strong pressure from the in-laws for a married couple to have children Politics in Kenya have been heavily ethnicized and tribalized. Having large families can be seen to benefit the tribe Religious institutions dont have that meaningful role in the decisions related to family planning as having children is seen as something personal. Even Catholics are using modern contraceptives widely despite of churchs strong negative stance Media can be an effective tool in spreading family planning information, unfortunately this information can be biased and affect individuals negatively

Family planning information Information about family planning is commonly received for the first time only after giving birth The information is often fragmented and collected from different sources and thus might lead to misconceptions The problem with one-sided top-down information is lack of the possibility to ask clarifying questions. These questions, often times left unanswered, may hinder the use of family planning

Challenging groups for family planning When it comes to family planning, men are the most challenging group to reach. Men are the decision makers of the family and also the main hindrance for women to use family planning. Yet they are also the group that has been neglected by different family planning programs. New, innovative and creative approaches are needed to involve men in family planning programs in all levels Other challenging group for family planning services and programs seems to be the single women. Family planning is usually introduced to women only after marriage and first birth and single people frequently visit clinics There are also challenges with reaching the adolescents as , in addition to this groups economical challenges, the service providers might have barriers towards serving this group and the opening hours of the clinics act as a restraint to students

Education as means to empower women in family planning Education can be seen as a means to empower women as educated women are more likely to have smaller families. The most important factor in education was seen to be the overall world view change it brings, such as understanding better the economic aspects of what it takes to raise a child 5

Mobile tools for family planning? There certainly is an opportunity for mobile communications as the need for information is acute Especially the role should be in addressing the root problems of family planning like the correcting the extreme rumors about the side-effects and engaging men to be involved in family planning However, this information should be provided with a possibility to interaction.

CONTENT
PREFACE............................................................................................................................................................. 2 EXCECUTIVE SUMMARY..................................................................................................................................... 4 1 INTRODUCTION ............................................................................................................................................ 10 2 METHODS OF RESEARCH .............................................................................................................................. 10 2.1 Expert interviews ................................................................................................................................... 10 2.2 Survey .................................................................................................................................................... 11 2.3 In-depth interviews ............................................................................................................................... 12 2.4 Challenges of the data collection .......................................................................................................... 12 2.5 Structure of the report .......................................................................................................................... 12 3 CAUSES AND CONSEQUENCES OF POPULATION GROWTH IN SUB-SAHARAN AFRICA ................................ 13 3. 1 Population growth ................................................................................................................................ 13 3.1 .1 Brief history of global population growth ..................................................................................... 13 3.1.2 Population growth in Sub-Saharan Africa ...................................................................................... 14 3.2 Explaining population growth ............................................................................................................... 15 3.2.1 Demographic Transition Theory ..................................................................................................... 16 3.3 Causes and consequences of population growth in Sub-Saharan Africa .............................................. 17 3.3.1 Economic growth ............................................................................................................................ 18 3.3.2 Poverty............................................................................................................................................ 18 3.3.3 Education ........................................................................................................................................ 19 3.4 Other consequences of population growth .......................................................................................... 20 3.4.1 Environment ................................................................................................................................... 20 3.4.2 Health issues ................................................................................................................................... 21 3.4.3 Challenges with young population ................................................................................................. 22 4 OVERVIEW OF FAMILY PLANNING PROGRAMMES IN SUB-SAHARAN AFRICA............................................. 22 5 USE OF FAMILY PLANNING ........................................................................................................................... 23 5.1 Use of family planning in Kenya ............................................................................................................ 23 6 HIGH-LEVEL CHALLENGES OF FAMILY PLANNING IN KENYA ....................................................................... 25 6.1 Family planning versus HIV/AIDS........................................................................................................... 25 6.2 Non-urgency of family planning ............................................................................................................ 27 7 SERVICE LEVEL CHALLENGES OF FAMILY PLANNING IN KENYA.................................................................... 28 7.1 Challenges of public family planning services ....................................................................................... 28 7.1.1 Commodity availability and logistics management ........................................................................ 29 7.1.2 Lack of resources and bad quality services .................................................................................... 31 7

7.1.3 The cost .......................................................................................................................................... 32 7.2 Analysis of NGO-run family planning programs in Kenya ..................................................................... 32 7.3 Analysis of private sector family planning services ............................................................................... 33 7. 4 Availability, access and services according to family planning users ................................................... 34 7.4.1 Availability and access .................................................................................................................... 34 7.4.2 Cost ................................................................................................................................................. 35 7.4.3 Public vs. private clinic.................................................................................................................... 35 8 CHALLENGES OF FAMILY PLANNING ON THE INDIVIDUAL LEVEL ................................................................ 36 8.1 Level of awareness concerning family planning on the individual level ............................................... 36 8.2 General perceptions about family planning and family size ................................................................. 37 8.2.1 Concept of family planning ............................................................................................................. 37 8.2.2 Decision-making over family planning ........................................................................................... 38 8.2.3 Discussing family planning .............................................................................................................. 39 8.3 General perceptions about family size .................................................................................................. 40 8.3.1 Desired family size and perceptions about large families .............................................................. 40 8.3.2 Planning the number of children .................................................................................................... 42 8.4 Economic, health related and socio-cultural rationales behind having large families.......................... 47 8.4.1 Economic rationales for and against large families ........................................................................ 47 8.4.2 Social and health related reasons .................................................................................................. 49 8.4.3 Socio-cultural reasons .................................................................................................................... 52 8.4.3.1 Fear of side-effects .................................................................................................................. 52 8.4.3.2 Preference for boys over girls................................................................................................. 60 8.4.4 Traditions vs. modern reality .......................................................................................................... 64 9 PRESSURE FROM THE OUTSIDE SOCIETY ...................................................................................................... 64 9.1 Pressure from the in-laws...................................................................................................................... 64 9.2 Pressure coming from the surrounding community ............................................................................. 66 9.3 Influence of the tribe ............................................................................................................................. 69 9.4 Influence of the religion ........................................................................................................................ 71 9.5 Media ..................................................................................................................................................... 73 10 RECEIVING FAMILY PLANNING INFORMATION .......................................................................................... 74 10.1 Sources of family planning information .............................................................................................. 74 10.2 Information lacked .............................................................................................................................. 78 10.3 Challenge with fragmented information and top-down information ................................................. 79 11 CHALLENGING GROUPS FOR FAMILY PLANNING AS A CROSS-CUTTING CHALLENGE ............................... 80 11.1 Men...................................................................................................................................................... 80 8

11.1.1 Challenges in involving men ........................................................................................................ 81 11.1.1.1 Cultural challenges ................................................................................................................ 81 11.1.1.2 Technical challenges .............................................................................................................. 83 11.1.1.3 Economic challenges ............................................................................................................. 83 11.1.2 Involvement of men into family planning programs needed ....................................................... 84 11.2 Single women ...................................................................................................................................... 85 11.3 Youth ................................................................................................................................................... 85 12 EDUCATION AS A MEAN TO EMPOWER WOMEN IN FAMILY PLANNING .................................................. 87 13 MOBILE TOOLS FOR FAMILY PLANNING? ................................................................................................... 88 13.1 Use of ICTs in family planning programs in Kenya ............................................................................. 88 13.2 Possibilities for mobile communications in family planning ............................................................... 89 14 CONCLUSIONS ............................................................................................................................................ 90 REFERENCES: ................................................................................................................................................... 92

1 INTRODUCTION

Population growth is one of the most complex and challenging problems facing the world today and its consequences are affecting peoples lives around the globe. The biggest burden of this growth is carried by the developing countries, such as countries located in Sub-Saharan Africa. One of the efforts in trying to manage population growth has been the introduction of modern family planning. By effective and informative family planning it is possible to give people an option to limit or space their children according to their preferences. However, despite the existing family planning programmes in sub-Saharan Africa the family sizes tend still to be large and the average number of births per woman is 5,4 being the highest fertility rate of any region in the world . Today, family planning faces wide array of challenges from the highest policy level right down to grassroots levels among regular mothers and fathers. This study aims to understand the process of family planning and especially those family-size related decisions coming from the individuals themselves as well as the influence coming from the surrounding society. Finally, the study aims to find out whether there could be a role for mobile communications in family planning. The study consists of three phases: desk study, expert interviews and field interviews.

2 METHODS OF RESEARCH

The study consisted of 4 phases: a desk study on causes and consequences of population growth, 11 expert interviews, a survey for 100 respondents and in-depth field interviews for 19 respondents. To reach as reliable results as possible, both qualitative and quantitative methods were included.

2.1 Expert interviews

The 11 expert interviews were conducted in Nairobi in the course of February 2010. The interviews targeted the following local non-governmental organizations (NGOS) working with family planning issues in Kenya, listed below: Marie Stopes Family Planning Options Kenya (FHOK) Family Health International Population Services international (PSI) Population Council African Demographic and Health Research Centre Path Finder

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In addition to these NGOs, a representative from the Division of the Reproductive Health, acting under the Ministry of Health (MoH) in the Government of Kenya, was interviewed. To get an understanding of the challenges faced at the service provision level, also a nurse from public family planning clinic and a doctor from private clinic were interviewed. Also, a representative of UNFPA (United Nations Population Fund) was interviewed. The aim of these interviews was to get an overall understanding on the success factors as well as the challenges faced by various family planning programs in Kenya operating at the different levels. The interviews also gathered information on the opinions of the experts about challenges that individuals face in the field of family planning.

2.2 Survey

In addition to expert interviews, a survey mapping family planning was conducted for 100 respondents in urban and rural Kenya. Due to sensitivity of the subject, male respondents were interviewed by males and female respondents by females. Sample for the survey was selected to be as representative as possible and included respondents from both sexes, different age groups, different religions, different income levels, with different educational levels etc. The composition of the sample was following: Table 1: Study Sample (N=100) Sex: - 52% males - 48% females Age: - 15% 15-24 years, - 51% 25-34 years - 34% 35-50 years Area - 50% urban - 50& rural

Religion: 59% Protestant 35% Catholic 5% Muslim 1% No religion

Income level - 42% poor (0-10 000 KES/year) - 31% low-income (10 000 20 000 KES/year) -15% middle income (20 000- 50 000 KES/year) - 12% high income (50 000 KES and above)

Educational level - 7% no education at all - 11% at least some primary education - 21% completed primary school - 6% at least some secondary education - 33% secondary education completed - 22% higher education 11

In addition to qualities indicated in the table above the respondents were chosen according to number of children they have, whether they were working or not, the area they live in and the tribe they belong to. As the sample of 100 respondents did not represent all the areas of the country, the Kenya Demographic and Health Surveys (KDHS) from the years 2003 and 2009 were used as supporting data. KDHS is a wide survey mapping the family planning user data and covers the whole country.

2.3 In-depth interviews

In-depth interviews were conducted for 9 male respondents and 10 female respondents according to specific profiles. The interviews targeted the poorest of the poor, people living in one of the largest slums in Sub-Saharan Africa, called Kibera as well as middle class people living in Nairobi. Different ages and people with different number of children were represented in the sample according to specific profiles. All of the interviews were conducted either in Swahili with English translation or in English. As was the case with survey, female respondents were interviewed by female interviewer and male respondents by male interviewer.

2.4 Challenges of the data collection

The data collection faced challenges especially with the survey interviews. The high income respondents were hard to reach and were reluctant to answer the questions. Also, challenges were faced with male respondents as they felt that family planning is a private issue or something that concerns mainly women. The same problem was faced with some ethnic groups, such as Somalis who had challenges discussing the subject. As mainly the survey interviews were conducted in Swahili, there were challenges finding Maasai respondents who spoke the language instead of their own traditional language.

2.5 Structure of the report

This report includes combined conclusions from all the phases of the research. The content of the report is constructed in a way that the subject of family planning and rationales behind having large families is presented from top down, from policy level, to service level and finally to individual level. As before understanding the challenges of family planning it is essential to understand the big picture behind it, this report starts with presenting the causes and consequences of population growth. After that 12

the report progresses to high-level challenges of family planning in general and especially in Kenya and then progressing to the challenges faced at the service level. Then, focus is shifted towards the individual level: the general perceptions about family planning and those socio-cultural and economic factors affecting the use of family planning on the grassroots-level. Also, the outside influence coming from the surrounding society such as religion, tribe and media is evaluated and the sources of family planning information are presented. Every chapter concludes with recommendations of What can be done that takes the analysis one step further, into a practical level. Finally, the report brings up the possibilities that mobile communications might have addressing the challenges presented in this report.

3 CAUSES AND CONSEQUENCES OF POPULATION GROWTH IN SUB-SAHARAN AFRICA

To understand the serious consequences that non-use of family planning brings, it is essential to take a closer look on the population growth. Next, the causes and consequences of this growth are elaborated. With this wider framework it is possible to recognize the importance of effective and informative family planning as well as to see the family size linkages to serious problems such as poverty, lack of education and environmental degradation. This chapter concentrates on Sub-Saharan Africa. Part of the chapter is also based on research concerning development countries. In these cases it has been noted that development countries is a wide concept including also countries such as China and countries from Latin America where the population composition is different from countries in Sub-Saharan Africa.

3. 1 Population growth

Population growth comprises of measured numbers of fertility and mortality and changes in one or both of these numbers and in some settings migration. In order to understand the scale of changes in global population growth, the brief history of this growth by numbers is presented first.

3.1 .1 Brief history of global population growth

Table 2: Global population growth1 Even though the current academic research on population growth has concentrated on descriptions on effects of the fast growing

Source: United Nations Population Division

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population, rapid population growth is not an old phenomenon. Until the 19th century the world population grew very slowly and started growing fast only after that. The curve describing the evolution of global population would thus present a sudden vertical rise at the end of the curve as presented in the picture above 2. Population growth was slow in the beginning of B.C.E when our planet was populated by only about 300 million people3. Population at that time grew very slowly as diseases, wars and famines were common factors that decreased the number of people. Worlds population reached the limit of one billion in the beginning of 19th century and in the beginning of 20th century the population was around 1,7 billion. 4 The Second World War marks another increase in population growth speed. In 1950 the world had 2,5 billion people and the milestone of 5 billion people was achieved in the end of 1980s and by the end of millennium the population was 6 billion5. For the past 50 years worlds population has multiplied rapidly. According to the latest United Nations estimates the current population of the world is estimated to be 6,8 billion. The number is expected to rise to 7 billion in 2012 reaching 9 billion in 2050. As the history has shown, the growth will remain concentrated in the populous countries. The biggest burden of this growth is carried by developing countries: their population is expected to add additional 2,3 billion people reaching 7,9 billion in 2050 while the population of the developed countries is expected to change only minimally.6

3.1.2 Population growth in Sub-Saharan Africa

Making estimates of the population growth in Sub-Saharan Africa has been challenging until the 1970s because before that the good-quality censuses conducted at the continent were only few. United Nations estimates indicate that the population of the region has increased from 229 million in 1960 to 518 million in 1990 and today the population has reached 836 million. The estimated population in 2050 in Sub-Saharan Africa will be no less than 1,7 billion.7

Table 3: Population growth in Sub-Saharan Africa 1960 1990 229 million 518 million

As precise number is difficult to estimate, in addition to United Nations estimate used here, there are different interpretations of the world population in the beginning of the B.C.E., mostly presenting estimates between 200-300 millions. Durand (1977, p. 8) estimates the number to between 270-330 million, while Mc Evedy and Jones (1978, p.342) estimate the number to be as low as 190 million. 4 th For different estimates see for example Durans (1977, p.34) presentation for 19 century estimates, which all top one billion 5 United Nations, World at Six Billion (1999,p.5) 6 For more current statistics, see World Population prospects, highlights: The 2008 revision, United Nations Population Division, Department of Economic and Social Affairs http://www.un.org/esa/population/publications/wpp2008/wpp2008_highlights.pdf 7 United Nations estimates for Sub-Saharan Africa can be found from http://esa.un.org/unpp/p2k0data.asp

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2009 2050

836 million 1,7 billion

One of the most striking achievements of the 20th century has been the declining mortality and the corresponding increase at the life expectancy in Sub-Saharan Africa. In 1950s the infant mortality rate was at highest almost 175 per 1000 live deaths. The same number today is a bit over 808. Population growth in Sub-Saharan Africa is mainly determined by fertility. Despite of the declining mortality, it is the high fertility that has been driving the population growth. Past decades have witnessed a fertility transition in Sub-Saharan Africa, a shift from high fertility to declining levels of fertility. Despite of the ongoing fertility decline the fertility rate is still the highest of the world compared to other regions. In 1950-1955 the total fertility average (children/woman) was 6,57, in 1970-1975 the number reached 6,73 and from 1980s onwards the number has declined to a bit over 5 children/woman today9. The same number in Europe is 1,5.

Table 4: Fertility rate in the world (births/woman) Sub-Saharan Africa Oceania Latin America Asia Northern America Europe 5,3 2,5 2,3 2,3 2,0 1,5

3.2 Explaining population growth

There are different models for explaining population growth. One of the most common one demographic transition theory is presented below. This model serves as a useful framework for explaining demographic change.

8 9

http://esa.un.org/unpp/p2k0data.asp http://esa.un.org/unpp/p2k0data.asp

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3.2.1 Demographic Transition Theory

The current academic literature recognizes different models for explaining the rapid growth in population starting from the 19th century. One of the most well-known of these theories is called the democratic transition theory. According to the theory the changes in population are tied to changes in mortality and fertility. The theory builds on historical factors and changes during industrial revolution and modernization in Europe, such as improved food supplies and living standards due to improvements in agriculture, transport, manufacturing and sanitary and medical advances together with uncontrolled fertility 10.These all factors contributed to demographic change. In a nutshell the theory of demographic transition aims to explain why all contemporary modern developed nations have gone through same three different stages of population change. Stage one describes stable or very small population growth before modernization process. Stage two, due to modernization process, is characterized by decline in mortality. This decline was not immediately accompanied by declining fertility and thus leads to demographic transition. During the transition period the growth is accelerated by declining death rates that precede the decline in birth rates.11 As a result of this process, in stage three, pre-modern societies with high levels of fertility and mortality, transfer into a societies with low levels of mortality and fertility12 .

