Why do most young women not take up contraceptives after post-abortion care? An ethnographic study on the effectiveness and quality of contraceptive counselling after PAC in Kilifi County, Kenya

Abstract

Post-abortion care (PAC) counselling and the provision of contraceptive methods are core components of PAC services. Nevertheless, this service is not uniformly provided to PAC patients. This paper explores the factors contributing to young women leaving health facilities without counselling and contraceptive methods. The paper draws from an ethnographic study conducted in Kilifi County, Kenya, in 2021. We conducted participant observation in health facilities and neighbouring communities, and held in-depth interviews with 21 young women aged 15–24 who received PAC. In addition, we interviewed 11 healthcare providers recruited from the public and private health facilities observed. Findings revealed that post-abortion contraceptive counselling and methods were not always offered to patients as part of PAC as prescribed in the PAC guidelines. When PAC contraceptive counselling was offered, certain barriers affected uptake of the methods, including inadequate information, coercion by providers and partners, and fears of side effects. Together, these factors contributed to repeat unintended pregnancies and repeat abortions. The absence of quality contraceptive counselling therefore infringes on the right to health of girls and young women. Findings underscore the need to strengthen the capacities of health providers on PAC contraceptive counselling and address their attitudes towards young female PAC patients.

Résumé

Le conseil en matière de soins après avortement et la fourniture de méthodes contraceptives sont des éléments essentiels des services post-avortement. Néanmoins, ce service n’est pas assuré de manière uniforme aux patientes ayant avorté. Cet article explore les facteurs qui incitent les jeunes femmes à quitter l’établissement de santé sans conseils ni méthodes contraceptives. L’article s’appuie sur une étude ethnographique réalisée dans le comté de Kilifi, au Kenya, en 2021. Nous avons mené une observation participante dans des établissements de santé et des communautés voisines, et organisé des entretiens approfondis avec 21 jeunes femmes âgées de 15 à 24 ans qui avaient reçu des soins post-avortement. De plus, nous avons interrogé 11 prestataires de soins recrutés dans les établissements de santé privés et publics observés. Les résultats ont montré que les conseils et les méthodes contraceptives post-avortement n’étaient pas toujours proposés aux patientes dans le cadre des soins après avortement, ainsi que prévu dans les directives pertinentes. Quand des conseils en matière de contraception après un avortement avaient été offerts, certains obstacles ont influé sur l’adoption des méthodes, notamment des informations inadéquates, la coercition de la part des prestataires et des partenaires, et la crainte d’effets secondaires. Ensemble, ces facteurs ont contribué à de nouvelles grossesses non désirées et à de nouveaux avortements. L’absence de conseils en matière de contraception de qualité porte donc atteinte au droit à la santé des filles et des jeunes femmes. Les conclusions soulignent la nécessité de renforcer les capacités des prestataires de santé en matière de conseil sur la contraception après avortement et de corriger leurs attitudes à l’égard des jeunes patientes des soins après avortement.

Resumen

La consejería y la provisión de métodos anticonceptivos durante la atención postaborto (APA) son componentes fundamentales de los servicios de APA. Sin embargo, este servicio no se ofrece de manera uniforme a las pacientes de APA. Este artículo explora los factores que contribuyen a que las mujeres jóvenes dejen los establecimientos de salud sin consejería y métodos anticonceptivos. El artículo se basa en un estudio etnográfico realizado en el condado de Kilifi, Kenia, en 2021. Realizamos la observación de participantes en establecimientos de salud y comunidades vecinas, y entrevistas a profundidad con 21 mujeres jóvenes de 15 a 24 años que recibieron APA. Además, entrevistamos a 11 prestadores de servicios de salud reclutados de establecimientos de salud públicos y privados observados. Los hallazgos revelaron que no siempre se ofrecía a las pacientes consejería y métodos anticonceptivos postaborto como parte de la APA según lo prescrito en las directrices sobre APA. Cuando se ofrecía consejería anticonceptiva durante la APA, ciertas barreras afectaban la aceptación de los métodos, entre ellas información inadecuada, coerción por prestadores de servicios y parejas, y temores a los efectos secundarios. Juntos, estos factores contribuían a repetidos embarazos no deseados y repetidos abortos. Por ende, la ausencia de consejería anticonceptiva de calidad infringe el derecho a la salud de las niñas y mujeres jóvenes. Los hallazgos subrayan la necesidad de fortalecer las capacidades de los prestadores de servicios de salud para brindar consejería anticonceptiva durante la APA y abordar sus actitudes hacia las jóvenes pacientes de APA.

Keywords:

• post-abortion care
• contraceptive counselling
• reproductive coercion
• reproductive health rights
• adolescent girls
• family planning
• Kilifi
• Kenya

Acknowledgements

We would like to thank the girls, young women, and their families for taking the time to share their experiences. Many thanks to the facility managers and healthcare providers in the facilities and communities for their help during the entire period of fieldwork. We are grateful to the Kilifi County Department of Health for their assistance in community and health facilities entry, and their continued support during fieldwork and dissemination of the study findings. Author contributions: MKM and RO led the writing of the original draft of the manuscript and contributed equally to its development. MKM, RO, MB, and JB contributed to the writing and review of the manuscript. SW, MM, GK, and KJ contributed to the review of the manuscript. JB and RO contributed to the acquisition of the project funds. MKM RO, JB, GK, SW, JS, SU, and AA contributed to the formal analysis, methodology, and validation. MKM, JS, SU, AA, RO, and GK contributed to the investigation of the study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The research was conducted by APHRC, Rutgers and the Kilifi County Department of Health and was funded by the Dutch National Lottery under the She Makes Her Safe Choice Programme implemented by Rutgers and partners in Kenya, Ethiopia, and a selection of Francophone West African countries. From its inception, guidance was received from staff from various programme partners including RHNK, DKT, IPAS, and an anonymous partner. Additional writing time for RO and KJ was partially supported by a grant from the Swedish International Development Cooperation Agency, Sida Contribution No. 12103, for the APHRC Challenging the Politics of Social Exclusion project. None of the funders were involved in the research implementation and did not have a direct influence or steering role with regard to the research.