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

Introduction

In Kenya, access to abortion is subject to legal restrictions, as in many countries in sub-Saharan Africa. Consequently, unsafe abortion remains a major public health problem.¹ While Article 26 of the Constitution allows for abortion when “in the opinion of a trained health professional, there is need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other written law”,² the penal code is still used to reinforce the illegality of abortion (Sections 158-160).³ Thus, this tension between the constitution and the penal code creates confusion among providers on the legality of abortion in the country.⁴ This situation leads women and girls to resort to unsafe procedures to terminate unintended pregnancies.⁵ For instance, a study conducted in 2012 revealed that 464,000 induced abortions occurred in Kenya and the majority were unsafe.⁶ More than 157,000 women ended up with moderate to severe complications that needed medical care in health facilities, with severe complications of unsafe abortion found to be more common among adolescent girls.⁶ Unintended pregnancies are disproportionately higher among adolescents and young women due to poor access to, and use of, SRH information and services.⁷ As part of the Kenyan government’s ongoing commitments to address unsafe abortion-related morbidity and mortality, the Ministry of Health (MoH), developed the “Standards and Guidelines for Reducing Morbidity and Mortality from Unsafe Abortion” in 2012 that were to assist health professionals and actors to make informed decisions about abortion care including post-abortion care (PAC).⁸ Therewith, the Kenyan government committed to guaranteeing PAC to all women in need of the service. PAC has five components that consist of: treatment of abortion complications; provision of psychological counselling; provision of contraceptive services; community and service provider partnerships; referral to reproductive and other health services.⁹ However, in 2014 the MoH withdrew the Standards and Guidelines, which involved banning the training of medical providers on safe abortion services including PAC. The guidelines were reinstated in 2019 by a court ruling, which was then appealed by the MoH; the outcome of the appeal is yet to be concluded.¹⁰ By forbidding training and maintaining the dual legal status of abortion in Kenya, the MoH jeopardised women’s access to quality PAC including contraceptive counselling.^4,11

Contraceptive counselling and provision as part of PAC are aimed at helping women to prevent repeat unintended pregnancies and unsafe abortions.¹² As such comprehensive PAC goes beyond the treatment of abortion-related complications to include counselling on contraceptive methods and offer the client her preferred method before she exits the facility. Patients treated for complications related to abortions (whether induced or spontaneous) are expected to get contraceptive counselling and methods as part of the PAC package, as laid out in the Standards and Guidelines.¹³ More specifically, the 2019 PAC guidelines stipulate that comprehensive post-abortion care should include family planning counselling prior to discharge.¹⁴

Nevertheless, existing studies reveal significant gaps in PAC quality¹¹ including PAC contraceptive counselling.^15–17 For instance, a survey conducted in Kenya in 2020 found that less than half of PAC patients (40.8%) received post-abortion contraceptive counselling. This was attributed to several factors, including unavailability of counsellors or overstretched providers, untrained providers, lack of a dedicated room for PAC procedures, limited contraceptive commodities and supplies, and providers overlooking contraceptive counselling in cases where patients were young and/or unmarried.¹⁷ Prior studies have also reported instances where women declined contraceptive methods after counselling due to limited information received from providers, lack of financial resources, or the unavailability of the preferred methods of choice.^18,19 Indeed, contraceptives are not included in the National Health Insurance Fund (NHIF) or the funded free maternity programme (Linda Mama Programme). Therefore, women may have to pay for it out of pocket, hence, decline to use when they face financial constraints.¹⁸ Other studies have also analysed correlates of contraceptive uptake by patients and reported factors such as education level, marital status, history of abortion, perceptions of contraceptive methods as well as the fear of the side effects.^16,20,21

Building on these prior studies, this article, based on an ethnographic study, takes a deeper look into women’s perspectives on, and providers’ practices around, contraceptive counselling when treating PAC patients. Ultimately, our paper aims to answer the question: why do girls and young women treated for abortion complications leave the health facility without contraceptive counselling and methods? We focus on the experiences of adolescent girls and young women aged 15–24 who received post-abortion care following complications and their interactions with healthcare providers offering PAC in public and private health facilities. To better understand girls’ and young women’s experiences, the study also includes the perspectives of healthcare providers and community members.

Methods

Study site and population

The data are drawn from a six-month (January to July 2021) ethnographic study conducted in Kilifi County, Kenya. The county is mostly inhabited by the Mijikenda, Pokomo, and Bajuni who speak Swahili and other local languages. According to the 2014 Kenya Demographic and Health Survey,²² Kilifi County records high annual rates (21.8%) of teenage pregnancies compared to the national rate (18.1%). Many of these pregnancies are likely unintended, and may result in abortions. In addition, the county has an act²³ that is more restrictive on abortion than national laws. According to the act, safe termination of pregnancy by a trained healthcare provider is only permitted when there is need for emergency treatment.²⁴ Four public health facilities located in urban and rural areas were chosen for data collection based on the expected PAC caseloads: two referral facilities (Level 4 and Level 3) in the targeted sub-counties and two primary level facilities (Level 2) with the highest number of PAC cases according to the PAC reporting in the sub-county referral facilities. Within the same areas, we also observed abortion service delivery in four private health facilities. Finally, we also collected data from the surrounding communities through participant observation and focus group discussions.

The larger study targeted various participants, including girls and young women, their relatives, healthcare providers, and community members. This paper focuses on the experiences of girls aged 14–17 years and young women between 18 and 24 years who received post-abortion care following abortion complications, as well as health providers offering PAC in public and private health facilities.

Data collection approach and participants’ characteristics

Data collection involved both participant observation and in-depth interviews (IDIs) done by four trained female research assistants with backgrounds in anthropology (MKM, JS, AA) and sociology (SU). After five days of training, the research assistants conducted participant observation of PAC services provision, including contraceptive counselling sessions in the selected health facilities. Data gathering entailed deep immersion in the service delivery processes at the facilities and taking up supporting duties such as filling admission forms, assisting during Manual Vacuum Aspiration (MVA) procedures by holding the flashlight to visualise the cervix and engaging patients and providers in informal conversations during the procedure. This immersion facilitated the documentation of provider-patient interactions during PAC and the identification of potential participants for interviews. Once identified, the research assistants interacted with the girls and young women, and with their relatives and occasionally partners, at times visiting their homes and integrating into their everyday activities throughout the data collection period. In addition to these participants, we also identified other young women who had had an abortion in the past year within the target community through snowball sampling, community health volunteers (CHVs), and young people involved in reproductive health advocacy in the county. After receiving an in-depth briefing on the study and the ethical protocol, these key informants were asked if they knew someone with a recent abortion experience and if they were willing to reach out to that person for purposes of participation in the study, all whilst preserving confidentiality.

