Disparities in contraceptive usage worry health experts

By GATONYE GATHURA

With a little more effort, more Kenyans can be saved from going through the pain, anguish and indignity of backstreet abortions.

Experts say most of the 465,000 abortions conducted last year could have been avoided if the cheap contraceptives subsidised by the government were supplied to those who needed them most.

But because these contraceptives were not supplied or requested, 119,912 women experienced abortion-induced complications and sought treatment in shady clinics even when the law entitles them to remedial treatment in government-run health facilities.

A report released by the Ministry of Health says that of the 465,000 women who had abortions last year,  325,000 had access to contraceptives but chose not to use them. The report, Our women matter,  says most contraceptives in government health facilities are free; in private clinics these contraceptives are highly subsidised.

For example, the injectable and most popular method in Kenya offering protection for about three months is free in many facilities but even in private clinics, the cost is nominal at Sh300 per year.

Speaking during the launch of this report, the Director of Medical Services, Dr Francis Kimani, said the most restrained use of contraceptives was in the previous administrative provinces of Western and the Rift Valley.

Therefore, last week we went to Bungoma in western Kenya to find out why so many women and girls—63 out of every 1,000—were procuring abortions. This was more than double the number of abortions in Nairobi and Central provinces and more than three times the number of birth terminations in Eastern Province.

So why these big regional variations? “The study has shown a clear link between the use of contraceptives and abortion with regions having highest use recording fewer cases of abortions,” says Dr Joachim Osur of Ipas Africa who were involved in the abortion study.

The current Kenya Demographic and Health Survey shows the use of contraceptives to be highest in Central at 67 per cent, Nairobi 55 per cent, Eastern 52 per cent but about 47 per cent in western Kenya.

“In some places the use of contraceptives is as low as 20 per cent,” said Florence Matanda, the reproductive health coordinator in Bungoma South sub-county during our visit to her workstation.

But it is not lack of contraceptives that is responsible for the low use in these areas, according to a policy brief prepared by the government in December showing the regional variation in the use of birth control interventions.

For example, while the availability of contraceptive services in western was found to be  93 per cent, use was only at 47 per cent, while use in Nairobi is 55 per cent compared to an availability of 68 per cent. In Central Kenya, availability was found at 89 per cent against the usage of 67 per cent.

Even when contraceptives were free, we learnt that demand for the products and services in western Kenya and Bungoma in particular was extremely low.

“We have emergency pills expiring in most hospitals because nobody  comes for them, especially in the rural areas,” says Dr Andrew Wamalwa, the District Medical Officer of Health in Bungoma West.

His equivalent in Bungoma South Dr Johnston Akatu said the high rates of backstreet abortions in the area was a major cause of maternal deaths and illness and a burden to an already stretched primary health care system.

Dr Osur attributed the high rates of abortion in western Kenya to higher poverty levels, gender-based violence and polygamous marriages. In western Kenya, about 25 per cent of women are living in polygamous relationships compared to only two per cent of women in Nairobi.

Poverty has also been linked to low adoption of family planning services and products. According the National Council for Population and Development (NCPD), Central, Nairobi, and Eastern regions that have the highest contraceptive use also have the lowest number of the poorest people.

On the other hand, North Eastern and Coast regions, which have the lowest contraceptive  use, also have the highest proportion of the poorest people in the country while western Kenya is not far behind.

 “Generally, wealth status has been found to have an influence on contraceptive use in that those who are wealthier have a higher chance of using contraceptives,” says the  NCPD.

“Rich or poor, a woman who has decided   to terminate a pregnancy will do so even at the risk of death,” says Dr Osur. The only difference is that the poor woman has fewer options and these are almost all injurious to her health,  he says.

 “This is why we are working in Bungoma to reduce the suffering of such women who otherwise when left to quacks will almost certainly die or develop life threatening conditions,” says the Netherlands ambassador to Kenya, Joost Reinjst.

Through Ipas Africa the embassy is funding a three-year project in Bungoma to address the issue of maternal mortality. In a tour of the project area last week, the ambassador said the Dutch government was spending 30 million euros on various projects in the country, including safe abortions.

“Our goal resonates with the thinking of the Kenya government that the best way to reduce maternal deaths is to prevent unwanted pregnancies in the first place but when they occur, offer women safe solutions in accordance with the law.”

The project involves 12 public health facilities in the county where Ipas has provided training to 32 government workers on how to procure safe abortions and also provide post-abortion care to those who may come to hospital with complications from abortions procured elsewhere.

 “In the last two years we have not lost a single woman who has come to the facilities for post-abortion care,” said Matanda during a visit to one of the medical clinics. The project involves providing the facilities with the approved abortion equipment and drugs even as personnel are trained.

“Since inception of the project we have seen the uptake of family planning products and services in some areas jump from as low as 20 per cent to 40 per cent,” said Matanda.

But from the medical personnel  we spoke to, there seems to be confusion over how far a government subsidy on maternal health is supposed to go.  The government has undertaken to  meet the medical costs of  maternal births in public hospitals. However, currently some facilities are only being reimbursed for the number of deliveries at the centre and the subsidy does not cover other peripherals such as post-abortion care or legal abortion.

 The project also involves educating the public in Bungoma County about provisions of the Constitution that allow for limited abortion, especially when the life of the mother is threatened. “The majority of the people have read the Constitution and understand their rights, especially the right to the highest standard of healthcare services and emergency medicine. We have been holding public meetings to create awareness on this and especially why a woman with an unwanted pregnancy needs to talk to us first before going to quacks,” says Dr Wamalwa.

The government has already prepared a Patients Rights Charter that expresses the legal allowance for limited abortions to ensure that  needy women enjoy this right.

 The charter published in April requires all health workers to familiarise themselves with the Constitution of Kenya and implement it. This means any woman who visits a hospital with an incomplete abortion must be attended to urgently.

At the same time, medical workers are  required to offer a woman with an unwanted pregnancy all options open to her including abortion where it is legally applicable.

The Ministry of Health has also published guidelines on how and who will carry out an abortion in both public and private health facilities.