Table 5: Demographic transition theory13

10 11

Szreter (1993, p.4) Todaro (1997, p.200) 12 Kirk, (1996, p.1, 5) 13 http://www.facs.gov.au/about/publicationsarticles/research/socialpolicy/Documents/prp13/sec1.htm

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The theory of demographic transition has been criticized for that its based on European experiences only and its applicability to Africa has been questioned 14.Even though the theory is a generalization of the typical sequence of events it also highlights that different societies experienced the transition in different ways. According to Lutz et al. empirical observed trends confirm the relevance as well as the predictive power of the theory for todays least developed countries (LDCs) where fertility decline is well advanced in all regions except Sub-Saharan Africa and even there the fertility transition can be observed and has been researched. 15 It has been argued that Sub-Saharan Africa is currently going through the second stage of demographic transition16. As the statistics presented previously in this study show, the mortality in the continent has declined and the same has happened to fertility, only in a more moderate way. The biggest difference between developed and developing countries concerning the transition process is namely the speed of mortality decline which in developing countries has been more fast than in todays more developing countries due to improvements in medicine and public health17. Instead of strictly elaborating the possible suitability of the theory to Sub-Saharan Africa, it can be seen as a useful framework for describing population growth by changes in fertility and mortality. In addition to this wider framework, especially in the case of Sub-Saharan Africa, it is important to concentrate on factors that both affect and follow high fertility. The next chapter will elaborate these important factors more closely.

3.3 Causes and consequences of population growth in Sub-Saharan Africa

In this chapter the causes and consequences affecting population growth, high fertility in Sub-Saharan context, are presented together. It is important to note that often times it is difficult to separate causes of the growth from its consequences as these issues are intertwined. Sometimes it might be hard to differentiate whether, for example, household poverty is a cause or a consequence of high fertility, or that they dont even cause each other but are caused by other factors such as poor level of education18. Thus, even though the composition of the following chapter is divided under different themes, this composition is artificial. Instead of looking at these causes and consequences individually, they should be seen as a net of causes and consequences affecting each other. As important is to keep in mind that the consequences presented below are not only caused by increase in population size but by also other factors. Ever since Thomas Malthuss famous predictions of the limited carrying capacity of the world there has been a debate over whether population growth inhibits improvements in the social and economic conditions of societies or not. The research in this field is by no means unanimous and assessments of the both causes and consequences of this growth have varied extensively. Even though the consequences of population growth are usually described to be negative, these consequences has to be evaluated in the light of what are the resources, possibilities and will of different
14 15

Schmeikka (2006, 16) Lutz et al .(2004, p. 6). Based on this theory Lutz et. al assume that fertility will decline in countries that have experienced mortality decline but still show high levels of childbearing and thus predict the end of world population st growth in the second half of the 21 century. 16 Todero (1997, 202) 17 Lutz et al. (2004, 8) 18 Ibid., 17

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regions in the globe to adapt these demographic changes. Thus, when it comes to Sub-Saharan Africa, the consequences of population growth have even more serious effects to continent than in developed countries, as the ability to cope with these consequences due to, for example, bad governance, weak institutions and infrastructure, widespread poverty and even armed conflicts, are not very good.

3.3.1 Economic growth

The economic consequences of population growth have been widely debated and are also highly divided ranging from positive conclusions that more population growth leads to more prosperity to more pessimistic ones stating that rapid population growth precipitates catastrophes. Focusing on development countries economists have addressed to questions: has the rapid population growth been good or bad to these countries economies. 19 More conventional theories have suggested that population growth is an essential ingredient in stimulating economic growth as larger amounts of population provide also large amount of consumers to create favourable economies in scale for production, to lower production costs and to provide cheap labour supply to achieve higher output levels. It has been even argued that free markets will always adjust to scarcities created by population growth. 20 Birdsall et al. have, however, found that high fertility often inhibits growth and successful efforts in fertility reduction on its behalf can accelerate economic development. Declining fertility can have positive effect on economic growth if policy circumstances are favourable. This is possible due to reductions in dependency ratio, also known as dependency burden. This means one-time opportunity, when labour force aged population is large related to dependent younger and older populations. 21 The poorer countries, such as the ones located in Sub-Saharan Africa, tend to suffer the impacts of population growth to their economies even stronger. The more effective the markets, governments and institutions, more the positive effects will be reinforced and negative effects will be moderated. The situation is worse for the poorer countries as all three factors are usually weaker and thus the negative effects hit more hard and positive effects are undermined. 22 It also self-evident that when population grows fast it restricts the possibilities to invest in basic infrastructure such as education and healthcare.

3.3.2 Poverty

Demographic factors play significant role in poverty reduction. Sub-Saharan Africa can be described as poverty trap, characterized by demographic factors, such as:

19 20

Birdsall et Sinding(2001, 3) Todaro (1997, 215) 21 Birdsall et Sinding (2001, 13) 22 Ibid.7

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- High fertility, - High infant and child mortality - Excess adult mortality.

The effects of the population growth to poverty in developing countries can be looked at on the macro level or on the micro level. Birdsall et al. provide an overview of the recent macro level research and conclude that recent evidence has shown that reductions in fertility may well be contributing to a decline of poverty rates and intensity.23 More concrete consequences of population growth to poverty can be presented at the micro level. The linkage between poverty and population growth has been widely recognized and there is little debate about whether poverty and household size are correlated. Moreover, those poor households with large number of children invest less in childrens education and health. Several studies have shown that at whatever level of disaggregation, for either a particular group or for a total population shows the commonness of poverty and house hold size increasing together. The problem with these studies, however, has been and is the difficulty in demonstrating a direct causal relationship between poverty and large families as many of the correlates with high fertility such as illiteracy and poor health are also associated with poverty 24 . Sometimes it might be even hard to differentiate whether household poverty is a cause or a consequence of increasing fertility, or that they dont even cause each other but are caused by other factors such as poor level of education. Despite these shortages it has been argued that the new findings suggest more strongly than before, that past high fertility in poor countries has been a partial cause of the persistence of poverty. The best way to describe this complex issue is a vicious circle where poverty and fertility reinforce each other. 25

3.3.3 Education

Education affects all aspects of peoples lives and is linked to demographic process closely. When family size increases, parents can less afford to send their children to school and especially girls are pulled out of school to take care of their siblings and help with household chores 26. Empirical studies have shown that childs school attainment is negatively associated with the number of siblings 27.

23

Birdsall and Sinding (2001, 14) For more information on the effects of population growth to poverty at macro level, see Lipton and Eastwoods research in the same volume. 24 Merrick (2001, 202) 25 Birdsall and Sinding (2001, 6) 26 Family size is not the only determinant for school attendance, also parental schooling and school-home-distance have been recognized also being important factors , United Nations (2006, p.65) 27 See for example National Research Council and Institute of Medicine (2005)

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Fertility affects also young girls schooling through pregnancy-related drop outs. While in many settings in Sub-Saharan Africa return to school after pregnancy is possible, re-entry rates are low28. Education also affects negatively to early-marriages, which also affect fertility decline. The importance of education has meaning also other way around: it is commonly known that education allows women to better take part in income generating activities as well as contributes to lower fertility. This way low educational level can also be seen as a cause for high fertility and this way contributing to population growth. Increase in womans education affects the number of children they have. The situation can be described as a vicious circle where high fertility has a linkage to lack of education which on its behalf has been researched to have an effect on large family sizes.

3.4 Other consequences of population growth

Previous chapters presented some of the most important factors, both causing and following population growth in Sub-Saharan Africa .There are also some factors, that can be seen more only as consequence of this growth, like environmental factors and health issues. They are elaborated next.

3.4.1 Environment

As it was case with previously presented factors, the effects of population growth to environment in SubSaharan Africa are complex. These effects are again many, and it is not only population growth, but population growth together with other factors, that contributes to environmental problems and climate change. Despite of complex nature of environmental problems, it can be argued that the environmental effects of population growth, via climate change or pressure it makes for already poor resources, are more stressful to countries in Sub-Saharan Africa than to more developed countries. One of the most debated environmental challenges of today is climate change. When it comes to climate change, the effects of population are far from straightforward. These effects are still not very clear because of the complex interrelationship between population growth, consumption, economic growth as well as production. It is well known, that the countries that produce that majority of greenhouse gases are those slowly growing populations with highly growing per capita incomes. In contrast, countries with fast growing population and low per capita incomes, such as the countries located in Sub-Saharan Africa, do not produce as much greenhouse gases29. Still it is these countries, especially women in these countries, who suffer the effects of climate change most. They must work even harder to secure food, water and energy due for example deforestation, drought and erratic rainfall 30. The extreme weather conditions are predicted to be even more unpredictable and frequent in Africa in the future31.

28 29

Lloyd (2006, 16) Guzmn et al. (2009, p.34) 30 http://www.unfpa.org/pds/climate/messages.html 31 UNFCCC (p.1)

20

Even though the linkage between population growth and climate change are far from clear, it has been argued that population growth affects even emissions. Population growth and size do matter for emissions projections over the long term, though the magnitude of this effect is hard to estimate. The scientific community seems to have a consensus that slower population growth will lead to decline in long-term emissions. These effects depend in addition to plain growth in population also on its special distribution, age structure and house hold composition. 32 Today the population is growing faster in countries, like the ones located in Sub-Saharan Africa where the natural resources are already poor. Growing population growth brings thus extra stress to these resources and as a consequence the already scarce resources are being overused. Agricultural intensification and expansion can cause crop failure and exacerbate environmental degradation as well as reduce biodiversity. This chain feedbacks again into biophysical system. The changes in climate usually only aggravate such interactions. 33 Another important resource in Sub-Saharan Africa is water. Generalizations of the population growth and its consequences to water can be misleading. However, in many regions, including sub-Saharan Africa water scarcity and quality affect mostly the poor. Africa will face water scarcity and there is a potential increase in water conflicts. The water scarcity on its behalf will again have effects on agriculture which heavily relies on water, which again effects human livelihood. 34 Closely related to both population growth and environmental degradation is migration. Many of the problems of the population may not arise for its overall-size but its concentration as a consequence of rural-urban migration. Migration, triggered by for example scarce resources can further cause environmental problems in urban areas, such as water supplies, sanitation and industrial waste in urban slums. 35

3.4.2 Health issues

High fertility has consequences for both mothers and children. High-risk births account for large proportion of deaths in development countries, also in Sub-Saharan Africa. This again contributes to high infant mortality rates, which have been almost 90 per 1000 live births between 2005-201036. The main factors of high risk pregnancies are: - Young age of the mother - Too closely spaced births. Closely spaced births increase the health risks during pregnancy and increase the risk of maternal mortality and diseases. New evidence has shown that when children are born at least three years apart, health and survival rates of both mother and children improve significantly. The health risks occur also if children are

32 33

Guzmn et al. (2009, p.7) Boko et al. (2007, p.441) 34 UNFCC (200, p. 18) 35 UNFPA (2003, p.4) 36 http://esa.un.org/unpp/p2k0data.asp

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born to young mothers. Children born to teenage mothers are twice as likely to die during their first year compared to those born to women in their 20s and 30s. Younger mothers are also more likely to experience complications during their pregnancy and childbirth.37

3.4.3 Challenges with young population

The fact that populations in Sub-Saharan Africa still tend to be young as fertility is high, bring even more challenges to the continent. The population of under 15-years old consist today over 42 percent of the population in Sub-Saharan Africa, in Europe the same number is 15, 4 percent 38. Beyond economic cost, the high rates of youth have social impacts to African societies. As employment rates are already low and labour markets are constantly entered by rising number of people, one of the biggest risks facing the evergrowing youth population is unemployment. In Sub-Saharan Africa the 3 in 5 of the total unemployed are youth. This group puts even more pressure to urban areas with a hope of finding a job in the cities. Youth, without nothing to do and with little hope of future, may not see any other alternatives but criminal activities or even taking up the guns by joining rebellion or armed groups and thus even having consequences on peace and stability. 39

4 OVERVIEW OF FAMILY PLANNING PROGRAMMES IN SUB-SAHARAN AFRICA

Programmes to promote family planning in developing countries began in 1960s as a result to rapid population growth. The first programmes of Sub-Saharan Africa were established in Kenya and Ghana in the end of 1960s. However, the new heads of African nations wanted to support strong African way of life right after the independence. This way of life neglected the womens right to use contraception and embraced larger families as well as belief that strong African nations would be built on large populations. 40 In 1970s the access to family planning programmes in Sub-Saharan Africa was extremely limited except for some pilot programmes and some NGOs operating in urban areas. Furthermore continents policymakers support for family planning was weak at that time. During 1980s attitudes, however, shifted and became favourable for family planning programmes as governments became more concerned about high population rates. In contrast with Asian tradition with emphasis on child limiting and developing family planning programmes supported by economic and demographic rationales, African policy makers opted for a health approach highlighting the importance of child spacing, and the delivery of family planning and reproductive health services within integrated health programmes. This was considered to be more culturally and politically appropriate for the continent. 41 Even though the attitudes of the African leaders have changed from the ones from the 1960s as fears of effects that fast growing populations have towards economic and social prosperity have emerged, the
37 38

United Nations (2006, 74-75) http://esa.un.org/unpp/p2k0data.asp 39 World Bank, (2008 p.1-3) 40 Caldwell and Caldwell (2002) 41 Miller et al. (1998, p.4-5)

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dedication for effective family planning is not widespread and high-level support for family planning is still lacking. This factor is elaborated in-depth in chapter 6.

5 USE OF FAMILY PLANNING

Chapter 3 briefly presented the complex causes and consequences of population growth in Sub-Saharan Africa. Next, the overview of the use of contraceptives is briefly presented. After that, we start elaborating the challenges of family planning in Kenya, progressing from high-level challenges to challenges faced at the individual level. According to the United Nations estimate, the percentage of contraception users, who are married or in a union, in Sub-Saharan Africa is 21,5% while the same number in Asia is 67,9% and in Latin America 71,4%. 42 Sub-Saharan Africa seems to stand out in these statistics with its low contraceptive use. Table 6: Contraceptive use in 2007 among Women aged 15-49 married or in union Sub-Saharan Africa Oceania Europe Asia Latin America Northern America 21,5% 54,9% 67,5% 67,9% 71,4% 73%

Also, the contraceptive use rate varies among the countries in Sub-Saharan Africa as for example only 7,9% of those married women in Somalia were using contraceptives the same number in Chad being as low as 2,8%43 From the number of women who prefer to avoid pregnancies and who at the same time do not use family planning can be counted the unmet need for family planning. Among the married women in Sub-Saharan Africa this unmet need is almost one in four. 44

5.1 Use of family planning in Kenya

42

United Nations, World Contraceptive Use 2007. For more statistics on contraceptive use, see http://www.un.org/esa/population/publications/contraceptive2007/contraceptive2007.htm 43 World Contraceptive use 2007, United Nations. The data from Somalia is from year 1999 and from Chad from year 2004. 44 http://www.prb.org/Articles/2007/UnmetNeed.aspx

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According to the latest Kenyan Demographic and Health survey, 46% of those women who are married are using contraceptives45. The contraceptive use is lowest with those aged 15-19 years (22,5%) and highest with 30-34 years (54,9%). Even though the contraceptive use is higher in Kenya than in Sub-Saharan Africa in average, it is still lower than the average in any other continent. The educational level has been widely researched to have an effect on contraceptive use. This is clearly visible also in the preliminary results of Kenya Demographic and Health Survey 2009:

Table 7: Use of family planning according to educational levels (KDHS 2009) Using No education Primary education incomplete Primary education completed Secondary + Not using 85,9% 59,7% 51,8% 40,2%

14,1% 40,3%
48,2% 59,2%

Whilst only 14% of the married women with no education were using contraceptives, the same number with those who had reached secondary school and higher, was 59,2%. The most popular contraceptive in Kenya is injection, pills being the second popular followed closely by natural family planning such as periodic abstinence referring to counting the safe days or withdrawal. Table 8: Contraceptive methods among those married women in Kenya who use contraception currently46 Injections Pills Natural family planning Sterilisation Implant Condom IUD/Coil 47 LAM48 21,6% 7,2 % 6% 4,8% 1,9% 1,8 % 1,6% 0,5 %

It must be noted here, that within Kenya the averages of the contraceptive use vary a lot according to the area in concern. For example, in the North Eastern Province49 the percentage of the married women using contraceptives is only 3,5.%.

45 46

Preliminary results of Kenya Demographic and Heath Survey 2008-2009 Kenya Demographic and Health Survey 2003 47 Intrauterine device/coil refers to T-shaped device inserted into womb to prevent pregnancies 48 LAM method refers to breastfeeding as a method of contraception 49 North Eastern Province was mentioned by the family planning experts to be a challenging area for family planning programs due to bad infrastructure e.g. lack of roads that hinders the delivery of information and service as well as for the overall conservative attitude of the area

24

6 HIGH-LEVEL CHALLENGES OF FAMILY PLANNING IN KENYA

The high-level challenges of family planning in Kenya, were highlighted in the interviews by the NGOs as well as a representative of Division of Reproductive Health from the Kenyan Ministry of Health and United Nations Population Fund (UNFPA). From the expert interviews it came up very clearly that family planning faces, or at least has faced, big challenges when it comes to the policy-level. It emerged that both public sector and NGO-run family planning programs in Kenya are highly dependent on external funding. Therefore any shifts in external or foreign policy priorities, and which affect the given budget allocations, will have consequences at their operational level. In todays world, where family planning has had to compete for the same funds as urgent crises, like HIV/AIDS, it is family planning that has been neglected in these cases.