Within the communities, the research assistants involved themselves in the daily activities of the participants and followed up with them throughout the data collection period to establish trust and encourage them to open up about their experiences. This was to understand the lives of participants, as well as perspectives and factors driving their vulnerability towards unintended pregnancies and unsafe abortion. Furthermore, as part of the immersion, they were able to give guidance to the young girls and refer them to health facilities for reproductive health services.

In total, we engaged 21 girls and young women (12 recruited through the health facilities and 9 from the communities) during the six months. In addition to informal conversations, we conducted at least two in-depth interviews (IDI) with each of them. The interviews and informal conversations with girls and young women focused on understanding their experience with unintended pregnancy, the decision-making process, the abortion, and PAC services-seeking pathways and the impact it had on their lives. The initial and follow-up interviews were conducted mainly in Swahili, sometimes mixed with English.

In addition, we interviewed 11 healthcare providers recruited from the public and private health facilities under observation. Among the providers, seven were clinical officers, three were nurses, and one a medical-legal professional. Four of these providers were from primary public healthcare facilities, four were from referral level public facilities, and three were from private facilities. The interviews, informal conversations, and observations with providers focused on understanding their role in abortion and PAC service provision in Kilifi County, including their practices around post-abortion contraceptive counselling.

Data analysis and management

All interviews and focus group discussions were recorded after receiving the participants’ consent. Audio files were then transcribed verbatim and translated into English (where needed). Informal conversations were not recorded but captured through note taking, after the participant had consented to participate in the research. A coding scheme was developed and the data were analysed based on the initial protocol and tools, and also additional emergent themes that were coming from the data. The data were coded by three team members [SW, GK, AA] using Dedoose software. While coding, the team met weekly online to check for consistency in the coding, discuss emerging codes or duplication, and get feedback on coding sections they had doubts about.

Ethical considerations

The study team received ethical approval from the African Medical and Research Foundation (AMREF) Ethics and Scientific Review Committee (ESRC P909/2020 of December 4, 2020). We also obtained research clearance from the National Commission for Science, Technology, and Innovation (NACOSTI) (Ref No: 857259 of January 18, 2021). In addition, we received approval from the local administrative and health authorities to access the targeted communities and observe PAC services provision. Participants above the age of 18 years provided informed consent before their involvement in the study. Given the sensitivity of the issue and the risk involved in getting parental consent for minors (many girls terminate their pregnancy without their parent's knowledge), we requested and obtained waiver of parental consent. Therefore, all participants who were below 18 also gave their own consent. The research assistants were trained to take extra care to communicate the study processes, potential risks, benefits, and details of participation to the minors by using familiar language, to ensure comprehension, particularly of their right to decline to participate. All research assistants were extensively trained on the informed consent processes and to ensure confidentiality and privacy of all participants and information. For the observation of PAC services provision, we requested and obtained consent from both providers and patients before we were allowed in the treatment room. In this paper, the names of the girls and young women were replaced with pseudonyms to ensure confidentiality.

Results

The socio-demographic characteristics of the adolescent girls and young women interviewed in this study are summarised in Table 1.

Table 1. Sociodemographic characteristics of adolescents and young women interviewed

Characteristics	Frequency (N = 21)
Age (years)
14–17	4
18–19	5
20–24	10
25–30	2
Education level
Primary school	7
High school	11
College	3
Area of residence
Urban	6
Peri-urban	7
Rural	8
Marital status
Married/cohabiting	2
Separated	1
Never married	18
Occupation
Student	9
Employed/informal labourer*	8
Unemployed/housewife	4

*Hairdressers, house girls, bartender, shopkeepers, waitress.

Our findings shed light on the various factors contributing to girls’ and young women's use (or non-use) of contraceptives after being treated for post-abortion complications. The results section will focus on describing providers’ practices towards contraceptive counselling, or the absence thereof, and how that influenced girls’ and young women’s decision-making on whether or not to use contraceptives and which method to use. We structured our results along patients’ counselling journeys, from receiving counselling (or not), to the quality of it, to decision-making about methods, and lastly to obtaining a method. The results also shed light on the accessibility of contraceptive methods within the facility settings, and the role of male partners and parents in the decision-making process.

Absence or poor quality of contraceptive counselling after PAC

The following vignette describes a typical situation of PAC provision and patient-provider interactions. It provides insights into one of the reasons why counselling on contraceptive use did not always happen.

“ … The procedure was challenging and it took longer than usual. Dr. K was concerned and said ‘This one today is complicated’. The young woman was crying in pain and I could see she was feeling pain, there was a lot of inserting and removing the cannula. … When Dr. K was done, he asked nurse M to help him clean up as he was needed at the theater immediately. He asked M to fill in the PAC register and to prescribe antibiotics to the patient … . The patient was sent to speak to the medical legal doctor and then she left the facility.” (Observation notes, level 3, Public facility, Peri-urban setting)

Here, the provider was busy dealing with a difficult MVA procedure, and immediately after he was done, he had to hand over the patient to his colleague and rush to attend to another patient. As a result, the contraceptive counselling did not take place and the patient left the facility without taking up any of the available methods. Our findings point to lack of contraceptive counselling, or inadequate counselling sessions, as well as factors that explain the absence of (quality) counselling, including workload and lack of training.

Only four healthcare providers in our sample of 11, including nurses, clinical officers, and medical officers, reported having received on-the-job PAC training, in addition to the basic training while still in school. The training was carried out by various organisations, such as Ipas and Reproductive Health Network Kenya (RHNK), and focused, among others, on how to integrate contraceptive counselling into PAC service provision. Ideally, during counselling, the patients would be told about the different reasons why they might need to use contraceptives, the types of contraceptive methods available, and possible side effects, among other information. The patients would then choose the type of method they preferred, which would then be offered to them.

