PERFORMANCE MONITORING FOR ACTION FAMILY PLANNING

PMA (Kakamega) Results from Phase 1 baseline survey

November–December 2019

overall key findings

There has been 49% of the women reported to 45% of the 77% of the users consistent decrease in have received comprehensive pregnancies obtained their current modern contraception methods information during were modern method from a use since 2016 for all the FP visit. unintended. . women. public health facility

SECTION 1: CONTRACEPTIVE USE, DYNAMICS, AND DEMAND

MODERN CONTRACEPTIVE PREVALENCE CONTRACEPTIVE PREVALENCE by Percent of women age 15-49 currently using modern contraception (mCPR) by method type marital status Percent of women age 15-49 currently using contraception by method type (PMA Phase 1 n=723) 100 100 90 90 80 80 74 70 70 68 66 70

60 57 62 60 49 50 53 50 51 47 40 45 40

36 29 28 30 30 26 25

20 20 24 23 23 22 10 10 1 1 1 2 0 0 Dec Dec Dec Dec Dec Dec Dec Dec 2016 2018 2019 2017 2016 2017 2018 2019 PMA2020 survey rounds PMA PMA2020 survey rounds PMA Phase Married women (PMA Phase 1 n=457) Short-acting methods Phase 1 Unmarried, sexually active women (PMA Phase 1 n=44) Long-acting methods 1 All women (PMA Phase 1 n=723) Traditional methods modern contraceptive Method Use, Unmet Need, and Demand prevalence by county Satisfied by a Modern Method Percent of women age 15-49 currently using modern contraception by Percent of women age 15-49 using contraception by method type, unmet need, Kenya county and demand satisfied by a modern method (PMA Phase 1 n=723)

100 50 90 83 81 79 80 49 80

Nandi 49 70 60 4 5 6 7 4 Kakamega 47 7 6 1 1 5 50 1 2 47 40 30 53 51 47 49 20 47 43 10 41 0 Dec Dec Dec Dec 2016 2017 2018 2019 41 PMA2020 survey rounds PMA Phase Kilifi 35 1 Modern method Unmet need for limiting West Pokot 19 Traditional method Demand satisfied by modern method Unmet need for spacing 0 10 20 30 40 50 60 Demand satisfied by a modern method is use of modern contraceptive methods divided by the sum of unmet need plus total contraceptive use.

TRENDS IN MODERN CONTRACEPTIVE MIX modern contraceptive method Percent distribution of modern contraceptive users age 15-49 by method and year (PMA Phase 1 n=340) mix Percent distribution of modern contraceptive users age 15-49 by method

1 2 6 36 41 6 45 46 30 Key for method mix charts: 30 3 Other modern methods 3 Emergency contraception 15 Male condom 33 Pill 30 28 39 Injectable (SC) Injectable (IM) 46 9 43 Implant 5 6 9 IUD 8 5 6 5 5 Female sterilization 6 5 4 5 ‘Other’ category includes 6 3 2 male sterilization, female 2 3 2 6 4 1 1 2 1 3 condoms, diaphragm, LAM, Dec Dec Dec Dec and standard days/cycle Married/in union Unmarried, beads. 2016 2017 2018 2019 women (n=280) sexually active PMA2020 survey rounds PMA women (n=30) Phase 1

Page 2 12-MONTH DISCONTINUATION RATE Among women who started an episode of contraceptive use within the two years preceding the survey, the percent of episodes discontinued within 12 months (n=378 episodes) 6% Reasons for discontinuation: Discontinued but discontinued to switched methods: become pregnant 3% 10% 12% experienced were concerned over had other fertility 22% 48% method failure side effects or health related reasons Switched discontinued for other reasons 4% 15% 4% other method- wanted a more other/don’t know related reasons effective method

KEY FINDINGS for section 1: contraceptive use, Intention of Most Recent DYNAMICS, AND DEMAND Birth/Current Pregnancy Percent of women by intention of their most recent birth or • Implants is the most dominant method of current pregnancy (n=406) contraception among all, married and unmarried sexually 15%wanted no more children active women. • 54% of the time, methods were discontinued within one year of starting. 6% did so to become pregnant and 22% 30%wanted later switched to another method.