6.1 Family planning versus HIV/AIDS

Focus shifted to HIV, which is very important but at the same time I think we shifted so quickly and radically that we forgot everything else, not just family planning, also safe motherhood we forgot, and everything shifted to HIV and now we are suffering because of that
[Project Director, Family Health International]

External funding from donors that supports family planning programs operated by local NGOs is essential in order to make these programs sustainable. Without consistent funding their efforts in the field of family planning suffer and this has, according to the local experts, direct implications also to the grassroots level. This lack of outside funding due to policy shifts was named by several experts to be one of the main challenges affecting them in the operational level as family planning programs tend to be donordependent. Globally, one of the biggest obstacles in the field of funding for family planning NGOS in the last decade has been the Mexico City Policy enforced by former US president George W.Bush 50. The Mexico City policy prohibited the provision of funds to certain organizations because on their stand on abortion. Due to this pro-life policy and the HIV/AIDS crisis taking over Africa, investment to family planning dropped significantly in Sub-Saharan Africa. In order to sustain their existence, these primarily family planning oriented organizations, such as Marie Stopes and Family Health Options in Kenya, needed to shift their thematic focus to HIV instead. Also the numbers tell the same story: funds allocated to HIV/AIDS from development assistance population funds accounted 9% in 1995 and 43% in 2005. With family planning the same numbers are 55% in 1995 and 23% in 2005. 51 According to the experts, as a consequence of lack of funding to family planning programs, the level of family planning efforts went down as did the contraception provision. Family planning or reproductive

50

The Mexico city policy, also known as Mexico city gag rule, was first introduced in 1984 by president Reagan, then lifted by president Clinton, introduced again by George W. Bush and lifted for the second time by president Obama 51 Pathfinder International 2005, Community based family planning in Kenya meeting new challenges.

25

health related information, education and communication activities were not available in the same way that they used to be. One of the darkest estimates made by one expert of this shift in policy was:

Due to this funding gap there are two generations that really dont understand what their reproductive health and family planning options are [Regional Manger, Population Services International]

It is not only NGOs but also the public sector who suffered from this funding shift. The Kenya Ministry of Health in its National Reproductive Health Policy 2007 also acknowledges the challenges of inadequate funding, due to general shift of focus of international assistance from population to HIV/AIDS. According to the policy, this has led to the deterioration in the quality of health service delivery and resulting in negative health indicators.52 Preliminary results of Kenya Demographic and Health Survey 2008-2009 indicate that since the early 1980s there has been a steady increase of contraceptive use among the married women. Then the contraceptive rate remained stalled between 1998 and 2003 to 39% and has now risen again to 46%. The same stalling period can be also seen with fertility rates. Todays results indicate that Kenya might be returning to decline observed from mid-1970 to the late 1990s. The decline in contraceptive use has had also effects to fertility rate. In 1975-78 the number of births per women in Kenya was as high as 8,1 and the same number in 1995-1997 was 4,7, as indicated in the table below. The fertility rate rose to 4,9 in 2000-02 and is today 4,6. Even though these numbers are affected by several different factors, one clearly affecting issue has been the global downsize of funding to family planning. Table 9: Fertility rate in Kenya53

President Obama lifted the ban in 2009 and according to the experts the lack of consistent funding has improved recently because of that. Now there is a much more interest in the part of the donors towards
52

National Reproductive Health Policy Enhancing reproductive health status for all Kenyans, Ministry of Health, Kenya 53 Preliminary results of Kenya Demographic and Health Survey 2008-2009

26

family planning. Also, the focus with HIV/AIDS has shifted now from creating awareness to actual treatment, which requires more technical knowhow. Thus NGOs involved in awareness-raising have moved on to for example community health issues and have started concentrating again on the issues like family planning.

6.2 Non-urgency of family planning

If you are sick, you are motivated to seek care, when it comes to family planning it is not seen something that needs care, its not an immediate thing, theres no immediate pressure [Program Officer, Population Council]

One of the most interesting facts that came up in the expert interviews was the fact that family planning is not seen as something urgent. This has effects from high-level policymakers to grass-roots individual level. First of all, it affects on the policy-level to the allocation of the funding to family planning. When something more urgent comes up, like what happened with HIV/AIDS, funding family planning is not seen as a main concern. One of the experts blamed the ministries for not having real motivation to address these issues. In over-stretched health facilities, it is the sick people who are given the priority compared to people seeking family planning, as family planning is seen more as social service. On the individual level also, family planning is not necessarily seen something that needs care as it is not seen something urgent in contrast to being sick. This can lead to lack of motivation for using family planning services.

Table 10: Non-urgency of family planning affects different levels

Policy level: The allocation of funding to family planning Health facilities level: Priority to sick clients instead of family planning clients Individual level: Family planning not seen as something that needs care

One of the main issues, however, seems to be that, the urgency that comes with population growth and the linkages it has to many social, environmental and economic problems are obviously not very well understood. If the consequences were understood correctly, providing family planning services should be seen as a priority. Clearly, there is a big need for advocacy on population issues in the higher level linking this issue to family planning as well as a need to inform ordinary grass root level people on the importance and urgency of family planning. One important tool in tackling the challenges of this non-urgency is the introduction of policies that highlight the importance of family planning. The UNFPA representative saw the future of family planning in Kenya in a positive light because of these policies and plans. The policy level outlook for the future in Kenya for the health sector has shifted from emphasizing preventive rather than curative services as indicated in The Second Health Sector Strategic Plan 2005-2010. This is a positive step for family planning, as it falls 27

into the category of preventive services. Ministry of Health has acknowledged many of the challenges that public sector family planning services face in its National Reproductive Health Policy, published in 2007. The aim of the policy is to reduce the unmet need of family planning, unplanned births as well as regional and socio-economic disparities in contraceptive prevalence rates. However, even though being an important tool, introducing new policies will not solve all of the practical challenges that family planning services faces. These challenges are elaborated more closely next.

What can be done?

- When initiating a family planning project or supporting a already existing one always make sure the funding is consistent in order to strengthen the sustainability of the project - Advocate the policymakers as well as donors to understand the drastic consequences that population growth has and on the various different levels of the society - Advocate on urgent action and highlight family planning as a means to address these drastic consequences

7 SERVICE LEVEL CHALLENGES OF FAMILY PLANNING IN KENYA

In this chapter the challenges of service provision level are elaborated more closely in the light of public and private sector as well as NGO-run services and programs.

7.1 Challenges of public family planning services

Overall, the public family planning programs in Kenya were seen by the experts to be doing a good job in reaching the poor in general and especially the rural poor. The public family planning services go right down to dispensary level and one is always supposed to get family planning services even at the lowest level. In practice, however, the access to these services faces challenges. The public family planning programs are concentrated in public health facilities where family planning services are provided. The six levels of these services are indicated in the table 11 below. The family planning services include counceling the clients on family planning as well as contraception provision. In addition to this clinical setting, the government through the Ministry of Health also trains community based distributors who provide commodities and refer people to clinics. In addition to concrete service, the government also has information, communication and education (IOE) activities. This information, concerning for example the effects contraceptives have on the users body as well as the benefits of family planning, is disseminated for instance via TV or publications. According to MoH representative the 28

contraceptive uptake has gone up in the provinces because of these IOE-activities but there still needs to reprioritization of these activities so that they are able to reach more people.

Table 11: Levels of care in curative and preventive services, including family planning, in Kenya54

The key challenges of public family planning services, highlighted by the experts, are commodity availability and logistics management, lack of resources and bad quality services and the cost of the services. These challenges are discussed in more detail next.

7.1.1 Commodity availability and logistics management

We have to move into a system where we can provide various family planning methods on various levelsand let the relevant departments to get it to the people according to their orders instead of just pushing
[Projects Manager, Marie Stopes]

The success factor and also a challenge for the public sector and especially to individuals was seen to be commodity availability. The government at least tries that every medical facility has commodities available, which was welcomed as a positive effort. The commodity insecurity was, however, also highlighted to be a big challenge for Kenya, a fact also acknowledged by the government. The governments representative named having all contraceptives available on all levels as the most effective way to manage population growth and at the same time concluded that when there are stock-outs, clients become frustrated and discouraged, if the method theyd like to have is not in stock. With the most common contraceptives the
54

National Health Sector Strategic Plan (NHSSPII)2005, 2010

29

situation seems to be better as according to the nurse working in public clinic they always have injections and pills in stock but when it comes for example to implants55, sometimes this is not the case. This view is also supported by the table below.

Table 12: Temporary Methods of contraception offered and availability on the day of the Kenya Service Assessment Survey 2004 (In addition to public sector, including also NGO, Faith-based organization and private facilities

In addition to general availability, the private sector doctor saw the lack of variety of methods as a challenge to public sector as they are not able to provide more rare methods such as family planning patches or hormonal IUCDs. However, this is a minor problem compared to commodity availability of popular methods. One of these issues closely related to commodity availability is commodity logistics management, which helps the provision of these commodities around the country. One of the experts rated the public sector services negatively on this aspect describing the current situation as not based on demand but more of a supply-led push of commodities to districts regardless of their needs or priorities and - resulting in a waste of resources on this. The government representative also named commodity logistics management as one issue that they are concentrating in developing in the future so that contraceptives would be at the right time at the right place.

55

Implants are small hormone bearing capsules rods which are inserted under the skin of a womans upper arm and release the hormone slowly over a long period of time.

30

7.1.2 Lack of resources and bad quality services

In the public sector there is a serious shortage of man power to that extent that they rather deal with people who are really sick, rather than social service such as family planning [Projects Manager, Marie Stopes]

The other challenges facing Kenyas public family planning activities, in addition to commodity availability, are caused by a lack of financial resources. This contributes to overloading of the health infrastructure, as a consequence of rapid population growth. The main problem is the shortage on man power, which in turn also contributes to the delivery of poor quality services. According to one expert, due to over-stretched facilities, the public sector services concentrate on people who are sick and not to issues that are seen not that urgent, such as family planning. Lack of manpower or workforce was also cited as main challenge by both the Ministry of Health official as well as the nurse in the public sector clinic. According to MoH representative the service providers are few and they are very stretched. The nurse-client ratio, or the doctor-client ratio is low, as indicated in the table 13. For public clinics, the problem with lack of man power concretizes in practice especially with time shortages. There are many clients waiting to get served and counseling and family planning takes time. Women are, for example, give a packet of pills without them understanding the side-effects as time is stretched. This again has other consequences that are elaborated more closely in chapter 8.4.3.1. Also, not everyone working in the clinic is trained on special family planning methods, so when the nurse who is specially trained is absent, the clients are told to go home. For example, IUCDs (Interauterine contraceptive devices) require special training from nurses. The overburdened health-providers are not able to give quality service when it comes to family planning. This again, feeds back into to the unfortunate fact that after bad quality service, clients wont go back.

Table 13: Registered nurses and doctors in Kenya in 2003 (number per 100 000 population)56

Doctors Registered nurses

15,3 33,1

56

Kenya Service Assessment Survey 2004

31

7.1.3 The cost

Public sector family planning programs are supposed to be free

[Official from Ministry of Health]

Some people are that poor, that they cant even afford that little amount
[Project Director, Family Health International]

One of the challenges that clients face in the field of family planning are financial ones. According to MoH representative the family planning services are supposed to be free. However, in practice this is not the case, a fact also acknowledged by the government. Due to financial constraints and in order to operate the public facilities have decided to issue a levy on provision of certain services. The financial constraints affect access to family planning in two ways: physically, in terms of the transport requirements to a family planning clinic located far away; and primarily in terms of the possibility to be able to access these services in the first place due to fees. The transportation problem is very evident in Kenya: on average over 50% of the population living in the rural areas have the distance of 5 kilometers or more to the nearest health facility, percentage reaching 100% in some rural areas 57. According to the public sector nurse the fees charged depend on the method concerned; injectables and pills cost 60 shillings whereas implants and IUDs cost 200 shillings. According to the nurse that is a challenge to some of the clients and they get women visiting and not having the money and then they are sent home. The problems with cost are also present in private family planning services, not only in the public ones. But what is most striking is that when these services in principle are supposed to be free for individual, in reality they are not. Although this may not be problem for all as the fees are still low, it can certainly act as a barrier to the very poor people, who are also the ones faced with the biggest challenges such as providing for many children.

7.2 Analysis of NGO-run family planning programs in Kenya

Family planning market is too big to be left to government, there is a very good role for NGOs [Programme Officer, Population Council]

The NGO-run family planning programs were welcomed by all the experts as complimenting nicely the public sector services. Family planning was seen to be too wide field for government to work alone in. As

57

Kenya Integrated Household Budget Survey 2005-2006

32

indicated in the chapter 6.1, the main challenge for the NGOs operating within the field of family planning during the recent decade has been inconsistent funding. Mainly NGO services were seen to reach middle-class people and also low-income earners in some cases. As public sector services are mainly concentrated on facilities, NGOs were seen to reach people better in the villages without these facilities, for example with their mobile clinics. The nurse in the public clinic praised NGO clinics for their well-trained staff and follow-up processes that are better than those in public clinics. The MoH representative gave good feedback for NGOs stating that their facilities are usually friendlier and that they stay loyal to their clients. In addition to the factors mentioned above, the success factors of these NGO-provided family planning services are hard to summarize due to the fact that these NGOs operate with very different stakeholders as well as have different services and projects. They have for example given valuable support to government ministries in the development of family planning policies, supported private providers in contraceptive provision, increased community awareness around contraceptives, had mobile services for reaching hard to reach and so forth. One could say, that NGOs have better resources for concentrating on specific groups or to specific themes more in-depth and they are able to use more innovative approaches in their projects than the public sector as it struggles with providing services to all. The main challenges, in addition to funding and difficulties with infrastructure in remote places, can be summarized as difficulties in reaching certain groups. These challenging groups are elaborated in the chapter 11.

7.3 Analysis of private sector family planning services

It is very obvious that the private sector family planning services reach different people than public sector services do. The main customer group, that private family planning services reach, is mainly middle or higher class people. Clients, who struggle with paying even the public family planning services, would not be able to cope with the private sector prices, as according to a private clinic doctor, they are also an obstacle to some of his middle class clients. Even though the clinic interviewed provides condoms, pills and injectables for free, a client has to pay a consultation fee for 2500 shillings. For IUCDs, their most popular contraceptive method, the clinic charged 4000 shillings and the hormonal IUCD up to 10 000 shillings. This price has been obstacle to clients wanting to use the specific method. The strength of the private sector, at least in the clinic interviewed in this study, is that it is able to provide a more wide array of methods to its clients than public sector or NGOs are able to due to their financial constraints. The clinic interviewed in this study provided for example family planning patch and hormonal IUCDs that are more rare methods. The private sector clinics also have the privilege of having good investigative facilities, which unfortunately lack in public or NGO clinics. With these facilities private clinics are able to identify certain complications affected by contraceptives promptly. The challenge with time restrictions are in addition to public sector also faced by the private clinics. The lack of time in counceling or educating client was named to be a big challenge also by the private sector doctor. In 10 minutes, the time reserved for these activities, one can only give very summarized information to the clients. This has consequences as clients may not properly understand the side-effects of certain methods. 33

The group of clients reached by the private sector services is very narrow for the very obvious reasons. What is striking, however, that it is the same narrow group, group of married woman with children, that is also mainly reached by other family planning services. This leaves out many groups with immediate need for family planning. These challenging groups are elaborated in chapter 11. .

7. 4 Availability, access and services according to family planning users

As indicated in the previous analysis chapters of different family planning programs in Kenya, family planning faces a lot of challenges in the service level. Availability and service were also themes that were asked about in both the survey as well as in-depth interviews.

7.4.1 Availability and access

When it comes to availability of different family planning methods, all of the in-depth interview respondents thought that they are easily available. The same case was with access to different methods: only one of the respondents highlighted that in some cases some of the family planning methods have not been in stock. Thus the problem in the urban areas, at least, might not be the lack of availability but more about the will or ability of the individual to obtain these methods.

For the married couples they are pretty much available, even for the people who are not married for people who just want to have sex and use contraceptives, yeah.. its there, you want, you get. [Female respondent, 20 years, college student]

These things are not difficult to get. [Female respondent, 28 years, lives in Kibera slum, sews clothes for a living]

The younger respondents were also aware of the places where one could obtain the methods. The university students said that e.g. condoms are available at the college clinic or all over the campus. Few of the respondents were even worried that the contraceptives might be too available, especially referring to emergency contraceptive pills, used mainly by young girls. Few of the respondent from the Kibera slum, mentioned a distance to clinic to be a challenge. Due to distance, they were forced to use private clinic instead public one, as the distance to public clinic was too long to walk. If one faces challenges with distance in urban areas, the situation is presumably even worse in the rural areas, where the nearest clinic can be located very far away and when there is no public traffic to use. 34

The positive attitude towards availability can also reflect the situation in the urban areas, as all the in-depth interviews were conducted in Nairobi. The availability of the methods is certainly more challenging in the rural areas as indicated in chapter 7.1.3.