“So, in terms of choice of family planning, we usually educate them. We tell them the type of contraception that we have. We explain the methods. So it is up to them to make an informed decision and decide which kind of family planning they want to use.” (Provider primary facility, rural setting)

For women who expressed the desire for another pregnancy, for instance, providers would advise the patient to use contraception in order to “rest” for about six months before getting pregnant again to allow them to heal, and “safely” carry another pregnancy:

“We offer family planning depending on the client's choice. Others might have aborted but she needs a child. When you tell her about family planning, she might not agree. But you can advise her on the benefits. You tell her that she needs to rest for some months before she gets another child.” (Provider, primary facility, rural setting)

In the case of induced abortion, they would explain to the patient the need to use contraceptives to avoid another unplanned pregnancy and risking their lives in the case of needing to resort to unsafe abortion:

“Normally for spontaneous abortion, we just give antibiotics and painkillers because the process is over. Then we do counselling for either family planning or such things. Okay. Normally, if it is post abortal, somebody has attempted, we normally do the management, the pharmacological management of the condition, then sometimes we sit down with them, we talk and do some counselling and then tell them if they can opt for family planning so that they don’t enter into the mix again.” (Provider, private facility, rural setting)

However, during the observations of PAC sessions, we noted that the content and the depth of information shared during contraceptive counselling conversations varied from provider to provider. In some instances, the healthcare provider would just tell them “not to get pregnant” in the coming months, while in other cases, some patients would just be asked whether they would “be interested in using family planning”. This was without any prior discussion on the matter nor any additional information on the type of methods available or offered. Even though some PAC patients still managed to decide on a method based on their prior knowledge, we later see how the limited information in some instances hinders girls and young women from making an informed decision on using a method following PAC.

Sometimes the counselling sessions happened after the treatment was completed, and in other cases, the counselling was done as the patient was undergoing the MVA procedure. This was the case of a 19-year-old student whom the provider decided to talk to about contraceptives while she was experiencing intense pain due to the MVA procedure and enduring verbal abuse from providers because she was not “cooperating”. This situation was not conducive for her to decide on using a contraceptive method and the girl eventually rejected the methods as she said it would increase her urge to have sex.

Findings also show that in most cases, the advice given during contraceptive counselling was tailored depending on the attributes of the woman. For instance, some young women would be advised to abstain and not to use contraceptives as it would make them age quickly or become promiscuous. Sometimes they would be advised to use short-term methods since long-term methods were considered more suitable for older and married women. On the other hand, students would be advised to take long-term methods so that they could avoid pregnancy and complete their studies. While some providers managed to offer counselling (see summary in Table 2), albeit the quality was lacking, others did not offer such services when treating patients for abortion complications. In total, 8 out of the 21 research participants did not receive any contraceptive counselling after they were treated for abortion-related complications in the public health facilities as shown in Table 3.

Table 2. Participants who received counselling and outcomes of the counselling

Facility type	Cases	Ages	PAC method	Contraceptive outcomes
Level 2	3	21, 21,29	All MVA	Rejected method as she said she didn't understand how they help
				Husband refused
				Rejected methods as she decided she would abstain until she get married
Level 3	5	18, 19, 20, 20, 21	MVA and one MA	Rejected as she said she won’t see men any more
				No method offered, Told to continue with current one (3-month injection)
				Decided to go home and think about it and did not go back
				Did not take it because she wanted to get pregnant again.
				Three months injection
Level 4	5	17, 19, 20, 23, 24	All MVA	Decided to use condom
				Rejected it as she says it will give her the urge to have sex.
				Decided to wait for 2 weeks and did not go back for the method
				Rejected saying she will use condoms as contraceptive
				Five-year implant

Source: See Appendix for individualised information on the counselling status.

Table 3. Participants who did not receive counselling

Facility type	Cases	Ages	PAC method	Contraceptive method
Level 2	1	30	MVA	None
Level 3	2	16	All MVA	None
		18
Level 4	4	14	MVA and one MA	None
		19
		20
		20
Private	1	16	MVA	None

Source: See Appendix for individualised information on the counselling status.

Those who did not receive the counselling were mostly younger women and this could be explained by the fact that most providers believed that contraceptives were more appropriate for older married women. As illustrated in the quote below:

He says: “It depends on the patient, we give what the patient wants, but for those who are not married, I wouldn’t recommend it. She will look like an old woman when she starts to use family planning. If you are not married, then you should not be there, you should not be with boys, you will do that when you are married. When you use family planning you age quickly and your husband might want to get another girl, if you start using it early, you will get old even before you get married.” (Observation notes, 20-year-old, single, manual worker, urban setting)

In some cases, participants reported that the lack of counselling was due to the providers’ high workload and the need for them to urgently attend to other patients. For instance, in the case captured in the opening vignette of this section, the provider was the only one on duty that day. After the procedure, he hurriedly left and was unable to counsel the girl. The patient was subsequently discharged by the nurse without receiving any counselling about contraceptive use. Since the PAC guidelines do not clearly state at which stage the counselling is supposed to happen, this is left to the discretion of the providers. Some would do it during the procedure, while other providers did so at the end of the procedure (while prescribing other drugs for instance), and others did not offer it at all. Sometimes their busy schedule or the patient’s condition would prompt providers to postpone the contraceptive counselling and recommend a follow-up visit, which was usually two weeks after the PAC services. However, some patients did not make it to the facilities for the follow-up consultation and would thus miss the chance to receive contraceptive counselling.

Some providers reported not being aware that counselling was supposed to be offered as part of the PAC package. During a conversation with one of the researchers, a provider from a referral level facility reported that he was not aware that contraceptives are part of PAC. Instead, he would send the women to the family planning clinic to get counselling and methods.

Cases of maltreatment and lack of information

After adolescent girls and young women received counselling, they had to make a decision on whether or not to use contraceptives and the specific method to use following their abortion. Among the 13 patients who received counselling, 4 agreed to use contraceptives, and 9 declined to use them (as highlighted in Table 2). Many adolescent girls reported that they declined to use contraceptives after they were counselled by providers. One of the reasons was the difficult interactions with providers. Some girls felt mistreated and abused by providers and therefore felt they could not trust them, nor accept their advice on contraceptive use, especially when they had reservations about the side effects. In other cases, the counselling was done during the painful MVA procedure and was also marred with harsh language. Consequently, girls reported that they would not listen to information provided by health workers, which could have given them additional information to quell their fears on the use of contraceptives. Moreover, some thought of fleeing the facilities to avoid unpleasant interactions (i.e. cases 201 and 202 in Appendix).

