NAIROBI, Kenya — “I got married at the age of 20 years seven years ago, just a year after finishing secondary school. My intention was to give birth to only two kids but my husband and his parents could hear none of it. Matters got worse when my second born turned out to be a girl like the eldest kid. My in-laws who live in rural Western Kenya said my husband was their only son so he was supposed to sire sons to inherit their land,” says Judy Akinyi (not her real name), a resident of Korogocho slum in the east of Nairobi.

Judy, who sells groceries in Korogocho slums, and whose husband is a casual factory worker says they struggle to take care of the kids. The mother of three says the husband still insists that she gives birth to a boy. “I am familiar with most family planning methods but can only use them covertly lest her my husband discovers,” she laments.

Her experience is not isolated. A study conducted by researchers at the Johns Hopkins Bloomberg School of Public Health, Johns Hopkins School of Nursing and Nairobi-based Ujamaa Africa, a nongovernmental organisation that works to prevent violence against women, indicates that reproductive coercion (RC) is rampant in Kenya’s urban settlements.

A summary of the studies is available here. [A link to the full study will be added if the authors make it available.]

According to the study, women in the urban settlements of Nairobi are expected by their male partners and the wider community to be “constant reproducers” of children, and are likely to experience violence and other forms of coercion if they take measures to limit their pregnancies.

Findings of the research which is part of a study that examined sexual and reproductive empowerment in sub-Saharan Africa were presented at the fifth International Conference on Family Planning in Kigali, Rwanda, from 12-15 November.

The study titled, “He tells you your work is to give birth,” was led by Shannon Wood, a PhD candidate at the Johns Hopkins Bloomberg School of Public Health, and principal investigator and Associate Professor Michele Decker of the Bloomberg School of Public Health, with support from IDEAS42. IDEAS42 is a non-profit design and consulting firm based in the US with offices in other countries that uses insights from the behavioural sciences to address complex social problems.

According to the findings, a commonly discussed form of reproductive coercion was men’s refusal to allow women to use condoms and other contraceptive methods.

“When women requested condom use, for example, partners would react by refusing, accusing them women of cheating and threatening them or physically abusing them. Consequently, they avoid contraceptives altogether,” it noted.

The results indicate that in the communities that have high fertility levels, coercive practices regarding condoms and reproductive health are pervasive.

Bernard Asira, project officer, Ujamaa Africa, explained that women experience intimate partner violence in Nairobi settlements. “As part of our safety aid intervention, we are enlightening women to understand that this abuse is not a cultural issue and they should be able to make their own family planning decisions,” he said.

He notes that they are also working to raise awareness and aid women to have healthier relationships. “Harmful beliefs exist around family planning use, leading men to believe that their women do not trust them,” he said.

In an interview with Health Policy Watch, Wood said it was an exciting study that emerged rather surprisingly out of formative work for a larger randomised controlled trial.

“The study took place in three urban, informal settlements in Nairobi and the researchers sought to understand barriers to accessing family planning services and safety strategies that women used to circumvent abusive partners,” she said.

Wood said they not only wanted to understand physical and sexual violence experiences, but also psychological abuse, inclusive of coercion. “As such, reproductive coercion inductively emerged as a theme across all three of our focus group sites,” she revealed.

The findings were rather unique given that commonly held views are that urban families in Kenya more easily adopt family planning than rural ones. A report by the African Population and Health Research Center (APHRC) titled, “Family Planning in East Africa: Trends and Dynamics” [pdf] released in January this year indicates that in East Africa the greatest gaps in family planning between urban and rural use are in Ethiopia, Uganda and Tanzania, while the smallest gaps are in Kenya and Rwanda.

However, the report cites opposition by husbands/partners as one of the reasons for non-use of contraceptives and other family planning methods.

Kenya is still experiencing comparatively fast population growth despite the total fertility rate declining. According a report [pdf] released by the United Nations in 2017, Kenya’s average household size declined from five people in 1969 to four in 2014.

The country’s population is projected to hit 95 million people by 2020.

Woods said during their study, women revealed feeling pressured to be constant reproducers by community members and partners. “Several participants discussed that they felt their work was to ‘give birth’ and that this was a source of their social value as a spouse and a woman,” she said.

The researcher added that stigma around condom use was often discussed as a norm that contributed to RC, as both partners believed that condom use request indicated that the other partner was being unfaithful.

According to Woods, women perceived their partner’s fear of their infidelity as a driver of intentional impregnation.

In terms of manifestation of RC, Woods cited discordance in reproductive intentions as being cited by respondents as a primary reason for reproductive coercion. “Women perceived financial implications of children, while partners focused on social value,” she added.

Common experiences commonly highlighted, noted Woods, were contraceptive refusal by men, particularly condom use, in addition to forced discontinuation of long-term methods.

In terms of mitigation methods, against RC, pointed out Woods, women revealed covert use of contraception, which was most often discussed in the form of the injectable.

The study did not however specifically discuss health implications of RC, but was focused on types of violence that women underwent and potential strategies for harm reduction. In other settings, RC has been associated with unintended pregnancy.

Woods said covert use of contraceptives is one method that women sometimes resort to when experiencing reproductive coercion. “Many women discussed this as a valuable strategy when faced with abuse in their relationship,” she explained.

Woods noted that the findings may help stakeholders understand rapid repeat pregnancy or unintended pregnancy, particularly in situations of abuse.

“Providers should be aware of the possibility of reproductive coercion and help women make informed decisions about contraceptive use,” she said. “We advocate for a woman-centred approach, inclusive of consultation on all contraceptive methods and side effects, to ensure that women are able to use methods best suited to fit their needs.”

According to Woods, the study took place in a social context where immense value is placed on childbearing.

“We learned that women were concerned with the financial implications of childbearing and were trying to plan for their families. They discussed that their partners were more focused on the social value of children. They perceived this disconnect between reproductive intentions as the primary driver of reproductive coercion,” she said.

She concluded that the study brought to the fore the fact that RC is a concern for women in settlements, but specifically issues of prevalence, severity, specific types of reproductive coercion, and impact on sexual and reproductive health still require further exploration.

Asira urged the Kenyan government to train community health volunteers working in urban settlements on reproductive health who can address the issue and also make available more information about it.

Image Credits: Justus Wanjala.