7.4.2 Cost

As indicated in chapter 7.1.3 the family planning methods provided in the public sector are supposed to be free. From the survey respondents, however, only 22,7% said that they had acquired family planning methods or free. Otherwise, 47% said that the price was appropriate whilst 28,8% complained that the price was too high. The majority of in-depth interview respondent confirmed they have gotten the methods they were using for free. Some of them however also said that they had to pay, also in the public clinic. Usually the price was regarded to be cheap or acceptable keeping in mind that most of the respondents got the method for free. The price was contrasted to the usefulness and thus, as family planning was seen as a necessity by some of the respondents, seen as worth the money.
Its a lot but I have to pay because I feel its necessary for me to have the injection. If they said it is free I would really run (laughter!). [Female respondent, 26-year old, lives in Kibera slum, makes and sells Chapatis for a living]

7.4.3 Public vs. private clinic

The most popular place for obtaining the family planning methods among the in-depth interview respondents was a public clinic. These clinics were praised for actually teaching people how to use a method. In contrast to positive comments given to public clinics, there seem to be deep suspect towards private family planning clinics. They were seen to be only after money and not caring about the clients health at all. Also the effectiveness of the method provided there was suspected.

Because you get them from the hospital and if you want good one, dont get from private hospital. Because there are not good and they wont give you any information. From a private it (family planning method) call kill because you dont know it has been there for how long [Female respondent, 41 years, lives in Kibera slum]

You will not (in the private clinics) be advised on how to use them. You will just take them as panadol
[Male respondent, 18 years, Kibera slum, collects scraps metal for living]

35

One of the respondents had taken advantage of this attitude and opted for private clinic as according to her they dont care if the client has high blood pressure, in contrast to public clinics, but give the method without questions if the client is willing to pay. Only one of the respondents, middle class female, would not have wanted to go for public clinic as she didnt trust the care given there.

8 CHALLENGES OF FAMILY PLANNING ON THE INDIVIDUAL LEVEL

Previous chapters presented the main high-level challenges that family planning faces both on the policy level and the service level. Now, a closer look is taken on the individual level. First, the level of awareness and general perceptions about family planning are discussed and then the desired family size is elaborated. After that the focus is turned to economical and socio-cultural factors that affect family planning on the individual level.

8.1 Level of awareness concerning family planning on the individual level

Level of awareness refers to the knowledge of family planning in general and knowledge of different family planning methods. The family planning experts felt that the level of awareness of the different family planning methods at the community level is high. However, some of the interviewees specified, that this awareness does not equal real understanding. The numbers, such as the Knowledge of contraception rate of 94% indicated in the 2003 Demographic and Health Survey, gives a bit too much of a positive picture of the actual knowledge of the people in the field of family planning. The knowledge seems to be of awareness of existence of some family planning methods not a real informed level of people knowing what all of their choices are as it was put by one expert. Another thing that came up in the interviews was the lack of operational knowledge of the contraceptives. It is one thing to be aware that the contraceptive method exists and another altogether of actually knowing how to use it. Private sector doctor even stated that his clients are in general poorly educated in terms of understanding different methods. All of the respondents of the in-depth interviews had at least some knowledge about different family planning methods, or at least one method. Especially among the young and the poor, some of whom have already gotten children, the level of knowledge was very weak. For those, with the lowest level of knowledge, what they knew, tend to be something negative e.g. information about how condoms are not preventative for either diseases or pregnancies.

36

8.2 General perceptions about family planning and family size

The perceptions on how many children makes a large family, the opinions about whom family planning is for and is family planning in the first place something one can easily discuss about paint a picture of the general attitudes towards the family size and family planning.

8.2.1 Concept of family planning

Family planning should be a tool for couples, whether married or not, to mutually manage the pregnancies Even though the methods are mainly planned for womans use, this should not mean that it is only womans responsibility. Indeed, in Sub-Saharan Africa one of the challenges of family planning is the lack of male involvement. Family planning is seen as a womans issue and men tend to rule themselves out because of that. This was clearly indicated also in the survey results. Overall, 51% of the respondents said that family planning is for a husband and wife (married couples58) whilst 40 % thought it to be a womans issue. Only 7,1% thought that family planning is mans issue. Again, the level of education clearly affects the perceptions: 71% of those with no education felt that family planning is womans issue whilst 91% of those with higher education felt that it is for the couple. There is a clear difference between those who have no education or low education to those who are highly educated as indicate din the table below. Table 14: For whom family planning is for? For the married couple No education At least some primary education Primary education completed At least some secondary education 14,3% 27,3% For woman (wife) For man (husband)

71,4% 45,5%

14,3% 18,2%

33,3%

52,4%

9,5%

33,3%

66,7%

58

The respondents were asked spontaneously to say for whom family planning is for without giving them any options. As almost all of them said that is for the wife or the husband or the married couple indicates that family planning is mainly seen to belong to marriage.

37

Secondary education completed Higher education59 All the respondents regardless of education

51,5%

42,4%

6,1%

90,9% 50,5%

4,5% 40,4%

7,1%

Interestingly, 58% of the male respondent considered family planning to be a couples issue while only 33% thought it was a womans issue. 48% of the female respondents considered family planning to be womans issue whilst 42% referred it to be a couples issue. 44% of the rural respondents said that family planning is a couples issue whilst 56% of the urban respondents said so. The responses indicate that for a large proportion of the respondents family planning is not something mutual, something that concerns both parties of a relationship. This contributes to unequal decisionmaking power. Also, as something that is not seen for oneself, might not be seen that important on the first place. If family planning is not seen to be a mans issue, it may not be seen something important at all. Thus it should be strongly advocated that family planning does concern both parties, even though the other one of the couple is not self using any method.

8.2.2 Decision-making over family planning

Closely related to the general perception of for whom family planning is for is the actual decision-making over it. Only 52,9% of the married people said that decision to use family planning is made together with the partner whilst 33,8% said that the decision is made by themselves. 8,8% said that the decision is made by the partner alone. 24% of the male respondents informed that they are the ones who make the decision whilst 49% females said so. This might refer to a phenomenon, where it is usually women who make the positive decision to use family planning whilst oftentimes men make the decision not to use. According to the Kenya Demographic and Health Survey 2003 16,6% of the married male respondents disapprove family planning the same number being as high as 49,7% among those with no education. The perceptions about the idea of family planning for the couples do not widely exist, at least not in the lower levels of the society. The same thing can be said about the decision-making - it is not equal. This leads easily to situation where using (in that case usually secretly) or not-using is not a mutual decision of the couple.

59

4,5 of highly educated responded all

38

8.2.3 Discussing family planning

Closely related to general perception about family planning is the ability to discuss about it. Is it seen as something normal and issue that people are comfortable discussing about? Or in contrast, is it seen as something embarrassing and uncomfortable? Discussing, especially with your partner, is essential in order to make a mutual decision about whether to use family planning and which method. 45,3 % of the survey respondents felt that family planning is a topic that they feel comfortable discussing about whilst 15,1% felt uncomfortable. 28,8% felt that family planning is a private matter and 5,8% felt that it shouldnt be discussed in public. If the couple decides to have sex, they should also be able to discuss about their options together: whether to use family planning or not. Discussing with partners, however, is not something self-evident. Only 36,1% of the respondents indicated that they discuss family planning with their partners whilst a majority, 39,9% said that they discuss about it with their friends and 20,2% referred to family and relatives. 87,3 % of those who were married were discussing family planning with their partner. This leaves out 12,7% of those who married, who do not discuss family planning with their partners. According to Kenya Demographic and Health Survey 2003, 36% of the married female respondents have not discussed about family planning with their husbands at any time during the previous year. Table 15: Discussing family planning with:

Partner Friends Family

36,1% 39,9% 20,2%

Whether one has discussed about family planning with partner also affects the ability or will to discuss it with other people. One of the female respondents pointed out that the reason for that she feels comfortable about discussing these issues is the fact that she has discussed it with her husband and they have a mutual understanding about it. Discussing is much more difficult for them who use family planning secretly, a phenomenon very much present also in Sub-Saharan Africa. Also the young respondents of the in-depth interviews admitted that they dont feel comfortable discussing family planning. Majority of them were living in the Kibera slum. The reason for feeling uncomfortable was named to be poor knowledge: what there is to discuss if they dont know anything about contraceptives in the first place?

Ive never discussed it with any person. You know you cant talk about it yet you know nothing as Ive told you Ive never used and I dont know how to go about it. [Female respondents, 20 years, lives in the Kibera slum with her child]

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This phenomenon was also confirmed by the young middle class respondent: It is embarrassing to discuss about something one has no clue about.

For the young people the main factor (of feeling uncomfortable discussing family planning) is not knowing, and you dont want to be seen that you do not know such and such a thing. Are you for real? Thats the main fear that I have noticed in people [Female respondent, 20 years, college student]

It seems that whilst majority of the respondents said that they felt comfortable discussing family planning, there are still a quite a few people who dont feel comfortable about the issue and feel that it is something private. The most worrying thing of course is, that for some, family planning is a subject, which is not even discussed with the partner.

8.3 General perceptions about family size

In addition to general perceptions about family planning, also general perceptions about the desired family size paint a picture about the attitudes within the families towards family size.

8.3.1 Desired family size and perceptions about large families

Desired family size gives hints about the general attitude, whether people prefer large or small families. The average number of children wanted in this sample was 4. The average was a bit higher with male respondents (4,03) than with female respondents (3,87). When asked about the family size, ideally, how many children would one want, the numbers were also clearly higher with those who had no education or low education. The majority of those with no education would like to have 6 or 10 or more children whilst the majority of those who had completed secondary education and those who had higher education wanted 3 children. Those with no education at all, wanted 4 children at minimum whilst everyone else wanted at minimum 2 children. It also has to be noted that the average of desired number of children in all educational level is at least 3 or more children.

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Table 16: Desired number of children according to education

Average number of children wanted

7 6 5 4 3

2
1 0

Average number of children wanted

No education

At least Primary At least Secondary Higher some education some education education primary completed secondary completed education education

To understand the concept of big family the survey respondents were also asked about their perception of how many children makes a family a large family. Again, the numbers were much higher with those who had lower education, as can be noted from the table below. This indicates that what is a large family to some, is considered to be a small family for others. For example, when the majority of those with no education considered that a large family is more than 10 children, majority of those with high education felt that 4 children make a large family. On average those with no education considered big family to consist of 9 children whilst those with higher education considered the same number to be 5 children.

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Table 17: Perceptions about large families by average according to educational level.

How many children is a large family?

10.00 9.00 8.00

7.00
6.00 5.00 4.00 3.00 2.00 1.00 0.00 No education Some primary Primary completed Some secondary Secondary completed Higher education

As elaborated in the previous chapters, education has role in perceptions about family size: Those with no education or with low education are more likely to have larger families Those with no education or no education or with low education are more likely to want to have more children Those with no education or with low education responded higher numbers when asked about the perception of s large family.

8.3.2 Planning the number of children

Important part of family planning, in addition to actual use of contraceptives, is the actual planning part of it. This refers to sitting down with your partner and actually discussing and deciding on the number of children you would like to have, when to have them and with how many years of spacing. This helps to avoid unwanted pregnancies too early and having children too close to each other. The planning part of family planning, however, is something that is not self-evident in Sub-Saharan Africa. In Kenya nearly 20% of the pregnancies are unwanted and 25% mistimed (wanted later)60. This s was also visible in the survey sample as indicated in the table below:

60

Kenya Demographic and Health Survey 2003

42

Table 18: Planning the number of children: Yes No education At least some primary education Primary education completed At least some secondary education Secondary education completed Higher education61 100% 54,5% No 45,5%

71,4%

28,6%

83,3%

16,7%

81,8%

18,2%

90,9%

91,9%

Even though the majority (80%) of the survey respondents62 indicated that they have planned the number of children they want to have, it still leaves 1/5 of the respondents who had not done this. As can be noted from the table above, for example, almost half of those who had primary education completed had not planned in advance how many children to have. Not planning the number of the children can lead to situations where the couple finds themselves with large number of children and realizing afterwards that they might be too many. This was also indicated in the nation-wide Kenya Demographic and Health Survey 2003 where considerable proportion of women reported their ideal family size to be smaller than their actual family size. The same phenomenon was clearly evident in the in-depth interviews, where some of the respondents, also the ones with large families, articulated that they would like to have less children instead of the number they had right now.

I would have wanted four [Female respondent, 41 years, lives in the Kibera slum, has 7 children]

I would like two children

61 62

4,5 of highly educated responded all Te average of 80% is also the same with those who already have children

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[Male respondent, 50 years, lives in the Kibera slum, mason, has 6 children]

Having that many, was just something that happened, and was not planned. It was an accident
You know by then I dont think we had any plan, if the wife tells you that she is pregnant, you can only tell her to give birth [Male respondent, 45 years, has 9 children]

In some of the responses, there was clearly a sign of regret: this was not how I wanted it to be. The economic restraints of the large family were realized only afterwards and not before getting pregnant. This indicates also a lack of planning concerning the reality and practical issues. Having children also requires planning of other things: planning on how one is able to feed children, how one is able to clothe them and provide shelter for them. Some of the respondents openly admitted that this was something they havent thought about before having children.

Because I had not given birth (I had not thought about the economic issues) but when I got many children I realized there is a problem [Female respondent, 41 years, lives in Kibera slum, has 7 children]

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Table 19: Example interview with 50 year-old mason from the Kibera slum who has 6 children

For how long have you been married? 21years How many children would you like to have? Two Why? When my wife went for family planning she got side effects and then the high number (of children) . Does your partner feel the same? I dont know Had you planned in advance for the children that you have? No, they just came. What is the space between them? Two to three years. Did you discuss with your partner about this spacing? No Is it possible that you will have more children than you have? No because of the increasing needs of children and there is no job. Does it make a difference to you for having a boy or a girl? A child is a child, but there are still the traditional believes that if a woman who fails to get a boy is divorced Have you ever tried to get a boy Yes Does make a difference to your partner? That is a plan of God Does it make any difference to people you know ? Yes. They value boys for inheritance of wealth. Does it make a difference to your community? Yes because they say a boy is one to take cake of the home when girls get married Are there issues one must think of before starting a family? You look for place or business to generate income from. Did you think about these issues yourself ? No

45

In one of the cases planning, having 2 girls and 2 boys instead of 8 children, was ruined by the unwanted sexes of the children. In some cases, as illustrated by this one, the original planning is overruled by cultural traditions, in this case trying to have a boy. This socio-cultural factor is elaborated more closely in the chapter 8.4.3.2.
The idea when we were getting married was that there would be 2 girls and 2 boys and you think kind of.. its automatic but no. That is what we had decided originally so.. there was this one boy and we got girls as we were looking for another boy. [Female respondent, 47 years, Head Teacher]

An essential part of planning is not just planning these issues by yourself, but discussing these issues with your partner. Some of the respondents of the in-depth interviews openly admitted that they had not discussed the number of children or spacing them with their partners. As planning the number of children concerns the both parents, making a mutual and equal decision is essentially important, like is the case with the use contraceptives. It also has to be noted, that planning part is not possible without knowledge that tools for such thing exists. This was case with for example one of the respondents who had only heard about family planning after the 7th birth. Knowledge about family planning can certainly help couples who have at least some knowledge about these issues. Spacing of children has, in addition to mothers health, other practical benefits. Spacing children can ease the economic burden with for example school fees as the children dont start school right after one another like put promptly by one of the respondents who had carefully planned her children:

Like my first born has a difference of five years with the second born and is school going and you can make to pay school fees while you take care of the other one before they get into school. But when you have many school going children some in secondary like three of them, there is nothing to do at that point [Female respondent, 26-year old, lives in Kibera slum, makes and sells Chapatis for a living]

It seems that all together, there are a lot of factors concerning the perceptions about family planning and family size that contribute to having large families as:

Family planning can be seen as something uncomfortable and something that should not be discussed in public It is not self-evident that family planning is discussed with the partner Use of family planning, in many cases, is not a mutual decision Perceptions about what makes a large family in the first place highlight that people with 3, 4 or even 5 children are not considered to be large families. Planning the number of children or planning their spacing is not self-evident Often timed having many children was accidental, just something that happened 46

What can be done? - In addition to providing mere methods, provide also education on the use of the methods that increases the operational knowledge of the users - Provide opportunities to openly discuss about family planning within communities highlighting that it is not something one should be ashamed of - Arrange discussions about family planning in peer groups for both men and women and encourage them to discuss these issues at home in order to address the lack of communication - Encourage couples to actually sit down and discuss about how many children they want and with how many years of spacing. - Spread information about benefits of child spacing closely related to the everyday challenges of the target group, e.g. ability to pay school fees

8.4 Economic, health related and socio-cultural rationales behind having large families
In order to understand the rationales behind having many children it is essential to understand the economic and socio-cultural reasons that may lie behind these decisions. Is having many children seen as an advantage? Is a large family something that family benefits economically from? Are there traditions that support having many children? What is the main cultural factor that hinders the use of family planning? This chapter concentrates on elaborating these issues more closely. Indeed a large family is seen as advantage by almost of the survey respondents as 23,9% of the survey respondents said agreed with a statement that a large family is an advantage whilst 62,5%, disagreed with the statement. Also, 20% agreed that a small family is a disadvantage and 73% said it was an advantage. When discussing about concept of large families it has to be kept in mind that the large families by the respondents mean having at least 4 children or more as indicated in chapter 8.3.1. All of the respondents were asked to name challenges and advantages of both, big and small families in order to find out about the rationales supporting large families.