In addition to being handled harshly, some participants reported that they did not get enough information about the methods to make informed decisions, as highlighted in these quotes:

“I was advised to use family planning if I do not want to get pregnant because they are available in the facility. But I did not choose to use (it) because I do not know what they help … Because I do not have proper information on which method to use.” (21-year-old, single, secondary student, rural setting)

“I was not given any counselling on family planning, but the doctor told me not to get pregnant up to seven months” (23-year-old, single, sex worker, urban setting)

As highlighted in the quotes above, some were either told just to avoid getting pregnant without any additional information on how this could be done, or to use family planning without further details on which methods they could use (as reported earlier). Yet, those participants explained that they would have loved to get more information on the type of methods available, how they work, their potential effects on the body and their fertility (especially as young women expected to have children at later time in their life when they get married) and if it would affect their sex life (fear of “getting cold” or “becoming promiscuous”). The lack of detailed information, combined with the fear of the contraceptive side effects that they had experienced or heard about from other women in the community, made them decline the proposition of using contraceptives.

“As we talk, I ask her why she doesn’t want any contraception, then she says the patch made her bleed for three weeks when she had it, then a woman she knows had the coil and it got lost in her body, the injections also make her fat that is what she says.” (Observation notes, 17-year-old, single, high school student, urban setting)

Beyond the health system: when spousal power dynamics and the fear of side effects affect contraceptive acceptance

Some women did not accept contraceptives after PAC because they needed to consult with their husbands/partners before making a decision. Indeed, this was the case especially for those who were married or cohabiting. They explained that they did not have the autonomy to decide on the use of contraceptives and felt they had to consult with their husbands before deciding. One of the participants cited that she had to consult her partner as in the Giriama community, women cannot make a decision on serious matters, such as contraceptive use, without their husbands’ permission. Even though she was accompanied by her uncle’s wife, the two women still could not make the decision.

I asked her if she had already been given family planning counselling and she told me, “I still haven't talked to my husband about that and I can't decide on my own”. I asked her if she ever used family planning and she told me, “I was using the 3-year implant but I decided to remove it after two years and some months since I had constant headaches, body aches, and too much bleeding”.[…] She introduced me to her aunty who looked as young as she was. I explained to the aunty the patient’s situation and that the doctor would advise her about family planning. She told me, “Call my nephew first because most Giriama men do not allow us, women, to make such decisions for ourselves”. (Observation notes, 23-year-old, married, casual worker, rural setting)

In such cases, the patients would request to consult their partner at home before coming back to take up a method. However, some ended up not returning because they were not able to get permission from their partner or they were reminded by their partner, relatives, or friends, of the challenges they went through (or others’ experiences) when they used contraceptives.

“She even told me to go back to be given the implant, but since I was not interested I didn’t want to listen, because my mother told me not to be cheated, and I don’t want to get fat.” (23-year-old, single, college student, urban setting)

The patient’s mother associated the advice on contraceptive use with “lies” or misinformation; girls would not be told about the side effects, and would end up getting fat, bleeding, or becoming infertile. Given that the counselling is not always client-centred (i.e. respectful, focused on the client's needs and allowing friendly conversation) and does not provide a friendly avenue for girls to ask questions and eliminate their fears, once at home, they cannot contest such advice from their close relatives. Moreover, one of the participants who needed to consult her husband decided not to come back because she did not like the disrespectful manner in which the providers spoke to her during the procedure:

“I was not happy. Honestly, the words that displeased me were about him (the provider) saying that I need to cooperate like I was during sex, it is the implication of the sweet sex I had. Then the nurse told me to use a family planning injection. She told me the dangers of getting pregnant again in the near future saying that I might end up losing it again and so it was up to my health, not my husband’s. It is not that I didn’t want it but I just wanted to consult my husband first so that I can accept.” (21-year-old, married, housewife, rural setting)

Covertly, some women did decide to take contraceptives without the knowledge of their spouses since they wanted to prevent unintended pregnancy and/or repeat abortions even though their partners were against contraceptives. For instance, they would choose to use methods that could be taken discreetly, avoiding their partners finding out, as illustrated in the quote below:

“He [the partner] said that he does not like them (the contraceptive methods) and that they make a woman ‘cold’ and come with some complications. But after the abortion incident I have been thinking about ways to avoid a repeat of it and so until recently I decided to go with my friend to the dispensary to go get a three-month injection plan which he does not know and I will not tell him.” (18-year-old, single, primary school student, rural setting)

As highlighted in the quote, this participant initially declined to use the contraceptive after she received PAC, out of fear of her partner's reaction and the potential complications that he mentioned. However, she ultimately visited another facility to get a method that she was covertly using when we met with her.

Some girls and/or their partners (after they consulted with them) also wondered why they are told of “family planning” and yet they do not have any children or family to plan.

“He told me not to involve myself with contraceptives because they are for family planning. You see? For me or him we had no family we were planning. He did not like them because they had their side effects. I told him those are the implants but I don’t think condoms have those (side effects).” (20-year-old, single, college student, urban setting)

Given that most providers use the concept of “family planning” when engaging with adolescents and young people, as well as the perceptions around contraceptives being for married people with children, they felt that it was not meant for them. Finally, other girls decided to refuse the use of contraceptives as they felt they would be engaging in more sex since they know they will not get pregnant.

“I don’t want family planning”, she responds, when the doctor asks her why she doesn’t want family planning, she keeps quiet, but when I ask her, she says it is because she doesn’t want to have the urge to have sex if she uses it she will have the urge to have sex. (Observation notes, 19-year-old, single, high school student, urban setting)

Factors supporting contraceptive uptake after PAC

Unlike these participants, a few immediately made up their minds about using contraceptives after their counselling. Their decision was mainly guided by the need to avoid a repeat unplanned pregnancy and having to go through an abortion and PAC procedure again, especially the pain, fear of disclosure, and maltreatment by providers. This was the case of Rukia, aged 19, whose abortion process using abortion pills was very painful and stressful. Rukia experienced complications, and this contributed to her relatives discovering that she had an abortion, and she was consequently blamed for it. During PAC, she reported intense pain when going through the MVA process, without experiencing any empathy from the providers. Despite her counselling being “poorly done” (providers threatened her and talked to her badly), she decided to use contraceptives to avoid going through a similar hustle again.