• 45% of the pregnancies were unitended with 305 been mistimed and 15% not wanted at all 45% 55% of pregnancies were Intended unintended

SECTION 2: QUALITY OF FP SERVICES AND COUNSELING

Method information index plus (miI+) Percent of women who were told about side effects, what to do about side effects, of other methods, and the possibility of switching methods (n=336)

When you obtained your method were Percent of women who responded “Yes” you told by the provider about side effects 34 66 to all four MII+ questions or problems you might have?

Were you told what to do if you experienced side effects or problems? 9 92

Were you told by the provider about methods of FP other than the method you 28 72 received? 51% 49% Were you told that you could switch to a answered “No” answered “Yes” different method in the future? 25 75 to at least one to all four MII+ MII+ question questions

No Yes

Page 3 Discussed FP in the past year client exit interviews with provider/CHW Percent of female clients age 15-49 who said yes to the following questions (n=449) Percent of women who received FP information from a provider or community health worker (CHW), by age During today’s visit, did the provider tell 48% you the advantages/disadvantages of the 52% FP method?

1% 7% During today’s visit, did you obtain the method of FP you wanted? 92%

3% 40 29 Were you satisfied with FP services you 15 received today at this facility? 97% 15-19 20-24 25-49 (n=158) (n=128) (n=437) Yes No Neither (follow-up visit)

Yes No Clients were interviewed immediately following their health facility visit to obtain FP counseling or services.

KEY FINDINGS for section 2: QUALITY OF FP SERVICES AND COUNSELING

• 97% of the clients reported satisfaction with FP services they received, however 48% reported that the provider did not discuss the advantages and disadvantages of the chosen method. • Adolescent girls are least likely to have discussed FP with their health provider or CHW in the past year.

SECTION 3: PARTNER DYNAMICS

partner involvement in FP Percent of women who are Percent of women who are not currently using FP and agree with currently using FP and agree with decisions the following statements (n=350) the following statements (n=331) Percent of women who are currently using modern, female controlled methods and agree with the following statements (n=336) Would you say Would you say that using FP is that not using Does your partner Before you started using this mainly your FP is mainly know that you are method had you discussed decision? your decision? using this method? the decision to delay or avoid pregnancy with your partner? 11% 49% 4% 15% 20% 29% 5%

40% 76% Yes <1% Joint decision 81% No 72% Mainly respondent Modern, female controlled methods Includes all modern methods except male Mainly partner sterilization and male condoms Other

KEY FINDINGS for section 3: partner dynamics • Among women using a modern method that can be concealed, 20% report that their partner does not know that they are using contraception. • 11% of women who are using contraceptive method report that it is mainly their partner’s decision. • 15% of the decisions not to use and 49% of the decisions to use FP are jointly made.

Page 4 SECTION 4: WOMEN AND GIRLS’ EMPOWERMENT

agreement with family planning empowerment statements Percent of all women who strongly agree to strongly disagree with each statement

Exercise of choice (self-efficacy, negotiation) for family planning (n=720) I feel confident telling my provider what is important when selecting an FP method. 10 4 2 15 69

I can decide to switch from one FP method to another if I want to. 12 4 2 14 68

Existence of choice (motivational autonomy) for family planning (n=713) If I use FP, my body may experience side effects that will disrupt relations with my partner. 52 11 4 14 20

If I use FP, my children may not be born normal. 72 9 2 7 9

There will be conflict in my relationship/marriage if I use FP. 64 14 3 7 13

If I use FP, I may have trouble getting pregnant the next time I want to. 62 12 3 8 15

If I use FP, my partner may seek another sexual partner. 69 14 2 6 9

Strongly disagree Disagree Neutral Agree Strongly agree

Women's and Girls' Empowerment (WGE) Sub-Scale for Family Planning The Women's and Girls' Empowerment (WGE) Index examines existence of Mean WGE score, by education Mean WGE score, by age choice, exercise of choice, and achievement of choice domains across pregnancy, family planning, and sex Overall 4.1 Overall 4.1 outcomes.

Presented results are only for the Tertiary 4.4 existence of choice and exercise of choice education 25-49 4.2 domains for family planning.

Scores from the above family planning Secondary 4.2 20-24 4.0 empowerment statements were summed education and divided by number of items (7) for average WGE family planning score across both domains . None/ Primary 4.0 15-19 3.9 education Range for the combined WGE family planning score is 1-5, with a score of 5 21 3 54 21 3 54 indicating highest empowerment.

