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Women's Experiences of Induced Abortion In TITLE WOMEN’S EXPERIENCES OF INDUCED ABORTION IN MOMBASA CITY AND THE KILIFI DISTRICT, KENYA Louisa Njeri Ndunyu M.A Population Studies (University of Nairobi, Kenya) Submitted in fulfillment of the requirements for a PhD (Population Studies) in the School of Built Environment and Development Studies, University of KwaZulu-Natal, 2013 Date: 29 November 2013 Supervisor: Prof. Eleanor Krassen Covan, PhD ii DECLARATION I, Louisa N. Ndunyu, declare that the work presented in this doctoral thesis is my own, and that it has not been submitted in any other form to another university. Where use has been made of any work done by other persons it has been duly acknowledged and referenced in the text. Candidate: Louisa Ndunyu Signature Date: 29-11-2013 Supervisor: Prof. Eleanor Krassen Covan Signature Date: 29-11-2013 ACKNOWLEDGEMENTS I wish to use this opportunity to express my sincere gratitude to many people and institutions for supporting this study. Due to ethical obligations and their large numbers, I cannot mention all by name. However, I wish to highlight in general the following: Prof. Eleanor Krassen Covan, my divine supervisor at the ‘eleventh hour’, for renewing my hope, inspiring and supporting me in the run to the finish of this project; for the extraordinary supervision and mentoring, I am truly privileged and obliged. Dr. Kerry Vermaark, for your commitment and support in the administrative processes to ensure the successful submission of this thesis, I am grateful. Prof. Eleanor Preston-Whyte for journeying with me; for the confidence you put in me and for dedicated supervision of this study from the mid-year 2007. Prof. Julian May, School of Development Studies, University of KwaZulu-Natal for trusting me and providing consistent support throughout my studies. Prof. Vishnu Padayachee, Head of School, Development Studies and the entire administrative staff for efficient management of research funds, library and workstation assistance. Prof. Francie Lund, thank you for encouragement and creating a ‘home away from home’ environment. My employer, Maseno University, for granting me initial study leave that facilitated this investigation. This investigation received financial support from the Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, (WHO). To them I am truly indebted. In particular, my thanks go to Dr. Iqbal Shah, Coordinator Scientist, Department of Reproductive Health and Research, for facilitating efficient transfer of funds and his willingness to review my manuscripts for conference presentations; Dr. Ina Warriner and Ms. Nicky Sabatini Fox for their efficient communication. iii Further funding was granted by the African Doctoral Dissertation Research Fellowship (ADDRF) offered by the African Population and Health Research Centre (APHRC) in partnership with the International Development Research Centre (IDRC) and Ford Foundation. To them I extend sincere gratitude. The entire APHRC team, I say thank you for your support and ‘family’ environment. In particular the Director, Dr. Alex Ezeh for granting me a work station at the APHRC as an ADDRF fellow in the year 2008. Dr. Chimaraoke Izugbara, thank you for the academic support, and together with Dr. Caroline Kabiru, you have enriched this study through skills acquired and networks created at the training workshops, conferences and other meetings courtesy of the ADDRF fellowship. I gratefully acknowledge Dr. Yazoume for introducing me to data analysis using MS Access; Mr. Anthony Maina and Mr. Morris Mbogo for invaluable technical assistance with IT. The Ethical Review Board of the Kenyatta National Hospital/University of Nairobi, in particular, Prof. Elizabeth Bukusi of the UoN/KEMRI; the administration of the CPGH, the KDH, MDH and HCs; and the local administration, for permission to do research among patients in health facilities and households. The research team, including the women studied, interviewers, field assistants, nurses, counselors, community resource persons, translators, and fellow researchers who double checked the transcriptions. Thank you for your participation. Reproductive health organizations and experts in Mombasa and the Kilifi districts, for corporate and individual technical support and information during the field exercise and dissemination. The Officer Commanding Police Division, (OCPD), Mombasa, is here acknowledged. KEMRI, Kilifi, in particular Dr. Evasius Bauni, and the then Mombasa District Hospital in Port Reitz, for the maps used in this study, thank you. Qualitative experts: Ms Parsy Clarke, retired ICT Division, University of KwaZulu-Natal for providing me with qualitative material for analysis and proof-checking text data; facilitators of various qualitative methods courses