8.4.1 Economic rationales for and against large families

The respondents indicated economic reasons for both supporting large families and on the contrary, those against them. 27% of the respondents agreed that large family benefits family economically. The most popular reason given for the positive view was if all are hardworking and cooperative they can raise the living. Again, the education affected the responses: 57% of those with no education agreed with the statement compared to 9% of those highly educated. This might indicate that for those who are not educated at all, there is always 47

a possibility that their children might end up being better off than their parents. Also, the economical benefits, even if small, benefit the poor people more than those who belong to middle class or higher. Economic wise, especially in the rural areas, many kids can be contributing to economic situation of the family when helping as a labor force. The higher fertility in the rural areas is also clearly evident in the statistics: in rural areas the rate is 5,3 births per woman compared to 2,9 births in urban areas63. Also, having a lot of children can provide a retirement package to parents. The percentages supporting the statement that large family bring security to the parents was 34,1% said they agreed with the statement. The main reason for supporting this statement was that children are always there for their parents. When one gets old there are always children who can take care of oneself. The most common benefit named for having a large family in the in-depth interviews was also that they are able to help family and each other, mainly financially. It seems that the male respondents saw the possible benefit of having large families in economic terms as this reason was mentioned by all of the men respondents except for one and brought up by only one female respondent. Overall women did not name many advantages of having many children. A large family can also be seen as a sign prosperity. However, a majority of the survey respondents disagreed with this statement while 20,5% agreed with it. 60,3% of the respondents admitted that large family brings economic distress, yet 36,3% disagreed. The worries for economic distress were also very visible in the in-depth interview where almost all of the respondents highlighted the severe economic restraints having a large family may bring or brings to them. Even the small families living in the Kibera slum with one or two children, had to struggle for providing even for their small families. Economic restraints mentioned related to providing for the basic needs, such as ability to feed, clothe and educate children. Many of the respondents noted that if the economic situation would be good, the challenges of larger families would be fewer.

If I had the ability (money) I would get two more children but I dont see myself I dont see like I manage to have more children because the more they are the more the problems [Female respondent, 26-year old, lives in Kibera slum, makes and sells Chapatis for a living]

Worry over school fees was the most common worry the respondents had, also among the middle class respondents.
I dont think its an easy thing and especially school like two of them.. about four of them are at the university at the same time coz its like a difference of one year one year. So I think thats quite a challenge for the parents because university fee is not an easy task. [Female respondents, 20 years, university student]

A few of the respondents even mentioned problems with inheritance and dividing the family shamba, the family land.
63

Kenya Demographic and Health Survey 2008-2009, preliminary results

48

The ability to cater for needs of the children was in turn mentioned to be the benefit of small family. Even the respondents who had large family themselves (6 children or over) said there are no advantages of having a big family. This indicates that even thought the challenges of having many children are well understood, it hasnt affected family sizes too much in practice.

I have not seen any advantage because they all depend on me [Male respondent, 50 years, lives in Kibera slum, mason]

There are still people who consider that having many children brings economic benefits to the family. However, on the contrary, it also clear that the economic restraints of having many children are very well acknowledged. As for many of these people, life is a challenge already with few children. Even those families with many children, mainly highlighted the challenges they face instead of advantages of the family size they have. Despite of acknowledging the economic restraints, the family sizes tend to be large. This indicates that there are stronger factors, one of them being the pure accident, that overrule these economic rationales.

8.4.2 Social and health related reasons

In addition to economic rationales the respondents named social and health related rationales supporting large families. One of the advantages of having many children, that came up in the in-depth interviews was the unique nature of the children. This means that every child has a different character and different skills. On the other hand the benefit of large families can also seen in having company or having someone to help around in every day chores. On the contrary, social challenges of small families related to possible loneliness or selfishness of the children and inability to share. One of the male respondents even highlighted that small family also means low number of clan members. This is elaborated more closely in the chapter 9.3. In addition to economic and social reasons referring to having company , there are also health related reasons behind having large families. One of the major heath related reasons is child mortality. 26% of the survey respondents agreed with the statement that having a large number of children is important as one may lose children when 71% disagreed. Again, the ones with no education or low education agreed more with the statement that those who were educated.

49

Table 20: Having a large family is important as one may lose a child Agree No education At least some primary education Primary education completed At least some secondary education Secondary education completed Higher education64 71,5% 27,3% Disagree 28,6% 72,7%

38%

61,9%

16,7%

66,6%

21,3%

78,8%

9%

81,8%

This can obviously refer to a level of housing conditions and access to health care that tend to be worse off among the poor than among the more highly educated people. However, according to the family planning experts having large family because of fear for losing them was not seen to be a valid reason anymore. According to the preliminary results for Kenya Demographic and Health survey the child mortality has indeed reduced significantly since the 1998 and 2003 surveys to 74 deaths per 1000 live births65. Same decline has occurred in under-five mortality rates.

Table 21: Trends in Early Childhood Mortality Rates in Kenya66 Survey year 1998 2003 2008-2009 Infant mortality Under-five mortality 74 77 52 112 115 74

Still, apparently this fear affects the decisions on the individual level, especially among the poor, noeducated people. One of the experts mentioned that education does have an effect here as those with
64 65

4,5 of highly educated responded all Ibid. 66 Preliminary results of Kenya Demographic and Health Survey 2008-2009

50

education are more aware of the factors that contribute to child survival such as boiling the water and bring sick child to the hospital.

Table 22: Advantages and challenges of large families communicated by the in-depth interview respondents

CHALLENGES FEMALE RESPONDENTS If there is no money children may end up street children, thieves or prostitutes Lot of stress for feeding, clothing and educating Lack of living space in the house Not treating them all equally Farm cannot sustain all the boys

ADVANTAGES Always noise in the house Children all have different characters and different strengths If someone dies, others remain Assisting parents There is always company Bringing up many good people to society Sharing of responsibilities at home

MALE RESPONDENTS

Favoritism, conflicts Lot of stress for feeding, clothing and educating Inheritance fights Dividing the shamba, the family land Hatred and lack of understanding, may lead to death and revenge

Helping parents and each other Bringing wealth to family provide security They all have different lucks

WHAT CAN BE DONE? Simply advising families on the economic constraints having large families might bring is not enough as people are usually aware of these challenges.

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8.4.3 Socio-cultural reasons

In addition to economic and health related reasons, there are also socio-cultural reasons that affect negatively the use of family planning and favor large families. These reasons, that came up very strongly among the respondents, are fear of side-effects and preference for boys over girls.

8.4.3.1 Fear of side-effects

Myths, misconceptions and extreme rumors about family planning, especially on their side-effects are one of the most important factors affecting the use of family planning negatively. In addition to specific family planning methods, they affect the perceptions of family planning in general. Instead of classifying the fear of side-effects under health related rationales they are seen more as cultural issues due to the above mentioned factors. Over 33% of the survey respondents, both men and women, named side-effects to be the reason why they are not using any family planning method67. Whilst there was no significant difference among genders, religion, rural/urban the younger people seemed to fear side-effects more than the older people, as indicated in the table below:

Table 23: Currently not using contraceptive because fear for side-effects

15-24 years 25-34 years 35-50 years

44% 39% 25%

The side-effects, whether real or imaginary, does not also affect people not to use family planning but also contribute to high discontinuance rate. A high discontinuance rate refers to a high number of people stopping the use of family planning. From the respondents, 17% named the side-effects being the reason for stopping the use of family planning. The same number is nationally even higher, 25%, as indicated in Kenya Demographic and Health Survey 2003. Also, when asked about the key information the respondents from different age groups lack, the side-effects was mentioned by the majority of the respondents.

67

Respondents who stated the reason for not using to be that they are not sexually active were excluded from the sample for obvious reasons

52

The high discontinuance rate was also observed by the private sector doctor interviewed who confirmed that high discontinuance rate, related to side-effects (mostly imaginary) is the biggest problem faced in his clinic. Every single health problem is associated to the family planning method and as a consequence women drop out using contraceptives. In addition to switching to other method or stopping the use for good, the fear also affects that people are even afraid to try or even discuss about these contraceptives.

I have a sister and she doesnt want to hear about family planning because she hears it makes people sick. I try give her advice but she doesnt want to hear it [Female respondent, 26-year old, lives in the Kibera slum, makes and sells Chapatis for a living]

According to the private sector doctor this fear has lead in some cases to use of herbal family planning methods as they are cheap and free of hormones and thus can be said not to have any side-effects. According to public sector nurse this is a popular method, especially in the slum areas. 5% of the survey respondents were currently using herbal method. However, this method is not reliable at all and was recently banned by the government. None of the respondents interviewed in the in-depth interviews had never used this method, but some of them have opted for safe days method as it is also a hormone-free, yet a method that requires regular menstruate cycle and high-level of attentiveness. These myths and misconceptions are present in every level of the society from lowest to the highest level. The most extreme versions of these rumors are, however, found in the lower levels of the society. Below, these myths and misconceptions are elaborated in more detail.

Changes in body color, mental illness, getting older fast to infertility- extreme rumors about side-effects of using family planning

One of the biggest concern among the in-depth interview respondents was the fear that what exactly, will the contraceptives do to ones body. This fear refers to fear of actual side-effects but also the feeling of uncontrollability. The concern of uncontrollability was directed especially to hormonal contraceptives that are not taken daily, such as injections and implants. The feeling of control is lost as one has no clue how much hormone is released to ones body. There is also a fear that because the method is not used daily, getting the hormones out of the body is not as easy task:

I also find it constantly in my blood stream and I have now control of how much is released, I just feel because I cant control it or what its doing in my body, it is uncomfortable. Also the injections I dont like because while in my system even if I react to it, I cant get it out. [Female respondent, 28 years, lawyer]

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In addition, there was fear towards body insertion referring to a foreign object, a contraceptive method in this case, being inserted inside ones body. It feels scary as it does not belong there naturally. Compared to concern of not being able to control the amount of hormones released, even bigger concern was also the uncontrollability of the consequences contraceptives might have to ones body, also known as the side-effects. It is commonly known as well as scientifically proven that some contraceptives, especially the hormonal ones, unfortunately may cause some side-effects to their users. The problem in Kenya, however, is not the actual side-effects per se: but the rumors about the consequences one may face when using them. These rumors, sometimes very extreme, are usually taken to be true, without even questioning the source of the information. This was very much highlighted in the in-depth interviews, as can be noticed from the examples below, describing the side-effects respondents articulated they were aware of: Female respondents: Causing the born baby to have hole in his/her heart Causing mental illness Getting pregnant despite of using coil and then giving birth to a child with a coil entangled to babys hand or leg Causing abortion Causing contraceptives to go into the veins

Male respondents: Causing one grow old faster Blocking the ovaries in such a way that women will never give birth again Having a big body that aches so much Change of body color/complexion Loosening the womb Getting pregnant despite of using coil and then giving birth to a child with a coil in his/her hand Causing heart attack Miscarriage Women losing the touch of the husband and body lacking stimulation Low libido in men

It seems that the most extreme versions of these rumors come from men even though it is the women who usually use the methods. This might also contribute to their resistance towards the use of family planning as elaborated in the next chapters. In addition to the examples mentioned above, there are also more minor consequences using , what according to the respondents, contraceptives might bring, or the ones already experienced by the respondents. These consequences include, among other things, different body aches, bleeding, weight gain, loss of weigh, dizziness, high blood pressure and infections. However, the one side-effect, also the most common factor causing fear, mentioned in almost every single interview was infertility and a fear of losing the ability to have children as a consequence of using contraceptives. As a majority of people would like to have a family and in this case more than one children,

54

this is an essential fear. For some reason, these concerns were especially addressed towards coil as it is inserted into womans womb for a longer time (e.g. 5 years). One of the most radical example, mentioned by one of the respondent, as a respond to the fear of infertility are young women using contraceptives and testing their fertility:

Like I know of some ladies these are single ladies who say okay I will control pregnancy for three years then the fourth year I allow it to get in to just confirm that I am still fertile and that I am still liable. Then after five months I abort and then continue with [Female respondent, 47 years, Head Teacher]

On the other hand, as much as the contraceptives were blamed to be causing infertility, as much they were blamed for causing unwanted pregnancies. In addition to deep suspicion about what they might do to ones body, there is also a lack of trust towards the protection element of the contraceptives. One of the respondents, a 16-year old girl form Kibera slum summarized this suspicion:

I think condoms are a lie. For some you might think you wont get pregnant but you actually do get pregnant [Female respondent, 16 years, student, Kibera slum]

Lack of womens decision-making power over thhealth

As can be clearly noticed from the examples above, it is no wonder that people feel suspicion or even fear towards use of family planning. The suspicion comes from both men and women and men have these fears for their wives as they are afraid the consequences these side-effects might do to them. This may lead, in the patriarchal society that Kenya is, husband deciding that wife is not allowed to use any or certain contraceptive, a perception also visible in the interviews:

I dont want my partner to be involved with any side effects like changing the color of the skin, or miscarriage after a while. [Male respondent, 21 years, lives in the Kibera slum, broker of vehicles]

I would like to try the Norplant (implant) for the hand but my husband will not allow me to use it, I would have to do it secretly without his approval. Because he hears people take long to get back fertility when using it and it gets to a point where it makes you weak and it gives you a lot of pains. I discussed with him about the side effects to do with the pills and he told me to go and explain to the people at the clinic, which I did and they changed to the injection. But for the injection I would not tell

55

him because usually with men if you tell them they will ask you to stop taking those things that are bringing you problems and making you sick all the time. So what to do? (laughter) [Female respondent, 26-year old, lives in the Kibera slum, makes and sells Chapatis for a living]

The challenge in this kind of situation is that the options for male family planning methods are few, namely a condom, and this may lead to situation where men have to choose if they are the responsible for the birth control or not. Whilst many of the respondents felt positively about the condoms and were using them regularly, this was not the case with all of the respondents. Few of the respondents felt that condoms are uncomfortable to use.

Since I was born and became a mature man, I have never used a condom. I dont know, I cant explain but I have regarded it as something very dirty [Male respondent, 30 years, lives in the Kibera slum, unemployed carpenter]

I am very fertile and then there is another husband here who does not listen to the idea of using a condom you know he could use the mechanical things, he will now say I cant enjoy with that thing He didnt want to use that so you seeIf you decide to use a condom he says it is not comfortable and he doesnt like using it. He will throw it away [Female respondent, 47 years, Head Teacher]

The lack of womens decision making power over their own health is clearly present also in the matters related to side-effects. Even if woman herself is willing to bear the possible side-effects, like indicated in one of the quotes below, the use of contraceptives can be ruled out by the decision of the husband. The only male method, a condom, is not considered to be comfortable option by some men thus possibly leading to a situation where opportunity to make informed decisions about the number of the children diminishes. In the situation like this women can opt for hiding the side-effects or obey the husband and stop using the method concerned.

Spreading these rumors

The myths and misconceptions described above are spread within the community and stirred by the writings in the media. The most important source of these rumors is discussions with the people around, especially with friends. Majority of respondents referred to this hearsay about the side-effects :

I heard others saying it is difficult to get pregnant when you discontinue its us or it entangles the babies body during pregnancy. While the Norplant used on the hand, people said you have to be very keen on it and if not careful can easily get pregnant

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[Female respondent, 26-year old, lives in the Kibera slum, makes and sells Chapatis for living]

I hear people get rashes because of using condoms About the side-effects, I have never really sat down to read about it, its mostly verbal or complaints from some of the people whove had sex before [Female respondent, 20 years, college student]

Because I heard they are not good. They go into the veins [Female respondent, 41 years, lives in the Kibera slum]

People say they make one grow old and cause low libido in men [Male respondent, 18 years, Kibera slum, collects scraps metal for living]

Ive heard with women its bad and when you have sex it goes further [Male respondent, 21 years, lives in the Kibera slum, broker of vechiles]

It is only natural that people share their concerns and tell stories about the different experiences they might have had or they have heard about the use of contraceptives. Even though they might offer help for someone figuring out which method to use, they do at least as much harm as well. These rumors are translated into evil myths that are highly exaggerated. Thats why it is always important to consult a professional about the possible side-effects. However, in this case there also lies a challenge in some cases as stories and experiences of the people around are kept in higher value than those of the doctors or nurses.
Actually I told my gynecologist, he was on the opinion that it wasnt the pill that was causing that, it was possible the schedule that Ive became more busy at the office or whatever. He dismissed that instead, it doesnt have anything to do with the pill, two of my other friends they had also noticed the same one. So I think that also for a larger part, encouraged me to go off (the pill) with it so I can find out for myself [Female respondent, 28 years, lawyer]

In addition to specific family planning methods, the myths also affect perceptions of family planning in general. Women using family planning may been seen as promiscuous as when they use they can walk around, i.e. cheat. According to the Kenyan Demographic and Health Survey 2003 43,5% of the male respondents agreed with the statement Women who use family planning may become promiscuous This stigmatization, of being promiscuous, was even faced by middle class teacher when she was using contraceptives. 57

Sometimes also they peg it as she is using contraceptives pills so she can walk around, she can move around. So they feel like the fidelity part of it is not there.
[Female respondent, 47 years, Head Teacher]

Brochure distributed in the public family planning clinic, that tries to address these issues, illustrates well the underlying challenge:

Some people think that talking about condoms or giving people condoms will make them have sex outside marriage. However, a World Health Organization review of a number studies found no evidence that sexuality education lead to earlier or increased sexual activity among young people. Other research has shown that condom availability does not increase sexual activity, but does increase condom use among already sexually active teens and young people do need protection

However, these kind myths were not commonly mentioned in the in-depth interviews and the myths about the side-effects were more strongly highlighted. This might be a sign that use of family planning has become more common and its use per se is acceptable in most of the cases. It is the side-effects that cause the main concern.

Result: Fear

All of the factors mentioned above contribute to a general suspicious attitude towards family planning. Even though this attitude might not be negative in a way that rules out the whole concept of family planning as people in every levels of the society have chosen to use family planning; it is certainly a main hindering factor for its use. Even the respondents, mainly young people living in Kibera, who basically had a very weak and almost non-existent knowledge of contraceptives, highlighted the negative aspects of family planning, mainly the side-effects and the fear because of them. This clearly illustrates that in the cases the only thing that is known about the contraceptives, is that they are something bad. A concrete word fear indeed was mentioned in many of the interviews, not only by women, but also by men.