Page 5 mCPR and intent to use contraception, mCPR and intent to use KEY FINDINGS for by categorical WGE score contraception, by employment section 4: Percent of women using a modern method of contraception Percent of women using a modern method of Women and girls’ and percent of women who intend to use contraception in contraception and percent of women who the next year by categorical WGE score (n=723) intend to use contraception in the next year by empowerment employment status (n=723) • Women who score 100 100 higher on the empowerment scale 80 80 are much more likely to be using a modern 12 60 60 11 contraceptive method 12 7 12 or intend to use in 40 15 40 Intent to use contraception the future. 49 55 54 mCPR • Women who are 20 44 20 39 33 employed are more likely to be using or 0 0 Lowest Median High Highest (5) No Yes intend to use modern (1) or low Work outside of the house in contraception. Intent to use contraception mCPR the past 12 months

SECTION 5: ATTITUDES TOWARDS CONTRACEPTION

Personal attitudes Percent of women who personally agree with statements made about contraceptive use, by age, residence, and contraceptive use status By age By residence By contraceptive use status Disagree/Strongly Agree/Strongly Disagree/Strongly Agree/Strongly Disagree/Strongly Agree/Strongly Adolescents disagree agree disagree agree disagree agree who use FP 15-19 54 46 are Rural 47 53 Users 47 53 promiscuous. 20-24 48 52 Urban 57 43 Non-users 51 49 (n=722) 25-49 48 52

By age By residence By contraceptive use status Disagree/Strongly Agree/Strongly Disagree/Strongly Agree/Strongly disagree agree Disagree/Strongly Agree/Strongly FP is only for disagree agree disagree agree married 15-19 56 44 women. Rural 58 43 Users 65 35 20-24 59 41 Urban 72 28 Non-users (n=723) 56 44 25-49 62 38

By age By residence By contraceptive use status Disagree/Strongly Agree/Strongly Disagree/Strongly Agree/Strongly Disagree/Strongly Agree/Strongly FP is only for disagree agree disagree agree disagree agree women who 15-19 59 42 don’t want Rural 62 38 Users 67 33 any more 20-24 67 33 children. Urban 72 28 Non-users 60 40 (n=723) 25-49 65 36

Page 6 By age By residence By contraceptive use status Agree/Strongly Disagree/Strongly Agree/Strongly Disagree/Strongly Disagree/Strongly Agree/Strongly agree disagree agree People who disagree disagree agree use FP have a better quality 15-19 53 47 Rural 45 55 of life. Users 40 61 20-24 43 57 (n=722) Urban 34 66 Non-users 47 53 25-49 40 60

key findings for section 5: attitudes towards contraception • More than half of the women agreed or strongly agreed that people who use FP have a better quality of life. •About 5 in every 10 adolescents believe that their adolescent counterparts who use FP are promiscuous. • About 4 in every 10 contraceptive non users believe that FP is only for married women.

SECTION 6: REPRODUCTIVE TIMELINE

Reproductive timeline Reproductive events by age 18 Median age at reproductive events, by urban vs. rural residence (n=187) Percent of women aged 18-24 who experienced reproductive events by age 18 (n=187) Urban women Rural women

1.4 average 1.6 average children at first use children at first use 22 First marriage 21.8 21.6 First contraceptive 48 use First contraceptive use 19 21.3 11 12 21 First birth 20.8 Had first Married by Gave birth Used 20.6 First birth First marriage sex by age age 18 by age 18 contraceptives 18 by age 18 20

KEY FINDINGS for section 6: reproductive 19 timeline First sex 17.8 • Rural women enter sexual activity earlier, marry earlier, give birth earlier, but initiate 18 contraception later than urban women. 17.3 First sex • While about half of the young women have 17 had first sex by age 18, only 11% are married by Median age that age and just 12% have used a contraceptive. Note: median age at first sex and first contraceptive use calculated among women 15-49 years; median age at first marriage and first birth calculated among women 25-49 years.