Many girls also wanted to give themselves time to accomplish their life goals, for example, some wanted to go back to school and complete their studies, some wanted to get a good job (i.e. some dreamed of travelling to Middle East countries for better opportunities) and some were hoping to find a man ready to engage and marry them. A case in point is Raha, who already had one child, and then went through an abortion experience. She decided to start using contraceptives after receiving the counselling. Raha indicated that she would continue to do so until she would get a partner who would be “good enough” for her:

“I saw the men were just making me pregnant and going away, so I said until I find someone who is good enough, I will not get pregnant. So I took the sindano (expression used to refer to implant) injection for five years.” (20-year-old, single, casual labourer, urban setting)

Contraceptives were therefore seen as a means to avoiding the same mistakes, giving oneself a second chance, and dealing with the unpredictability of sexual intercourse in their relationships. Another reason pushing young women to be receptive to contraceptive use was the desire to stop having children.

“Right now I don’t want other children. The ones I have are enough, it is even hard to take care of them.” She says. I ask her what the husband says. “My husband is also okay, he doesn’t want any other children. Children are very costly.” she says. (Observation notes, 32-year-old, married, stay home mum, urban setting)

For two participants who had not previously used contraceptives for fear of side effects, the counselling they received provided the opportunity to get additional information that helped counter those fears. They initially feared using contraceptives, following the story of a woman who suffered from stomach cancer and the community members attributed it to the use of contraceptives. They both explained that during the counselling session, they got a chance to ask questions about their fears and gained clarity about the use of contraceptives, and then decided to use the three-month injection.

Decision-making on which method to use

After they accepted to use a method, the young women also went through a decision-making process regarding which method they could use. On these paths, women were guided by the accessibility/convenience of the methods. Students, for instance, said they preferred long-term methods such as implants that would allow them to complete their studies. In addition, such long-term methods would prevent them from frequent visits to health facilities, together with the challenges and financial implications that could come with such visits (i.e. cost, lack of time, risk of stigma by adults they are likely to meet or providers). However, while some girls wanted to use long-term methods, the findings show that providers ended up influencing or convincing them to use an alternative method. A case in point is that of a 26-year-old patient, Kadzo, who had three children and was not married. Kadzo requested a sterilisation but the provider did not agree, as we see below:

She (the doctor) tells her of the implant, the coil, the injection, and the pills. […] The patient listens keenly and says she doesn’t want children anymore, so she wanted the method for those who don’t want kids anymore (meaning sterilization). Then the doctor asks for her age, “at 26 we can’t do sterilization for you, you are too young for that” she tells Kadzo. […] Kadzo says she is supposed to leave the country and go to Saudi Arabia to work for two years, so she doesn’t want any children. (Observation notes, referral level facility, urban setting)

The provider later explained that the community did not understand that the sterilisation procedure was permanent since in their local language it was referred to as “kupendua kizazi” (to turn the womb upside down) and they thought it was reversible. Although this refusal to conduct a sterilisation could appear as a good gesture from the provider since he was trying to offer all the information for the patient to be able to make the right decision about contraceptives, it did not meet Kadzo's needs, and she ended up leaving the facility without a contraceptive method. In other cases, some providers would discourage the young girls from using intrauterine devices (IUD) and implants citing that they had adverse effects on their bodies (namely getting infertile, over-bleeding) or that they were meant for married women, as captured in the quote below:

“That nurse has explained to us about family planning. She said that for five years they insert it on the arm and also for three years. But she told us not to use them because they are long-term. She said they are to be used by grownups who already have children and do not want to get more anytime soon. So she told us to use the pills or the 3-month injection. So we decided to use the injection because where will we put the pills at home? You will find the parents will know or people will see you taking pills every day and wonder if you have HIV.” (19-year-old, single, primary school student, rural setting)

In most cases, unmarried girls were advised to use either the everyday pill or the three-month injection. However, while following up on those girls who left the facility with short-term methods, we found out that some of them ended up discontinuing the use of these methods for various reasons including the challenges involved in using and accessing such methods as explained by the girl above. While she chose to use injectables to avoid the challenges related to the use of pills, she finally had to stop using them because they required frequent visits to the facility with many implications, such as finding time as a student to visit the facility. Others were also convinced by people in their network to stop the use because of occurrence of side effects.

“Currently, I came for the three months injections but after the three months, I will not come for a repeat because I was told that they are not good for use especially for young girls since when you get married you will experience difficulties when trying to get pregnant.” (16-year-old, single, primary school student, rural setting)

This shows that post-abortion contraceptive counselling and the coercion of girls to use a particular method had only temporary effects on contraceptive uptake since girls would later stop using the methods they were given. We also found other forms of coercion in the choice of methods whereby parents (in collaboration with providers) decided on behalf of the girls and young women. In the case below, the decision to use the implant was made by the young woman’s parents and the provider who happened to be close to the family. Together, they chose for her the implant so that she could return to school and complete it without getting pregnant.

“After they (providers) removed it (the pregnancy), they put one for me, for five years, so they (provider and parents) told me they will put it for me so that I (can) go back to school.” (24-year-old, single, manual worker, urban setting)

While in some cases, the parents used to be generally against the use of contraceptives for fear that the daughter would become promiscuous, they only changed their mind once the girl got pregnant and aborted. This situation made them become open to contraceptives, to the extent of not giving their daughter any other option, in order to avoid new “mistakes” that could also tarnish their own reputation. In situations where the providers are relatives or close friends of the family, and share the same perceptions on contraceptive use, they would sometimes suggest that the girls use long-term methods to avoid pregnancy which is contrary to what they would do with their other young patients.

Gaps in the accessibility of contraceptive methods

The interviews and field notes also provided insights on the access to contraceptives once the girls’ and young women’s minds were settled on which method to use. Overall, contraceptive methods were offered to the PAC patients at no cost in the public health facilities observed, regardless of the type of methods received by the participants. Looking at the locations where the patients would get the method, we found out that in one of the level 4 facilities that had a specific room for the MVA procedure, contraceptive counselling, and methods were reported to be offered in the same room.