They (contraceptives) bring fear to me [Male respondent, 18 years, Kibera slum, collects scraps metal for living]

It was also reflected in the interviews that because of this fear, it takes courage for women to start using contraceptives. Usually when they have the courage to start or try, the fears usually wither away. 58

 I would fear before I have not used them but now I use them and the day you try you expect anything to happen. But if it does give you problems like mine is great, I have not seen anything wrong with them. As go on with live knowing I am okay with it. [Female respondent, 28 years, lives in the Kibera slum, sews clothes for a living]

However, usually the fear and suspicion remains towards other family planning methods, the ones that one has not yet personally experienced as all of the respondents, even the ones currently using family planning, seemed to be very suspicious towards certain methods. As indicated above, a lot of cultural beliefs and rumors are linked to contraceptive methods. Contraceptives are not just contraceptives but also something else. For some women, living in countries where contraceptive use has been a norm for decades, using a pill is no big deal, condom users are normal people, and coil is simply nothing more than a way to manage births. In Sub-Saharan Africa this is not the case. There are simply other dimensions to contraceptives too. They are not just a tool or a method, but seen as much more. These added values, here strongly negatively laden might and according to this study actually commonly do, overrule the original value of these methods: that is controlling the births.

59

What can be done?

- Provide accurate and easily understandable information correcting the myths and misconceptions about family planning methods in all levels of the society from slums to universities Address the concerns by providing information about the real side-effects of the different family planning methods Provide information ruling out the most extreme rumors about the side-effects Encourage users always to consult medical personnel when they think they might be facing sideeffects Encourage users to continue using the methods despite of minor side-effects, such as head ache, as they can be managed with painkillers Address also the men about the real side-effects, and not just woman users as the use can be ruled out by mans decision Encourage users to overcome the fears of starting to use family planning by using peers with positive experiences as role models as it is important for users to hear it from one of them instead of doctors and nurses. Experiences told by others are considered to be among the most reliable information Spread positive information about family planning instead of the dominant negative information by highlighting the benefits it may bring Address especially the fears and myths associated with coil

8.4.3.2 Preference for boys over girls

In Nyanza province, we have been using the example of President Obama. President Obama has only daughters, and there are only two. A girl can be just as good. Given that Obama is from this area, he is a good role model [Research Associate, Family Health International]

One of the most important cultural factors affecting the family-size related decisions is a traditional preference for boy children over girls. The tradition of valuing boys contributes to having large families as some families have many children because they have tried to seek for a boy. 64% of the survey respondents agreed with the idea that sometimes people have large families because they want to have a boy. Four of the most important reasons given by the respondents were because boy inherits the wealth (24,2%) because of the continuity of the family (10,5%) and because boy makes you more proud than having a girl (8,4%) and because boys bring security to the family (8,4%). The reasons boys are valued over girls were elaborated more closely in the in-depth interviews and were mentioned by the respondent to be the following: 60

Girls: - Marry off and leave and dont help the parents - Girls will bring the wealth to husbands family instead of her own family - Girls have early pregnancies and do things that do not impress the community - Girl might become a prostitute

Boys:

- Boys will inherit the land and wealth - Instead of marrying off to a distant place boys will stay home and help the parents - Boys carry the name of the family and continue it - Boys are more hardworking and productive than girls

For the African society continuing the family lineage and the family name is still very important. As the girls marry off and become a part of their husbands family a son will continue its own family name. As can be also reflected from the responses, with having son, the family wealth, through inheritance, is kept within the family and is thus safe. The rationales behind preferring boys have been mainly practical and economical and thus very much reflect the agricultural based society that does not exist on the same scale as it did a few decades ago. Even though the economical rationales might not be very valid anymore the cultural value for boys still clearly exists. 3 of the in-depth interview respondents communicated that they have purposely tried to have a boy child. However, in all of the cases the initiative for this came from the husbands side. Whilst other respondents didnt have any personal preference over the sex of the children almost all of them knew someone close to them who preferred boys over girls and the recognized the prevalent attitude in the society for valuing boys over girls. Trying to have a boy, has led, in one of the example cases, to a family of 8, where the first born was a boy and the seven others were girls:

That is what we had decided originally so.. there was this one boy and we got girls as we were looking for another boy. And in the African culture the boy child you feel like it is very very important. [ Female respondent, 47 years, Head Teacher]

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Even though boys seem to be valued more than girls in the society, surprisingly, modern realities have also shaped this tradition. As can be noted from the rationales favoring boys described above these reasons mainly relate to a perception that boys bring wealth to a family and take care of the inherited land whilst girls go away when they marry. In todays Kenya ability to share the family shamba, the family land, between the boys, because of its tiny size or even having a one in the first place, is becoming more and more difficult. Thus, as indicated in one of the interviews, some of the respondents favored girls as they dont have any land boy could inherit.

He says he wants girls even with my first pregnancy he wanted a girl because he doesnt have a big farm and usually boys will need to inherit land [Female respondent, 26 years, lives in the Kibera slum, makes and sells Chapatis for a living]

This adjustment of tradition was also brought up by the Kenyan newspaper Daily Nation68. According to the article published recently there is a clear trend for aborting boy children with a motivation to trying to avoid fights over inheritance, mainly over land. However, this adjustment of the traditions has not overtaken the whole society as especially in the lower levels of the society boys are still valued for bringing more wealth to the family and for continuing familys name. Another interesting thing, closely related to the sex of the child, is related to continuing the family name. 39% of the survey respondents said that having a large family is important for continuing the family name. This was clearly more important issue for rural respondents as 66% of them felt so contrasted to 33% of the urban respondents. Yet again, the level of education seems to be an important factor affecting the attitudes:

Table 24: Large family is important for continuing the family name: Agree No education At least some primary education Primary education completed At least some secondary education Secondary education 85,7% 36,4 Disagree 14,3% 54,6%

57,2%

38,1

50%

50%%

27,3%

72,8%

68

Daily Nation April 21, 2010

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completed Higher education69 22,7% 68,2%

Closely related to continuing the family name is a tradition for naming the children after the grandparents. In practice this means that first boy is named after husbands father and second boy is named after wifes father whilst the first girl is named after husbands mother and second girl after wifes mother etc. Some grandparents may feel hurt if they dont have a grandchildren named after them as it is seen as a sign of respect. This was also highlighted by UNFPA representative to be a source of pressure to have many children and confirmed to be reality also by one of the respondents.

When the mother-in-laws know that you are using family planning and you have two boys and you havent named her. Chaos. [UNFPA representative]

Then there is also us Kikuyus the way we name our children, the first boy is named after his father, the second boy is named after my father. The first girl is named after his mother and the second girl is named after my own mother. So if one is not born its like my father is feeling disadvantaged and any time it is like there is a chance you see now [Female respondent, 47 years, Head Teacher]

Naming the children after their grandparents is a sign of respect and especially in the situation where children have been named after only other sides parents, there might be feel of neglect from the other side. Even though both of the cultural factors, preference for boys and naming the grandparents might not be the only reasons behind having large families they certainly create pressure to have more children as seen from the concrete examples above.

What can be done? - Targeting people, especially men, about the equal value of girls - Figure out new innovative ways to help people to show respect to their grandparents than naming their children after them

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4,5 of highly educated responded all

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8.4.4 Traditions vs. modern reality

In the rich cultural heritage embraced by the African society, many of the traditions have supported and are still supporting having many children. Nowadays, these traditions seem to be in conflict with modern reality where raising many children is considered to be demanding. Even though the respondents seemed to be well aware of the economic restraints that bringing up a large family brings with feeding, clothing and educating the children, the family sizes remain large. This reflects the strength of these traditions. Despite of the strengths, these traditions are not unchangeable as was reflected with the example of preferring girls over boys due to lack of land. This tells that these traditions can adjust. They just havent adjusted widely. As indicated in the responses in the previous paragraphs, it seems that socio-cultural factors affect more strongly those with no education or low education. Maybe the education gives tools to better compare these traditions against other, such as economic, rationales. Especially the young urban generation , according to the experts, are starting more and more plan ahead their lives, including their families. These are also the people who might not be affected by the traditions as much. However, this is just a small proportion of the society. This does not, however, mean that the traditions do not exist among those educated and well-off people. Clearly, there still exist traditions that support having many children. The challenging thing for family planning is that they are not that easily changed, especially from the outside. Providing more information is easy as is providing more methods. Changing the deep-rooted attitudes are not.

9 PRESSURE FROM THE OUTSIDE SOCIETY

In addition to NGOs and the public and private sector, there are also other stakeholders in the field of family planning. As decisions related to family planning and family size in general are not decisions made in the vacuum, but are also affected by the outside society it is essential to find out where does the pressure come from and whether it actually influences people. This outside pressure may come from the people surrounding oneself like the community and family members or it can come from higher level such as from ones ethnic group or religion. Next, we take a closer look on the effect that different stakeholders might have when it comes to family planning starting from the ones close to the individual and progressing to higher level up until tribe and religion.

9.1 Pressure from the in-laws

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When it comes to the outside pressure, it is clearly the in-laws who pressure the couples to have children the most. In addition to the pressure for naming the children after their grandparents, a challenge elaborated more closely in the chapter 8.4.4, there is also pressure to have children right after marriage. According to the respondents of the in-depth interviews, the couple is expected to start a family right after they get married. These expectations, coming from the family, were articulated especially by the female respondents, regardless of the income or educational level. Especially in the lower classes of the society, the value of woman seems to be in bearing the children. If not, they are seen as useless and lazy.

They say the women without children just want to sit and eat free food, a lot of stuff. You just want to be comfortable but if you give birth the child will keep the woman busy. [Female respondent, 26-year old, lives in Kibera slum, makes and sells Chapatis for a living]

This pressure seems to be especially coming from the husband sides mother in-law. In the African society, when woman gets married, she will become part of the husbands family. Thus the pressure for continuing the family lineage is coming from the husbands side as explained by one of the respondents. The word demand was commonly used describing the pressure coming from the husbands family. Womans family does not bother as it is not their family lineage in concern.

Once a woman is married to someone it is a requirement for you to get pregnant and not just sit around without giving birth because your in laws start talking and want to chase you away or your husband starts beating you up wanting you to give birth. I stayed for only 7 months without a child and they begun saying that I was not a proper her to marry and I am old and tired. [Female respondent, 26-year old, lives in the Kibera slum, makes and sells Chapatis for a living]

If there is a problem, as in challenge with having children, it is often assumed to be womans fault. Man is encouraged in these cases to leave the woman and remarry in order to have children. This has been experienced by the friends or relatives of the respondents too. Also in these cases, the pressure to leave the woman seems to be coming from the husbands mother in-law.

They tell their son to re-marry or he will die without seeing his duplicate! They tell him to marry other women if the one he has cannot bear children. Because if you are the first wife they will tell the man to re-marry so that they see whether the second wife will give birth and then they can judge who has the problem

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[Female respondent, 26-year old, lives in the Kibera slum, makes and sells Chapatis for a living]

The norm in the society is for the couple to have children. This is usually the case also elsewhere in the world, not only in Sub-Saharan Africa. There, however, the couples without children face an extra hard time. They are, according to the respondents taken very negatively and they are seen as outcasts and they have shame.

If you dont have a child, they will hate you [Female respondent, 28 years, lives in the Kibera slum, sews clothes for a living]

In fact they are not taken very well. People like you having kids as soon as you get married. In fact in Kenya the family is such that you must have children otherwise thats not a family. [Female respondent, 25 years, administrational assistant]

As people in Sub-Saharan Africa tend to marry young, the first child, right after marriage is also born to young parents. In Kenya the median age at the first birth is only 19,8 years and in Nyanza province only 18,4 years70. This leaves more time to have many children than starting a family later on in the marriage. One middle class respondent couple admitted they were facing a lot of pressure as they wanted to wait for few years after getting married to get to know each other before getting children. There certainly is a pressure to have children coming from the family and especially in many cases from husbands family. As the pressure is coming from so close, it certainly can have an effect as mother in-laws might have a big influence to their sons decisions.

9.2 Pressure coming from the surrounding community

In addition to ones family, the pressure to have children can also come from the surrounding community. They might encourage people to have many children or discourage them to use family planning. It has to be noted that it is difficult to draw a line between the community and the ethnic group. When asked about the community, regardless of the ethnic group, the respondents usually referred to their family and neighbors. So here, when discussing about the community, we refer to people living around you, regardless of the ethnic group. Although in some cases the community and ethnic group refer to same group as often times or at least sometimes ones family or even neighbors comes from the same ethnic group. Over of the survey respondents felt that those who use family planning are seen negatively by the community. Male respondents felt this more strongly than the female respondents as 23,3% of them

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Kenya Demographic and Health Survey 2003

66

strongly disagreed that family planning users are seen positively by the community and 7% disagreed whilst the same percentages for the females were 13,3% and 8,9%.

Table 25: Statement: Family planning users are seen positively by the community Stongly disagree Men Women 23,3% 13,3% Disagree 7% 8,9% Total 30,3% 22,2%

Large proportion of men strongly feel that family planning users are seen negatively by the community. This is interesting as it is very rare that men use family planning, e.g the condom, and family planning is mainly used by women. Thus it is usually women facing the negative attitudes, not men. It seems that men might react more strongly to general negative perceptions about family planning than women, who might face a lot more mocking from the community as they are the ones that actually use it. It came up in the in-depth interviews that indeed, within the community, some are encouraged to use family planning whilst others are not. Discouraging, according to respondents, refers to mocking people for example for gaining weight because of using contraceptives and telling negative stories about the sideeffects that using family planning can cause. These stories are mainly incorrect and exaggerated, as indicated in chapter 8.4.3.1. This can lead even to stigmatization of those who are using family planning. Thus some respondents said that they dont tell anyone they are using and keep it as something private.

People stigmatize and discriminate. They will be laughing at you saying that he/she became big because of family planning pills [Male respondents, 18 years, lives in the Kibera slum, collects scraps metal for living, has 2 children]

Two of the respondents, husband and wife had even heard even more serious mocking from the community:

If they know you are using family planning to limit the number of children they say your husband is foolish for letting you go for family planning because a woman is required to give birth till all the eggs in the stomach are finished. (laughter) And you are killing kids and its a sin and you will not go to heaven. People tell you to give birth and to stop killing children. Give birth! [Female respondent, 26-year old, lives in the Kibera slum, makes and sells Chapatis for a living]

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The community was seen not have too much effect on peoples personal decisions to have children. These perceptions within community both encourage and discourage having large families.

No. there is no way it can affect you. [Male respondent, 41 years, lives in the Kibera slum, polygamous, unemployed mason]

Some of the respondents mentioned, that in todays world the community encourages one to have small families due to bad economic times. Life is hard, especially for the poor, and having many children is seen to make the situation even worse.

In our community if you get many kids, you are called a fool [Female respondent, 41 years, lives in the Kibera slum, has 7 children]

On the other hand there are also opposing opinions, coming especially from the community elders, or the men in the community who encourage people to have many children. Why they prefer large families, was not mentioned.

Only men who say that women should not use family planning so that they bear many children [Female respondent, 41 years, lives in the Kibera slum, has 7 children]

Like our community they love children they even hide that their children are not willing to have children [Female respondent, 47 years, Head Teacher]

The community leaders, such as group of elders were seen as the gatekeepers of the community and important partners in the field of family planning by the family planning experts. It was highlighted that is important to work with them as they are the ones spreading the information among the community. Their role was seen both positive and negative among the experts. On the negative side they might encourage people to have big families but also, according to nurse working in the public family planning clinic, they have encouraged people to get into the clinics once they have been informed about the services available. The respondents of this study did not refer to them, however. Maybe their role is highlighted more strongly in rural areas where the communities might be tighter than in urban areas.
It

seems that preference for large families is still a norm in many communities. Even though the respondents stated that this hasnt affected them, the fear of stigmatization for those who use family 68

planning, can certainly affect someone. To resist all the negative perceptions that exist around takes, in any case, takes a lot of courage.

9.3 Influence of the tribe

Kenya is a country with an ethnic diversity. The main ethnic groups, also included in the survey, in the country are:

Table 26: Ethnic groups in Kenya

Kikuyu (22%) Luhya 14% Meru 6%

Kalenjin 12%, Luo 13% Other African 15%,

Kamba 11% Kisii 6%, Non-African (Asian, European, and Arab) 1%

One of the most striking issues that came up in the expert interviews was the attitude that certain politicians have towards family planning. During the last decade the politics in Kenya has been heavily tribalized and ethnicized . According to the family planning experts, this indicates that one more baby equals one more vote as having as many constituencies as possible is a means to power. The issue of numbers seems to have effects on the high-level and the recent Demographic and Health Survey was brought up in this light by one of the family planning experts interviewed:

Look at how contentious the whole census issue is. They are not releasing it because they are not happy with the higher numbers of certain ethnic groups or in certain districts

The rhetoric itself can be harmless, what matters, is whether it reaches people. The majority of the survey respondents disagreed with the statement that politicians have encouraged people to have large families. However, 13% of the people agreed with the statement. This indicates that at least some people are aware of this rhetoric and that is actually does exist, at least in some scale, in the Kenyan society and politics. Despite of this, rhetoric coming from the politicians does not seem to affect individual decisions, at least not consciously, as they see politicians as something distant like came up in the in-depth interviews. The question on tribe caused much more stronger reactions in the respondent than the question about the politicians. 42% of the survey respondents felt that large family is good for the tribe. 33% of those who agreed stated the reason to be that having large families contributes to making the tribe famous. The

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division to responses to mainly strongly agree and strongly disagree tells that this issue is sensitive and causes strong reactions. People living in the rural areas (63%) agreed more to the statement compared to those living in urban areas (44%). Thus the importance of the tribe seems to be stronger in rural areas. The level of education, again, seems to be the strongest determinant affecting the opinion as indicated in the table below:

Table 27: Agrees with the statement Having large family is good for the tribe No education At least some primary education Primary education completed At least some secondary education Secondary education completed Higher education 80% 67%

50%

50%

44%

25%

Some of the respondents of the in-depth interviews , admitted that their own ethnic groups favor large families. This pressure does not, however, come from the tribal leaders or the politicians but from the family elders.