Page 7 SECTION 7: SERVICE DELIVERY POINTS trends in method availability: iud trends in method availability: implant

Public facilities (PMA Phase 1 n=86) Public facilities (PMA Phase 1 n=86) 3 3 7 3 6 7 5 10 3 7 10 3 1 14 16 10

97 90 86 90 93 76 79 79

Dec Dec Dec Dec Dec Dec Dec Dec 2016 2017 2018 2019 2016 2017 2018 2019 PMA PMA PMA2020 survey rounds Phase 1 PMA2020 survey rounds Phase 1

trends in method availability: trends in method availability: male injectables condoms

Public facilities (PMA Phase 1 n=86) Public facilities (PMA Phase 1 n=86) 1 3 6 3 3 2 17 13 17 9 16 14 14

97 97 97 87 87 69 78 69

Dec Dec Dec Dec Dec Dec Dec Dec 2016 2017 2018 2019 2016 2017 2018 2019 PMA PMA PMA2020 survey rounds Phase 1 PMA2020 survey rounds Phase 1

trends in method availability: Pills Public facilities (PMA Phase 1 n=86) 2 3 3 5 14 30 10 7 Currently in stock and no stockout in last 3 months 7 Currently in stock but stockout in last 3 months

97 Currently out of stock 76 83 63 Not offered

Dec Dec Dec Dec 2016 2017 2018 2019 PMA PMA2020 survey rounds Phase 1

Page 8 facility readiness fees for services Percent of facilities that provide IUDs and Percent of facilities that provide implants Percent of facilities where FP clients have to have a trained provider and and have a trained provider and pay fees to be seen by a provider even if they instruments/supplies needed for IUD instruments/supplies needed for implant do not obtain FP insertion/removal (n=86) insertion/removal (n=81) Public facilities (n=86) 24% 21% 2%

No No Yes Fees Yes 98% No fees 79% 77%

key findings for section 7: service delivery points

77% of women obtained • 77% of the women obtained their current modern method from a their current modern public health facility. method from a public health (facility (n=336) • Contraceptive stock-outs are still prevalent for IUD, implant, injectables, male condoms and pills in public health facilities.

Page 9 Tables: Contraceptive prevalence and unmet need

all women CPR mCPR Unmet need for family planning

Data Round/ Data Female CPR% SE 95% CI mCPR% SE 95% CI Unmet SE 95% CI source Phase collection sample need (%)

PMA R5 Nov-Dec 521 49.44 2.75 43.44 55.46 48.61 2.95 42.19 55.07 11.85 2.07 8.02 17.15 2020 2016

PMA R6 Nov-Dec 490 53.56 3.50 45.87 61.08 53.01 3.46 45.43 60.46 10.66 2.12 6.85 16.22 2020 2017

PMA R7 Nov-Dec 502 51.88 2.16 47.13 56.60 50.96 2.19 46.14 55.76 11.98 1.54 9.00 15.78 2020 2018

PMA Phase 1 Nov-Dec 723 49.01 2.00 44.89 53.13 46.91 1.94 42.93 50.93 9.05 0.92 7.32 11.14 2019

women in union CPR mCPR Unmet need for family planning

Data Round/ Data Female CPR% SE 95% CI mCPR% SE 95% CI Unmet SE 95% CI source Phase collection sample need (%)

PMA R5 Nov-Dec 314 69.22 3.78 60.39 76.83 67.85 3.97 58.64 75.86 12.88 3.24 7.33 21.66 2020 2016

PMA R6 Nov-Dec 294 71.24 3.20 63.77 77.71 70.33 3.09 63.16 76.62 11.24 2.37 7.02 17.50 2020 2017

PMA R7 Nov-Dec 291 75.26 3.17 67.70 81.53 73.65 3.04 66.49 79.75 12.62 2.68 7.85 19.67 2020 2018

PMA Phase 1 Nov-Dec 457 64.68 2.38 59.62 69.44 61.83 2.28 57.01 66.42 10.69 1.37 8.18 13.85v 2019

PMA Kenya (Kakamega) collects information on knowledge, practice, and coverage of family planning services in 25 enumeration areas selected using a multi-stage stratified cluster design with urban-rural strata. The results are county-level representative. Data were collected between November and December 2019 from 830 households (99.2% response rate), 723 females age 15-49 (99.3% response rate), 100 facilities (98.0% completion rate), and 459 client exit interviews. For sampling information and full data sets, visit www.pmadata.org/countries/kenya. PMA uses mobile technology and female resident data collectors to support rapid-turnaround surveys to monitor key family planning and health indicators in Africa and Asia. PMA Kenya is led by the Ministry of Health in collaboration with International Centre for Reproductive Health Kenya (ICRHK), National Council for Population and Development, and Kenya National Bureau of Statistics. Overall direction and support are provided by the Bill & Melinda Gates Institute for Population and Reproductive Health at the Johns Hopkins University and Jhpiego. Funding is provided by the Bill & Melinda Gates Foundation.

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