“In cases of post-abortive contraception, we do not give them here (the family planning clinic located in the facility), we only give them to people who have come here themselves. The post-abortive family planning is given in the MVA room when the MVA is finished.” (Provider, level 4 hospital, urban setting)

According to this provider, this is meant to increase the likelihood of patients leaving the facility with a method. However, during our observation in this setting, we noticed that some patients after receiving the counselling were referred to the family planning clinic within the facility, due to the absence of some preferred methods in the PAC room. In one of the primary level facilities, both counselling and provision of injectables were offered in the same room where babies were being delivered, and patients requiring all other types of methods such as implants or pills would be sent to the Maternal and Child Health (MCH) clinic where contraceptives are provided. In both the level 3 and the second level 2 facilities, the PAC procedures and contraceptive methods were offered in different locations. For instance, in the level 3 facility, the PAC was done at the casualty area and afterward, the girls would be sent to the family planning clinic which was in the MCH clinic.

In facilities where contraceptive services were offered in different locations, some patients did not follow up due to various reasons such as fear of disclosure, stigma (since they were young), or the likelihood that they would meet someone who knew them. It was also observed that the patients who came for PAC services at night, were asked to come back to the facility during the day for contraceptive counselling and methods as it was only offered during the day. Even during the day, it was observed in one of the level 2 facilities that contraception services were offered mostly during the morning hours. When they needed to receive these services in the afternoon, the patients would have to wait until the nurse was available or come back the next day.

In one of the cases, after the patient chose the three-month injection, the doctor informed her that they could not give her the injection immediately as she had to recover first from the PAC offered. She then left the facility without any methods and yet she had expressed an interest in having contraceptives, as explained below:

The patient then says she wants the three-month injection, “we cannot give you now, you have to go home and rest and recover then you will go to the clinic to be given after two weeks, it is free”, the doctor answers. (Observation notes, referral level facility, urban setting)

Consequences of poor or absent contraceptive counselling after PAC

As a consequence of these missed opportunities, namely lack of counselling or poorly done counselling (as described above), some girls and young women did not take up contraceptive methods or disrupted their use, leading to repeat unplanned pregnancies. Among the 21 cases that received PAC, four got pregnant again by the time the study team left the field after six months of immersion. Tunda, a 20-year-old casual worker, is one of them. After she experienced complications following an incomplete abortion through a combination of medical abortion pills and shubiri (a traditional bitter medicine), she was taken to a healthcare facility for PAC where she was given some medicines to “clean the womb”. The doctor then advised her on family planning but she rejected it and left the facility without the contraceptives.

“He (provider) told me to put the thing (injection) for three months, maybe it might help me. I told him to leave alone helping me because of the heartbreak that I have got. I don't see if I'll continue with this life of relationship. I have already given up, let me just stay that way […] I told him ‘let me go and think, then I will be back’ and I have not yet gone back.” (20-year-old, single, hairdresser, peri-urban setting)

About a month after our meeting (two weeks after receiving PAC), Tunda informed us that she had gotten into a new relationship and since she was not using any contraceptives, she got pregnant again and had to flee her parents’ home for her grandmother's place. Although she was not expecting to be pregnant again so soon, she decided to keep the pregnancy to avoid another abortion and partly because the new boyfriend had promised to marry her. So, Tunda got pregnant just the month following her abortion complication and the refusal of contraceptive methods. Like Tunda, two other participants also decided to keep their pregnancy, while the fourth girl, Dama – a 23-year old-sex worker – reported experiencing a repeat abortion. After declining to use contraceptives during PAC counselling, she became pregnant again almost immediately after and felt she had to terminate the pregnancy.

Discussion

Our study examines the reasons why some girls and young women treated for abortion complications left the health facility without contraceptive counselling and methods or sometimes discontinued their use once they got back home. In the analysis of our findings, we emphasise the individual, societal, and structural factors as well as the fact that most women’s and girls’ reproductive rights are not being met in the current situation, which may be considered a form of reproductive injustice.²⁵ Our findings show that post-abortion contraceptive counselling was not always offered to PAC patients, and when it was offered limited information was provided and providers failed to address women’s concerns about contraceptive side effects. The physical (environment) and interpersonal (communication) context in which counselling was provided was often not conducive to sustained contraceptive uptake either. Furthermore, we found that relatives of young women (i.e. parents or their partners) play an important role in the PAC contraceptive uptake, and tend to take advantage of the prevailing power imbalance to coerce girls and young women to accept, decline, or discontinue contraceptive use, which can be considered a form of reproductive coercion. Underneath the above-mentioned obstacles to post-abortion contraceptive uptake are the broad structural factors that we analysed. These factors include the limited training providers had received on comprehensive PAC, limited staffing, and the stigma around abortion and contraceptive use by young and unmarried women. Altogether, within the timespan of our study (six months), the above-mentioned factors led to four new unintended pregnancies after PAC.

We found that the lack of (or ineffective) counselling after PAC was due to the heavy workload of providers,¹¹ as well as their limited understanding of the necessity and importance of such timely contraceptive counselling. The latter could be attributed to the fact that there was a big gap in training from 2013 after the withdrawal of the Standards and Guidelines by the MoH which meant that the providers were not allowed to be trained on the same.⁴ This meant that most women who were treated for PAC missed the opportunity to get contraceptives while exiting the health facilities. These findings concur with other studies done in some African countries and the Dominican Republic where there was insufficient PAC contraceptive counselling.^15,16,21,26 The 2018–2019 quality of PAC study in Kenya found that 60% of PAC patients did not receive any contraceptive counselling, and the reasons were quite similar to those highlighted in this study.¹⁷ Moreover, our findings suggest that the lack of dedicated PAC providers is a key factor for women exiting health facilities without counselling, since most providers have multiple tasks. Equipping facilities with dedicated medical staff who are trained on PAC provision can help curb the poor counselling and provision of contraceptive methods.