The (ethnic) community wants to have people. In a fact the cry that is there now is that the community has more children. The level of population growth has gone down because most of the families is one child two children. The grandmothers like now my parents now they are the ones who are crying are the elders, the elders are the ones who are crying that the community we dont have people and you see the people that are there they are lost in things like drugs, illicit brew. So you people give birth bring forth children so that we can have a people. [Female respondent, 47 years, Head Teacher]

The general attitude seems to be that having a large family is good for the tribe. Whether this perception actually has an effect to individuals decision, is another thing. In-depth interviews painted a picture, where ones ethnic group has not too much influence on ones decisions related family size. Respondents of the indepth interviews saw that number of children is somewhat a personal decision, something that cannot be affected by ones ethnic group.

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My tribe cant affect the decision that I have already made because once I make one I have to do it. [Male respondent, 17 years, lives in the Kibera slum, student]

Overall, the issue concerning the importance of large families to a tribe, seems to be a sensitive one as can be noted from the division to responses to strongly agree and strongly disagree. The ethnic groups certainly have their importance in politics and in the attempts to gain power. The latest culmination of this was the election violence that took place in Kenya in 2007. Whether the making the tribe popular is a rationale having large families, is yet unclear but the survey results tell that the issue of tribe is a meaningful one.

9.4 Influence of the religion

Kenya is strongly Christian country as 45% of the population is Protestants and 33% Catholics. Muslims and indigenous beliefs both mark 10% of the population whilst 2% are representatives of other religions. The work done in the field of family planning by religious groups was mainly seen positively by the experts. It was considered to complement the efforts of NGOs and the government and these groups were seen as important partners for both. One of the experts even highlighted that the family planning services provided by religious organizations are of higher quality than public sector services, possibly due to more consistent sources of funding. When asked about the religious groups involved in family planning activities from the experts here was a clear division: Protestants relate to family planning positively whilst the Catholics prefer natural family planning methods and are against modern family planning. Thus the Catholics were also seen as a problematic group for some of the family planning programs. Their stance is very clear and is also well articulated. For example, the Catholic priest commented the news concerning the high number of modern contraceptive method users in Central Province in Kenya71:

This cannot be good news, this is disastrous. From moral, economic and political and social perspectives the statistics are bad for Central

Only one expert mentioned the Muslims and their negative stance on family planning and highlighted that even this stance has been mellowing and they are starting to use family planning. Yet again, it is one thing that the rhetoric exists than that is actually reaches people and affects their decisions. Both, the public sector nurse and private sector doctor confirmed that Catholics have been visiting their clinics and using modern contraceptives. The UNFPA representative highlighted that some of the Catholic women want to use family planning secretly from their fellow-community and partner and thus opt for injections that are easy to hide.

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Among the survey respondents 93% of the Protestants and 76% of the Catholics were indeed using modern contraceptives.

Table 28: Percentage of Protestants and Catholics using modern contraceptives (N=100)

Protestants Catholics

93% 76%

Even though Catholic church strongly advocates for natural family planning the churchs will does not seem to fulfill as of the Catholics are using modern contraceptives despite of churchs stance. The non-users of modern family planning, 24% of the Catholics is still, however, much higher compared to 7% of the Protestants opting for natural family planning. The survey respondents were also asked to name reasons for why they are not using family planning. 10% of the respondents named religion to be the reason why they are not currently using family planning. Surprisingly of these 10%, 57% were Catholics and 43% Protestants. One of the Catholic respondents , who had tried all of the existing modern methods, wanted even to address a question to Catholic Church that whether the natural family planning, that they recommend, is even possible in todays world:

From the church point of view the information that I would like to know, if you would want everybody to use natural family planning is it possible in todays setting? Or is the church fixated? Can the church, or should it be able to get out of that hole because that time when naturally family planning was working maybe the husband and the wife were not staying together. This time it is the husband and the wife they are coming home in the evening together, is it going to be effective so that is why I am saying so maybe the church should be able to change or maybe advice better. [Female respondent, 47 years, Head Teacher]

It came up clearly from the in-depth interviews that the Catholic respondents were well aware of the negative stance towards their church has towards modern family planning and were still using modern contraceptives like pills and injections. For the majority of the respondents religion is a very important part of their lives, however the religious authorities doesnt seem to affect too much he use of family planning as having children is seen as a personal decision and at the end of the day church is not the one taking care and bearing the responsibility of the children but a family is. This means that churchs stance is known, but having children or using family planning is seen as a personal decision.

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9.5 Media

The role of media in educating public in family planning issues was seen both positive and negative by the experts. The media, especially the radio, can be seen as an important tool in spreading the family planning information. These sources of information are elaborated more closely in the chapter 10. Media gets the debate out there and gets people talking. However, this information is not necessarily correct. There has been negative reporting on different family planning methods in Kenya and this reporting can be a source of rumors and myths spreading around. The worrying issue is that people, mostly women, are affected negatively by this reporting. Both of the clinics interviewed, public and private, confirmed that they have been affected by the media and the biased information spread by it. The nurse in the public clinic and doctor in the private clinic for example have had to reassure their clients on certain methods safety as they wanted to remove it because of the misconceptions spread in the media. The most recent example on this kind of biased reporting concerned implants, stated to be causing infertility and cancer. To tackle the implant fuss, the MoH had to assure the local media with paid advertisements that the two implants in the market are safe72.The other contraceptive methods have also gotten their part of the negative press with headlines such as:

Injection linked to loss of bone mass73 Women on pill less attractive to males74 Nutrition: What the pills depletes from your body75 Tough Choice when hormonal contraceptives dont work for you What makes women grow fat76

Three of the experts mentioned that the media does not have any social responsibility when it comes to spreading information on family planning. Even though one can find also positive reporting on family planning it seems that the negative reporting has more effect. The problem with media in Kenya, according to private sector doctor, is that it easily quotes the opinions of the individuals that are incorrect, like was the case with reporting on the dangerousness of implants. According to one NGO expert they are constantly working against these negative perceptions spread in the media and asking the Ministry of Health to have a response to these reports.

The media has the weakness to be too ready to quote the statements of individuals. In the recent past there was a doctor quoted in the media who was telling about the complications of the implants and he
72 73

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said that this method is not used in Western countries. And within a couple of weeks we had a whole lot of patients coming for the removal [Doctor working in a private clinic]

Other concrete example of the lack of social responsibility mentioned was World Contraceptive Day. It was very expensive to get a page on the newspaper and this seems to be the case with also other family planning related placements that spread the positive message on family planning. However, also the NGOs got their part of the critique. The UNFPA representative criticized strongly the support of certain NGOs to certain methods. According to him the media is biased towards those commodities that are supported by certain organizations who have the money to promote them. If these organizations have the resources, they will pump the information of those methods. This could leave out promotion of some methods and can affect the choices of clients as they go to clinics and are offered methods that they have never heard of in the media. What is lacking, according to the UNFPA representative, are different programs that would try to tackle the myths and misconceptions of family planning.

10 RECEIVING FAMILY PLANNING INFORMATION

To find out the most effective sources to deliver family planning related information the respondents were asked about the different sources they have received this information.

10.1 Sources of family planning information

29% of the respondents indicated that they have first time heard about family planning from the clinic whilst 25% of the respondents had first heard about it from school. The percentage of those who had heard it from church was also an important source of information with 15%. This 15% consisted mainly from Protestants. The importance of church, as a first source of information is emphasized among those who have no education (50%).

Table 29: From which source heard about family planning for the first time 74

Family planning clinic School Church Media Friends Marriage councelling Community Family Group of women who educated

30% 26% 15% 12 % 7% 4% 3% 2% 1%

For those who received information from the school, it was mainly received from secondary level (43,2%) and primary level (40,5%). What was very striking in the survey responses was that over half of the respondents (52,7%) had heard about family planning for the first time only after giving birth. The very important factor affecting the responses seem to be the education: all of the respondents with no education had heard about family planning only after giving birth. This factor is at least partly explained by the fact that information about family planning can be received from school. One of the in-depth interview respondents living in Kibera slum, had only heard about the possibility to prevent pregnancies only after she had given birth to her 7th child. All of the respondents, who had heard about family planning only after giving birth, admitted that it would have been useful to hear about the options before birth:

Yes (it would have been useful to hear about family planning). Before I gave birth to many children [Female respondent, 41 years, lives in the Kibera slum]

Table 30: Has received information about family planning only after giving birth

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No education at all Some primary/primary education completed Some secondary/secondary education completed Higher education

100% 57% 45% 33%

In addition to asking about the sources where the respondents have first heard about family planning , the respondents were also asked about the sources in general, from which they hear about family planning. The media was named to be the most popular source of information.

Table 31: Sources of family planning information

Media Family planning clinic Friends School Community Church Marriage councelling Family Self-help group

20% 18% 16% 13% 11% 9% 7% 6% 0,3%

From the media, the main sources of information were radio and tv. Table 32: Main media sources - 43,5% radio - 30,4% tv - 17,4% print media - 8,7% internet

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From the media, the radio was the most popular source of information also among those living in the Kibera slum as came up from the in-depth interviews. For the middle class respondents the main source was internet. It was clearly noticeable that the middle class respondents had a bigger variety of different sources , where they can receive information about family planning from whilst the information sources for the lower class were mainly the clinic, radio, schools and friends. Middle class respondents also have a better opportunity to find answers e.g. from the internet to the questions they might have concerning contraceptives. Media seems to be an effective tool in delivering the message, whether correct or not, as 51,7% of the respondents felt that media has affected their family planning usage. Especially it seems to have affected men as 68% of them admitted medias affect whilst 64% of the women said it hasnt had any effect. Main reasons for this effect, for example, were named to be: - Receiving extra information - Encouraging use of family planning - Choosing wisely on the method to use However, there also lies a danger within the information received from the media as the information spread there might not be correct as indicated in the chapter 9.5. Family planning clinic was seen to be the best source of information according to the respondents with media considered to be second best. Most of the respondents of the in-depth interviews named the clinics to be the most reliable source of information as the professionals working there are trained about these issues. The challenging thing with clinics are that they usually reach people who already have children and people who are single or dont have children might not feel comfortable visiting clinics. Also, in the rural areas clinics might be off long-distance.

Table 33: Source that gives best information about family planning Family planning clinic Media School Church Friends Family Community Group of women who educated 36,6% 35,7% 12,9% 4% 4% 4% 3% 1%

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The family planning campaigns as a source of information was mentioned only few of the in-depth interview respondents. This indicates that the spread of these campaigns is not very significant. None of the female respondents of the in-depth interviews living in the Kibera slum were aware of different campaigns promoting family planning in their community whilst few of the male respondents were and almost all of the middle class respondents had experienced a family planning campaign in their community. In the slum areas womens territory, where they stay is pretty small if they are at home taking care of the children whilst men might travel to further distance because of work. This might explain why men in the slums were more aware of the campaigns than women as they move around more.

10.2 Information lacked

32% of the survey respondents felt that they havent received enough information about family planning. Also, almost all of the respondents in the in-depth interviews felt that they have not received enough information about family planning. This all indicates that there certainly is still a lot of work of to be done in the field of spreading information. As came up from the in-depth interviews, even those who stated that they have received enough information about family planning had clear gaps and misconceptions in their knowledge. All of the respondents felt open and positive about receiving more information. Table 34: Has received enough information about family planning Yes No Neither agree or disagree 64% 32% 4%

The information that survey respondents indicated they lacked: Information about family planning methods The best type of family planning method Male methods available New methods of family planning initiated in Kenya What different methods are out there? Demerits and merits of family planning methods Information about new methods

Effects of family planning methods The side-effects Which methods dont cause problems to ones body? Whats the best method to use after one has decided to stop having children? Effects of the long-term use

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The interaction between the body and the hormones e.g. injections it stays in the body for three months and now when I go for the other one after three month, will the first one be still there or where does it go? How one can be on family planning methods and still become pregnant

Family planning use Who should use family planning and who should not What will happen after one stops using family planning?

The information that the respondents indicated that they lack reflects the insecurity that family planning causes among people. There were a lot of questions, again, about the effects that family planning may cause but also about basic information of what are the different methods out there.

10.3 Challenge with fragmented information and top-down information

Overall, the information the in-depth interview respondents had, especially those respondents living in informal settlements, was not too specific and mainly on the general level. Some of the respondents had tried different methods and thus knew about them but many of the respondents were aware of only a few methods. Incorrect information didnt concern only the poor: also the information that the middle class respondents had included some misconceptions, e.g. about the side-effects. Usually the problem seems to be a lack of the understanding of the whole picture. Information, often poor one, is collected piece by piece from different sources and thus the information is easily fragmented. One of the respondents said that the information she had heard about family planning was something she overheard her aunt talking with other ladies whilst one respondent said she heard some information about contraceptives from her neighbors radio but did not hear everything as she was doing her chores at the same time. Information gathered from these pieces might be better that having no information at all, but can be also harmful as the information collected from different sources might be contradicting each other and some crucial information might be left out. Receiving information from different sources is not a challenge per se, but it becomes a challenge when this information is fragmented. The puzzle is hard to make complete, if there are some pieces missing. In these situations the importance of verbal communication and information received, whether correct or not, via discussions is emphasized. Thus it is very important to provide in-depth information in one part, as a complete package. This prevents people from combining fragmented information from different sources and ending up with totally wrong conclusions about contraceptives. Other important thing worth noting is the form of information. Discussing about family planning and sharing information is an important source of information as one can participate in to these discussions and ask questions. The information provided by the media, for example, works only to one direction: from top to down. This leaves people with questions in a situation where no one is able to address them. The 79

appreciation for verbal communication might also be the reason why clinics are popular source of information: one can ask from professional, who has reliable information. As in Kenya, when the different myths and misconceptions about family planning are a huge challenge, giving people an option to ask about the things they fear or feel uncertain about is the best way to put the record straight. This information is useful for both those who havent used family planning and are too afraid to use because of rumors and those who are using and may be worried about the side-effects. In the situations where there is no knowledge there are no options either. And having options, the ability to choose the number of children, is a right of every human being. By providing information equals also giving options.

What can be done?

Target people with information early on to prevent the possibility that they only hear about family planning after giving birth Target especially those with no education or low-education as they have the poorest possibilities in receiving information Instead of providing information only from top-down, provide information with a possibility to interaction. People have a lot of questions about family planning and best way to correct the myths and misconceptions is to provide accurate information to questions they might have.

11 CHALLENGING GROUPS FOR FAMILY PLANNING AS A CROSS-CUTTING CHALLENGE

There is one major cross-cutting theme in the field of family planning. This is involving challenging groups both in to grass root level family planning as well as to family planning programs. These groups are men, single and youth. Involving these groups and addressing their needs is essentially important in making family planning successful and more importantly, sustainable.

11.1 Men

Family planning programs always attract women, women, women, without recognizing that male involvement is really a backbone to success in bringing men and woman to use family planning [Projects Manager, Marie Stopes]

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One of the most challenging groups to address in family planning programs are men. The challenge with men is also mentioned in the Ministry of Healths National Reproductive Health Policy 2007. According to this policy low involvement of men in family planning is listed as a key challenge and also as a priority action. What makes the situation even more challenging is that it is usually by and large men that are the decisionmakers in the family, also in the matters of family planning. In other words, the group that makes the actual decision whether to use family planning or not, is also the group that is the most difficult to address in the family planning programs. This was seen to be tracing back into the time when family planning was first introduced to Kenya. It was introduced as a mother-child thing only and men were excluded right from the beginning. Even though the problem of this neglect was widely recognized by the experts, there still seems to a big gap in the programmatic level. Some experts saw this ignorance even to be one of the factors that drive population growth in Kenya.

11.1.1 Challenges in involving men

The problems with including men in family planning can be seen to be three fold: cultural, technical and economical.