organized by the Reproductive Health Research Unit (2007); iv the joint APHRC/UAPS (2005); and the joint School of Development Studies, UKZN/Groningen University (2005), I here acknowledge the skills you imparted on me. Ms. Princess Nhlanqulela, UKZN, who tirelessly processed the transcripts in to Word documents. Colleagues of the consortium for abortion research in Africa, thank you for valuable discussions and facilitating dissemination of this study. Special thanks to Dr. Ann Moore, Guttmacher Institute, for granting me the DELL laptop that I now use to complete this study as the battery in my original computer failed me. My daughter Kazuri for sacrificing her laptop after the battery in the DELL laptop recently expired!. My colleagues in the PhD office F200, School of Development Studies, thank you for making this academic endeavour a bearable journey by your lunch hour and tea-break companionship, global political discussions, jokes, ‘braais’ and football games by the beachfront, and being a valuable sounding board for my ideas. Dr. Janet Muthoka of the Gender Studies, UKZN thanks for reviewing the narratives, affirming the gender themes and the fruitful discussions we had. My friends and colleagues: Ms. Olympia Jelagat Okal, your dedication in keeping me connected to my employer and encouraging my family while I was away in Durban, is fully appreciated. Together with Dr. Pauline Andang’o, your support and encouragement during a difficult writing period as I struggled to teach in Kisumu and be there for my family in Nairobi, receive my many thanks. 2 My long-suffering family: my daughter Kazuri and son Steven who bravely and selflessly allowed me to study in South Africa leaving them behind; they have grown and advanced to the university in the years I have spent completing this study; my mother who has grown frail; and my brother, Christopher, his wife Luiza and their four children namely, Alvin, Ethel, Triza and Tracy for graciously embracing my children in the years I was in Durban, I am greatly indebted. To God be the Glory, Louisa .N. Ndunyu Maseno University, Kenya v DEDICATION This thesis is dedicated to the women of Mombasa and the Kilifi districts for their courage to share and lay public their private lives with the hope that it will make a contribution towards improvement of Kenyan women’s lives. The experiences of these women left a remarkable change in me and I hope the reader will be similarly influenced by these accounts. vi ABSTRACT The primary objectives in this study were to gain a deep level of understanding of Kenyan women’s experiences of seeking abortion, both safe and unsafe, and to explore how social and legal issues impact their choices and the routes they take to obtain abortion. I explored the contexts and interpreted 49 in-depth narratives of women’s emic experiences of abortion in Mombasa city and the Kilifi district, Kenya, using a qualitative form of inquiry conducted between April and July 2005. Ethical Review Committees granted ethical clearance to this study. This emic work revealed gender inequity consistent with developing feminist theory and thus how women conceive gendered relationships is introduced in this analysis of women's narratives. The findings provide new insights as well as useful confirmatory knowledge, gleaned from detailed empirical evidence within Kenyan women’s social contexts. The women have revealed the evidence through their narratives; such an approach is largely missing in existing abortion literature. The prominent finding is that women do not abort motherhood, but they do abort particular pregnancies to protect motherhood; to avoid a difficult motherhood likely to compromise the quality of care they envisage for their potential and existing children. This includes ensuring the best nurturing environment, paternal and religious identity, social legitimacy. The abortion decision is difficult to make and thoroughly considered. The married women make a consultative decision with their ‘breadwinners’ having the upper hand. Legal barriers cannot bar abortion but entrench inequities in abortion care access, heighten secrecy, stigma, and hamper prompt comprehensive post abortion care seeking. Thus, financial resources, peers, geographical remoteness, and knowledge significantly influence the type of abortion accessed. Consequently, unsafe abortion threatens motherhood of the most vulnerable groups of women. The foremost recommendation is that public health law must ensure healthy, enjoyable, dignified motherhood for the women; hence safe early abortion (first trimester) must become accessible to alleviate existing health care inequities. vii TABLE OF CONTENTS ACKNOWLEDGEMENTS ..............................................................................................
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