Where counselling was provided to patients, our findings show that the context and timing was not conducive to patients being receptive to the counselling (i.e. counselling was done during painful MVA procedures or in a tense provider-patient interaction due to stigma) leading to low contraceptive acceptance and uptake by women as noted in other studies.^27,28 The tension in the patient-provider interaction left patients with limited information to make informed choices on which methods to use. Since they were hardly given the chance, or were afraid to ask questions, they especially lacked information that could have helped them overcome the locally prevailing fears of modern contraceptive side effects. Hence even if they left with a method, these persistent fears and the negative feedback from people close to the women would discourage method continuation after counselling.^29,30 Contraceptive counselling and uptake also had limited success when it was done during the (sometimes very painful) MVA procedures, as our observational data shows. Providers are left to decide when to do the counselling because the PAC guidelines do not highlight the appropriate time for counselling. Thus it is important to organise training that would help explain the appropriate ways to offer PAC counselling and improve provider-patient interactions.

Providers tailored the contraceptive counselling depending on women's attributes (married, single, young, or older) and sometimes their acquaintance with patients. In most instances, such behaviours were influenced by gender norms and power imbalances in patient-provider interaction, leading the latter to consider girls and young women as social cadets who are unable to make appropriate decisions, and for whom men, caregivers and social elders must decide on their behalf and for their good. As shown in a systematic review, these gender biases and discrimination can affect the patient and provider interaction and result in health inequities that can affect “individual health-seeking behaviour, access to good quality healthcare, and, ultimately, health outcomes”.³¹ In our study, the tailored contraceptive counselling led to the young girls being steered towards specific methods, especially short-term methods, since providers viewed the long-term methods to be more suited for older married women. Although it was not focused only on young unmarried women, another study that analysed contraceptive uptake after PAC in Kenya, also found that most participants after PAC were offered short-term methods rather than long-term methods.¹⁷ In our study, going home with a method that was not their own choice contributed to discontinuing the method thus increasing the risk of repeat unintended pregnancies. Access to a wide variety of contraceptive methods after counselling is important to ensure women and girls get their preferred method.³²

The biased forms of contraceptive counselling practices and interactions can furthermore be understood as a form of contraceptive coercion that comes from providers, partners, and community. Contraceptive coercion occurs when providers or partners interfere in women’s decision-making on contraceptive use.^33,34 This presents in various forms including providers convincing women to accept a particular method and their refusal to discontinue long-term methods such as implants or IUDs;³³ men destroying the contraceptives or forcefully bringing back their partners to the clinic to remove methods; and male partners getting angry with their female partners for using contraception and either insisting or using threats to get them to stop using contraception.³⁴ Contraceptive coercion, a form of reproductive coercion,³⁵ in our findings, took place through the provision of biased counselling, with varying content depending on women's attributes, and/or convincing or refusing a women to choose a particular method just as it was found in other studies.^19,33 This coercion was sometimes done in collaboration with parents who decided on the particular method on behalf of their daughters. Reproductive coercion was also revealed through male partners’ influence on PAC contraceptive uptake in cases where women requested to go back home and consult with their partners first. Many of them ended up not returning to the facility. While we do not know their reasons for not returning, some may not have returned because the partner refused their use of contraceptives, which was the case in a study conducted in Nairobi, Kenya.³⁴ Negative attitudes from providers may also have contributed to some patients not returning. This evidence of reproductive coercion in the PAC setting suggests that counselling was not patient-centred, but that information and choice gravitated towards those in more powerful positions (providers/ parents/ partners) and hence reflected the strong patriarchal structures in place. These structures prioritise control over women’s bodies and reproductive abilities by men and society and sanction women’s individual choices. In the case of partner refusal, women sometimes resort to the covert use of contraceptive methods to prevent pregnancies.^36–38 Continuation of covert contraceptive use has, however, proved to be challenging due to the difficulty to conceal use and possible side effects, obtaining money for continued contraceptive use and risk of violence at discovery.³⁹

The fear of side effects (such as infertility) and stigma around contraceptive use by girls and young women contributed to them rejecting contraceptive use despite having terminated an unintended pregnancy. This concurs with the findings from other studies in several African countries which showed how women’s previous experiences with, and/or rumours about side effects (such as heavy bleeding, weight gain, reduced libido, infertility) prevent them from taking up contraceptive services.^40–42 Regarding infertility more specifically, an earlier study conducted within the same setting reported that women feared using contraceptives because they wanted to avoid the social stigma of not having children when they eventually get married.³⁰ Indeed, in a context where childbearing is not just a social role for women but a status symbol, womanhood is usually expressed and confirmed through maternity. Consequently, girls and young women take extra precautions to protect their ability to have children when they eventually get married, including declining contraceptives or methods if they are perceived as a threat to their fertility.^30,43 A study conducted in 10 countries in Asia and sub-Saharan Africa showed that adolescents and young women were significantly less likely to choose a long-acting, reversible contraceptive than those ages 25 or older; among other reasons were the non-suitability of such methods with their age and the fear of infertility.⁴⁴ While quality counselling could have addressed these fears, the insufficient information provided during PAC and the attitudes of providers toward girls and young women, were not helpful. This, again, could be seen as not providing “patient-centred care”, which infringes on the right to reproductive health information.¹¹

While other studies highlighted the role that parity, the level of education or income played in contraceptives uptake,^45–47 our study underscores the quality of counselling, potential coercion, and availability of methods as factors that influenced contraceptive uptake or refusal. To deal with this, it is important for providers to tailor their communication to women’s specific needs to reduce scepticism about family planning methods.⁴⁸ An evaluation study in Togo showed how changes in the adaptation of counselling to a specific context led to a significant increase in the number of women receiving contraceptive counselling and acceptance of methods after PAC.⁴⁹ This was achieved by reorganising services to ensure that contraceptives are provided at the point of treatment for abortion complications, before PAC clients are discharged; improving provider competencies in family planning services, including in providing long-acting reversible contraceptive implants and intrauterine devices; ensuring that contraceptive methods are available to all PAC clients free of charge; standardising PAC registers and enhancing data collection and reporting systems; internal supervision systems at facilities and teamwork among PAC providers; and engaging PAC providers in community talks.⁴⁹ Similar and adapted client-centred approaches could be applied to the Kenyan context to improve acceptance and use of contraceptives following post-abortion care.