11.1.1.1 Cultural challenges

Cultural challenges with men and family planning have been reflected throughout the report. These challenges come down to unequal decision-making power between men and women. In majority of Kenyas communities men are considered the head of the family and even the custodians of the culture, and if they feel negatively about family planning, theres not much a woman can do or say about it. The data from 2003 Kenya Demographic and Health Survey indicate that only about half of all women participate alone or jointly in decision-making in their own health care. Increasing womens empowerment is thus essentially important. Table 35: Married womens participation in decision-making over their own healthcare (KDHS 2003)

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50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0%

10.0%
5.0% 0.0% Self only Jointly with husband Jointly with someone else Husband only

The mans strong authority was also reflected in the in-depth interviews:

You see now it is like our African men the responsibility of controlling the family is for the woman. So for him it is to be satisfied and be served and nothing else [Female respondent, 47 years, Head Teacher]

Even though not many of the in-depth interview respondents complained about the authority of their partners per se, this can be clearly read between the lines of their responses. The unequal relationship is very much part of the society and can be seen as a norm and something natural without even questioning it. The men being heads of the family is in-built into the society and clearly affects also family planning. The situation is challenging when this authority actually hinders the decisions to use family planning or decisions to manage the number of children. As indicated before, culturally, family planning is considered by and large to be womans issue. Woman is the one giving birth thus its her responsibility to use family planning. However, the decision not to use family planning is usually done by men. If woman is the one who wants to use family planning, then it is the men who can forbid it. The private sector doctor interviewed also confirmed this challenge. According to him it is a significant problem that male partner either resists some particular method or ignores the logical advice about these methods given by the doctor. T hey might fear that women gets cold or they just feel negatively about family planning in general. As a consequence of this, those women who want to use family planning use it in secret. For those women, who are in consensus with their husband about using, even discussing about family planning becomes easier as they have the acceptance from home. Male control can also the reach the reaction to the side-effects. Even when the woman is ready to face these, man might insist on quitting the method. In addition to use of family planning mens opinion overrules womans opinions on the family size:

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When we start talking, I can say many children while he wants few we can compromise with his decision because he is the head of the family [Female respondent, 28 years, lives in the Kibera slum, sews clothes for a living]

The man (decides how many children to have). Because he has the authority and he is the head of the house [Female respondent, 41 years, lives in the Kibera slum, has 7 children]

In addition to decision-making power, there is also the male preference for boy children. As was pointed out in the chapter 8.4.3.2 this can lead to large family sizes. The bias in the equality of the relationship was also reflected for example in the situation where the couple has challenges with having children. In these cases it always woman who is blamed and it is justified for man to find another wife. The education also has an effect here. As indicated before, those who are more highly educated tend to think that family planning is a couples issue and tend to make the decisions, whether on family size or the use of contraceptives together. It seems that education contributes to increasing the household equality.

11.1.1.2 Technical challenges

The factor, that family planning is a womans issue is also supported by technical aspects of contraceptive methods. Technically, most of the family planning methods are designed for womens use. The only male option out there is the male condom, in addition to vasectomy, that is a permanent method. The lack of methods for men is one excuse for them to rule themselves out.

If you decide to use condom he says it is not comfortable and he doesnt like using it. He will throw it away [Female respondent, 47 years, Head Teacher]

In the situations where, if for some reasons, woman has challenges in using family planning and the man refuses on using condom, this can lead to couple giving up using family planning at all.

11.1.1.3 Economic challenges

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Family wants a meal, if man queues in a clinic, who brings the food home [Programme Officer, Population Council]

According to the family planning experts, one of the challenges with including seems to be economical. Majority of the workforce are men. When it comes a time to go to a clinic, it is seen as a womans responsibility since she is at home and not working. Like it came up in one interview: If family wants a meal and man is queuing in a clinic then who is the one that brings the food home?. Family planning services are usually offered in clinic-based settings that are not seen very male-friendly in the first place. There are no different clinics for men and women and men dont feel comfortable queuing with women and children and they just want to visit the clinic as quickly as possible. This was also confirmed by the nurse working in public clinic who highlighted that men see that clinics are for women and they are impatient and dont want to wait for the service.

11.1.2 Involvement of men into family planning programs needed

Men are not the problem. We are the problem, we havent focused on men. Men have been left alone. It is the programs that have left them alone [Project Director, Family Health International]

There are clearly many problems when it comes to men and family planning. Some of the challenges are purely cultural and hard to change, like composition of the strongly patriarchal society. Including men into family planning programs was not seen as a mission impossible by the family planning experts. According to some experiences, by including men and informing them properly on the current projects in the community in the field of family planning, they actually might support their wives. Once the awareness is raised and services are made a little bit more male-friendly, there is a response. Few of the NGOs had themselves targeted men in their family planning programs. Men have been targeted in their own clubs or merry-go-rounds by bringing to them materials there and informing on them on different methods. Some projects have even targeted factories, where men work. One of the NGOs have tried to improve the male-unfriendly clinical settings by introducing express-services for couples in the clinics meaning the couple are seen ahead of anyone else, even though it was admitted that is has not worked that well. In addition to women empowerment over the decision-making what are really required are creative and innovative strategies for including men. According to the experts, the problem is not the end of the day the men as such, but their inadequate involvement in family planning programs and excessive targeting of only woman in the situation where it is known, that men are the main hindrance for women to access or use family planning.

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11.2 Single women

In Kenya, we believe that if we are single and not yet married you are not supposed to use contraceptives, thats why those who come are married [Nurse working in the public sector family planning clinic]

In our culture we dont marry and wait. Once you are in, youre a wife, you get pregnant [Projects Manager, Marie Stopes]

Single woman can be seen as challenging group for family planning programs, as the main group of using these services is already married. According to the public family planning clinic nurse, the typical customer using the family planning services is a married woman who already has kids and is between the ages of 21-38. The private sector clinic confirmed also that the main clientele consist of married women. Single women visit the public clinic very rarely, if they do, they usually are those who already have a child. Private clinic has some singles visiting, but also as a low proportion. The average number of children the clients was estimated to be for the private clinic 2 and for the public clinic 3 children. Also the preliminary results from the Kenya Demographic and Health Survey show that it is the married woman with 3-4 children who are most likely to use contraception77 . It was seen to be in the culture that children belong to marriage. Maybe this could also be the reason why single feel shy about asking for family planning. Other reason for not reaching the single women is that women are usually being told about the family planning after they have given birth, as indicated in chapter 10.1 . And those who give birth, are mainly those women who are married.

11.3 Youth

People who have been trained were trained a few years ago. They think that when you say family planning, it is for the people with families who plan [ MoH representative] There is a need to push education to earlier levels, when girls have not menstruated yet. That is my understanding of what I see. The earlier we teach them, the better we catch them. When a girl has menstruated, she says Im sexually mature, I can get pregnant any time, Im fertile. And she needs to know at that point [Projects Manager, Marie Stopes]

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The private sector doctor confirmed that young people visiting his clinic were a small minority and also the public sector nurse did not mention the youth to be amongst the people using their family planning services. This also supported by the numbers: according to the preliminary results of Kenya Demographic and Health Survey, the contraceptive use is lowest for women aged 15-19. The challenges with youth were seen to be threefold: attitude of the service providers, limited access to services and economic. First of all family planning services can be said to be unfriendly to the youth because of service-barriers of the staff working in the clinics. Quite a big part of the staff was trained quite a few years ago and they see family planning as something that belongs to families, not for young people. This was also confirmed to be true other way around in the in-depth interviews where it was indicated that young people might have issues buying contraceptives from the pharmacies because they get ashamed. There are also constrains with access , concerning the opening hours of the clinics, the same way as with men who are working, to the youth who are at school. When young people get out of school, services are closing. Condoms might be easier to get as they might be distributed on the campuses for example, but with permanent methods, such as pills, a clinic visit is required. Also, economic wise it is difficult for young people to find the money needed to get family planning services because they are too afraid to ask it from their parents. One of the NGO representatives highlighted the need to increase family planning education at schools, especially to levels when girls have not menstruated yet as some girls become sexually active at that time. This has consequences in the reality as there are cases of girls getting pregnant at 5th grade. As highlighted in the chapters above, reaching and serving different groups in the field of family planning might be difficult. Thus family planning programs should be carefully designed to address the challenges and meet the needs of particular groups.

What can be done? Target men as much as women with positive family planning information as in many cases they are the decision makers and tend to decide about the use of family planning negatively. In some cases the decision is negative due to lack of correct information Create new and innovative programs to include men in family planning Have a separate component for men in every family planning program Target men in their work places and clubs Encourage men to discuss about family planning e.g. in a community event led by male family planning expert Spread information about family planning as a mutual issue, not only as something that belongs to women When providing information about different family planning methods, always provide information also on male condom Design also single-friendly and youth friendly family planning services and programs and spread information specifically targeted to these groups

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12 EDUCATION AS A MEAN TO EMPOWER WOMEN IN FAMILY PLANNING

An educated woman is more likely to change the attitude of their spouses towards family planning. An educated woman can better articulate the usefulness of family planning, we have 8 children, we are going to have problems. Uneducated woman is there only as a vessel, just keeps giving birth child after child [Director of Programs, Family Heath Options Kenya]

The factor highlighted by all the experts concerning family planning, was education. Education can be seen as a means to empower women and as a consequence of this empowerment, women usually want to have a smaller family. Some of the experts even mentioned poor education as a factor driving population growth. Education, indeed, has been a cross cutting theme in this report as well. As clearly came up from the survey results, education does matter. There are distinct differences between those who had education compared to those with no education or low education. When it comes to family planning, education is a significant factor affecting the opinions and perceptions. Those with no education at all or with low education are more likely to: - Not use family planning - Think that family planning is only a womans issue instead of being a couples issue - Hear about family planning only after giving birth - Not to plan in advance the number of children they want to have - Have higher number of children - Have the higher ideal family size - Consider that having a large family is important as one may lose children - Think that a large family is important for continuing the family name - Think that having a large family is good for the tribe

All of the factors mentioned above contribute to non-use of family planning and thus, to having large families. What is it then, in the education that affects also family planning behavior? First of all, practically thinking, going to school delays the age of first pregnancy. More importantly it was considered that education affects the overall worldview of the women. Through education they are better able to understand economic issues, such as the cost of raising a child. Also, because of the tools given by the education she is able to better articulate a usefulness of family planning to her spouse. According to the preliminary results of latest Kenya Demographic and Health Survey the contraceptive prevalence increases dramatically with 87

increasing level of education. 60% of married woman with at least some secondary education use a contraceptive method compared to just 40% of women with incomplete primary education and only 14% of those who never attended school. 78 Education was also seen to increase womens empowerment over their own body. Education also opens doors to other ways, than having many children, of supporting oneself. An educated woman is also more exposed to modern way of life. It also goes without saying that she is more likely to enter the job markets and have career aspirations. Education raises womans status and she is less likely to have time for taking care of many children. With education and possible career, women also want to provide the best possible for their children when it comes to clothing and feeding, for example. This was also seen as a factor that supports having only a few children. However, even though the effect of education to family size was concluded to be more of a reason of the overall world view change, and not on the education on contraception as such, however, education can also increase access to information on family planning: as was previously indicated in chapter 10.1 those with no education are more likely to hear about family planning only after giving birth. More importantly the education increases womens knowledge of the factors that contribute to better child survival. An educated household is more likely to take children to treatment when needed and boil water in order to avoid diseases and death. This is also an important factor as child mortality was still seen as a one rationale behind having many children, especially among those with no education. It was highlighted that it is womans education that has the effect. One of the experts concluded that sometimes it doesnt matter how much education man has, if woman is zero-educated. One interesting aspect, brought up by the UNFPA representative, was that these educated people are also seen as opinion leaders when they go to rural areas, or back to their communities. He saw these people as a vehicle of spreading the information of family planning and thus highlighted the need to educate college students about these matters.

13 MOBILE TOOLS FOR FAMILY PLANNING?

Mobile communications can serve as tool in addressing different socio-economic problems faced in the developing countries. With new and innovative ways to utilize mobile phone there are a lot of possibilities in providing solutions to grassroots challenges in various sectors. African continent has witnessed a remarkable growth in the field of mobile communications within last few years. Family planning provides an excellent base for new solutions because as many there are challenges, as many there are possibilities

13.1 Use of ICTs in family planning programs in Kenya

Majority of the interviewed organizations are not currently using any ICTs in their family planning programs excluding TV and radio. The Division of Reproductive Health of the MoH has been using mobile
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phones on getting information on numbers of contraceptive use with facilities sending these reports via mobile phone. Family Health International was currently piloting a project concerning educating or responding to issues clients may have after they have started using family planning method. Clients can send an SMS to certain number and after sending the message one gets a response from a prompter with questions to guide one further: Do you want information on contraception? Or you want information on specific method? If it is specific method, what you want to know about it, is it the side-effects or something else? The project is piloted in Nairobi in 16 facilities run by Marie Stopes Kenya and Family Health Options Kenya. Family Health International was planning also looking at possibility to use the same SMS-prompter system with service providers and addressing the questions they might have. Family Health Options saw the role of ICT in getting the information out there , especially to the youth, and came up with different suggestions of where mobile phones could be utilized such as: Sending SMSs to clients of which family planning methods are available and where Using SMSs to send reminders to clients to take contraceptives Building a database that clients can ask information from with their mobile phones

In addition to that, Population Council has used mobile phone for collecting data in their family planning studies and Population Services International in conducting panel studies.

13.2 Possibilities for mobile communications in family planning

A quick browse on the internet reveals that indeed mobile phone has been used also in the field of family planning. They have been used as a tool to address e.g. the data collection to more specific concepts like solution supporting standard days method where the client can inquire via SMS her fertility status79. These solutions, however, do not address the root problems of family planning but only scratch the surface. In the light of this report, there are two major challenges that could somehow be addressed with mobile technology: Addressing the myths and misconceptions , mainly concerning the incorrect side-effects, of different family planning methods Lack of male involvement

As indicated in the chapter 10.3 providing top-down information is not on itself enough and importance of interactive information was highlighted. Thus just sending one-way information on family planning via mobile phones does not provide a sustainable solution.
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More information on mHealth solution for standard days method please see http://www.slideshare.net/IRHgeorgetown/family-planning-via-mobile-phones-proofofconcept-testing-in-indiacycletel

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14 CONCLUSIONS

For Kenya, population growth is really the elephant in the corner: we would rather not talk about it. But 80 we are left with little choice

Population growth is a serious problem to Kenya and all the experts were very concerned about the consequences this growth has brought, brings and will bring to this country. Today, Kenya is in a situation where its economic growth is below the population growth rate, a fact seen very concerning by the experts. In Kenya the economic growth in 2009 has been 1,8% whilst the population growth rate in 2009 was 2,7%81. If one adds to that a fact- that the biggest part of the population is young dependent population and not economically productive, the situation is even worse. This constant growth puts pressure on countrys infrastructure, especially to education and health infrastructure. One of the most common consequences mentioned in the Kenyan context was pressure of this growth has to land. Only a small proportion of land is productive and question was raised that for how long this small piece, when over-used already now, can feed the ever-growing mass of people? And yet, as the expert interviews clearly indicated, in this situation family planning is not seen as something urgent even though it is a mean to avoid having too many, too close, too soon as one of the experts aptly put it. This report presented the results for the interviews of different family planning experts and the people of the grassroots levels, regular mothers and fathers, young girls and boys. The interviews painted an overall picture of family planning programs in Kenya, the success factors and more importantly the challenges they face. However, the main focus of this study was on the challenges faced on the individual level and in trying to find out the factors driving the existing preference for having large families. The challenges, in all of the levels, are many. Every level from policy level and to service level all the way down to the individual level suffers because family planning is not seen as something urgent. Strong advocacy is needed to change these perceptions in the high level as well as in the grassroots level. Family planning is urgent as population growth is urgent. Family planning must be seen as a cost-effective way to manage this growth as well as a way to save lives of both mothers ad children not to mention as a tool to empower couples to have options for both spacing and managing the number of children they want to have. This report has pointed out the important role of outside funding. When it comes to Sub-Saharan Africa, its role is highlighted even more. Consistent outside funding is needed to keep family planning programs sustainable and to avoid funding gaps. The consequences of shift of funding from family planning to HIV/AIDS is still visible both in the statistics as on the individual level. Due to this gap, as highlighted by the experts the contraceptive use went down and even more importantly, there exists a generation who doesnt know what their reproductive health options are. Even though consistent funding provides an essential base for different family planning programs and projects on itself it does not provide sustainable solutions. What has been underlined in this report are the

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Peter Wanyoni, Daily Nation December 22, 2009 CIA world fact book

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crosscutting problems that these programs face. These challenges can be said to be crosscutting as they affect all the sectors of family planning. One of the most important of these challenges to be addressed is the male involvement. It really is a backbone to success in getting couples to use family planning as it affects the use of family planning in so many ways. Providing solutions to making family planning something mutual that is an interest of the both parties and to make the decision-making equal, is not an easy task. The patriarchal societies of Sub-Saharan Africa are constructed in a way that the male dominance is a norm, not often times even questioned. In the long run, empowerment is clearly needed also in the matters related to family planning. The male involvement is, however, not a mission impossible. One concrete first step is to actually target men: Men must be taken to be target group of family planning programs as much, or even more, that women are. So far, this has been neglected. In addition to the male involvement, the big challenge is also the pro-natal attitude of the whole society. The pressure to have children is coming from the different directions of the society whether it is from those closest to oneself like the in-laws, the people around like neighbors, the church or even the tribe. Even though there might not be one source of influence, the general pressure is there. This does not mean that this pressure is influencing everyone. But it certainly can affect someone. It takes a lot of courage to resist this pressure. The main socio-cultural factors that contribute to having large families are the fear of side-effects and preference for boys. It is no wonder that some people actually fear the use of family planning if they are told that it can cause mental illness or to cause the contraceptive method entangled to the yet unborn babys hand. Some of these rumors are in a fact terrifying and thus hinder effectively the use of family planning. This means that having access is always not enough. Why to use family planning if it is seen as something harmful? In addition to the fear of side-effects also the general perceptions of family planning might be negative. Some people think that the use family planning allows women to be unfaithful to their partners. This all means that family planning in Sub-Saharan Africa is not just family planning and family planning methods are not just family planning methods. They are something more. This cultural value, mainly negatively ladden, must be understood in order to realize the range of obstacle there exists for using. These myths and misconceptions need to be urgently corrected. Another socio-cultural factor that affects the use of family planning negatively is the preference for boys. Some people still have large families as theyve tried to seek for a boy. The unequal position of the sexes is already reflected in the beginning of life. As already said, challenges in the field of family planning in Sub-Saharan Africa are many. This means there is a lot of work to be done, a lot of awareness to be raised and a lot of issues to be clarified and more importantly a lot of options to be given. At the end of the day informing people about family planning and tackling the obstacles for its use is giving people options. This is also the best way to manage population growth. The elephant must be chasen away from the corner.

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