For girls and women who were eager to use contraceptives, our findings show the absence of contraceptive methods (or the woman’s method of choice) in the area where PAC was provided led to patients leaving without the methods. In such cases, patients were requested to go to a different ward or unit to receive their method of choice, as was also evidenced by other studies.²⁶ However, some of these patients just left the facility because they feared being seen walking within the facility premises, especially particular units or departments which may raise suspicions about their abortion and lead to disclosure. Also, because of the poor interactions with providers, some girls were in a hurry to leave the facility.

The findings of this research, with four research participants facing a new unintended pregnancy quickly after receiving PAC, imply that providing quality contraceptive counselling is key to preventing repeat unintended pregnancies. As this study equally reveals, providing true patient-centred care came with many challenges. The workload affecting providers and the legal, social and policy context in which they operate limit providers’ availability (time), skills (lack of training), and attitudes (fear of stigma/ fear of encouraging adolescent sexuality) to provide patient-centred contraceptive counselling.¹¹ Societal norms also attach limited value to the need for SRH information and contraceptive services for girls and young women, fearing their promiscuity and infertility when they would take up contraceptives.⁵⁰ Without relevant information, decision-making power is withheld from these girls and young women, their right to reproductive health is denied with grave social, health, and economic consequences for them and their (future) families, such as repeat unintended pregnancy, school drop-out, forced marriage as a result of unintended pregnancies, and unsafe abortion leading to complications and exposure to stigma, among others.^48,51–54 To do justice to girls’ and young women’s reproductive rights requires more effort from the Ministry of Health; there is a need for greater investment in the prevention of unintended pregnancies, the training of health service providers on SRHR and PAC (including a gender-transformative approach and a special focus on youth – friendliness of services), and provision of a curriculum on comprehensive SRHR for adolescents and awareness campaigns on SRH nationwide.⁵⁵

Strengths and limitations of the research

The strength of this research lies in the unique data that was obtained during the extensive and repeated observations that the researchers were allowed to make during PAC service provision. The time spent in the research setting (six months) allowed for regular follow-up with girls and young women recruited into the research. This provided unique insights into what happened after the contraceptive counselling took place, including negotiations with partners at home, uptake, and sometimes discontinuation of methods, and the occurrence of repeat pregnancies.

Limitations stem from the fact that the study was conducted during a specific period; after the Ministry of Health reinstated the PAC guidelines in 2019 but before PAC training was rolled out on a large scale in Kilifi County. When this will happen is uncertain due to the MoH’s appeal to the High Court’s decision. Even if the training will be rolled out, we are not sure what kind of change this will have on the quality of contraceptive counselling provided to adolescent girls and young women. We do expect that some of the barriers to contraceptive uptake described in this article will remain even if training is widely rolled out as these barriers require more systemic change to be resolved. Since the study interviewed a small number of participants in a selected number of public health facilities, we cannot claim generalisability of the findings to all PAC clients. It is also possible that there was a modification of behaviour by the health workers and participants in this study when they knew they were being observed, although our extended observations in the clinical setting and the nature and variety of our findings suggest that this effect is limited.

Conclusion

Our ethnographic study offers insights into factors leading to PAC patients in Kilifi County exiting health facilities without contraceptive methods. This is a key public health problem as it increases the risk of girls and young women experiencing repeat unintended pregnancies and repeat (often unsafe) abortions. The latter have a great impact on the health and life of girls and young women as well as on resources in the health system in Kenya. The factors identified were both at the individual (fear of side effects), societal (stigma on girls who use contraceptives and who abort, interpersonal power dynamics), and structural levels (health facilities’ preparedness to offer PAC, policies withdrawn, and contradictory laws). Together, these factors led to women either missing counselling completely or missing out on the opportunity to leave the health centre with a suitable method. Hence this research shows how women’s reproductive rights, enshrined in the Kenyan constitution, are infringed upon in the everyday practice of the incomplete provision of PAC.

The findings imply the need to rethink the content of PAC counselling and the manner in which the sessions are done to reduce the coercion at play and increase the likelihood of PAC patients getting patient-centred care that will allow them to make informed and fitting choices with regard to contraceptives. Adapting counselling to women's realities (especially their specific fears about the use of contraceptive methods, stigma, and home-level coercion) and improving the quality of provider–patient interactions could lead to better results. Similarly, PAC training should be rolled out much more extensively and systematically. Availing all the types of contraceptives at the PAC ward could increase the uptake of contraceptives following PAC.

Follow-up research is needed to understand whether and how the roll-out of PAC training and the making available of the PAC guidelines since our fieldwork has impacted the quality and provision of post-abortion counselling and contraceptive uptake.

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.

Appendix. Access to counselling and contraceptive methods after PAC among study participants

Table

Cases	Age	Facility level	PAC Method (MA/Surgical)	Counselling took place (Yes/ No)	Contraceptive outcomes
c219	14	Level 4	MVA	No	No method offered
c356	16	Level 3	MVA	No	No method offered
c305	16	private	MVA	No	No method offered
c216	17	Level 4	MVA	Yes	Decides to use condom
c368	18	Level 3	MVA	No	No method offered
c361	18	Level 3	MA	Yes	Rejected methods as she said she won’t see men anymore
c306	19	Level 4	MVA	No	No method offered
c312	19	Level 3	MVA	Yes	Received counselling, no method offered, told to continue with current one (3-month injection)
c201	19	Level 4	MVA	Yes	Rejected methods as she says it will give her the urge to have sex
c204	20	Level 4	MA	No	No method offered
c207	20	Level 4	MVA	No	No method offered
c211	20	Level 4	MVA	Yes	She decided to wait for 2 weeks and did not go back for the method
c367	20	Level 3	MVA	Yes	Wanted to go home and think about it and did not go back for the method
c373	20	Level 3	MVA	Yes	Did not take it because she wanted to get pregnant again
c271	21	Level 2	MVA	Yes	Her husband refused
c264	21	Level 2	MVA	Yes	Rejected method as she said she didn't understand how they help
c370	21	Level 3	MVA	Yes	3-months injection
c202	23	Level 4	MVA	Yes	Rejected methods proposed, says she will use condoms as contraceptive
c209	24	Level 4	MVA	Yes	5-year implant
c266	29	Level 2	MVA	Yes	Rejected methods as she decided she would abstain until she gets married
c310	30	Level 2	MVA	No	No method offered