Advocates Promote Reproductive Health Care in Kenyas Coastal Towns

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KILIFI, KENYA - The sun slowly peeps through the clearing clouds in the bold, blue sky. The enveloping humidity generously gives out bear hugs to residents here, leaving brows doused in sweat. A salty breeze flaps the branches of the palm trees lightly, teasing the sweaty multitude in the coastal town of Kilifi. Kilifi is just one of the many towns in southern Kenya that lie on the coast of the Indian Ocean. It's a paradox of beauty, relaxation and rich, sandy beach resorts amidst a populace plagued by illiteracy, poverty and high fertility rates. Racheal Kirangazi, 59, is a single mother in a village within Kilifi town. She and her son are the primary breadwinners for the 24 people - her other five adult children, their spouses, her 10 grandchildren and her mother - who live in houses within her homestead. But she says that she is used to taking care of others, as she's been doing so since she was a teenager. Kirangazi dropped out of school when she was in fifth grade, when she was 14, to get married. "I wasn't fully aware of what I was doing," she says. "I just knew I needed to get married." But she says that there's nothing unusual about this. Her mother, Fatuma Mramba, calmly agrees. Kirangazi says she has no regrets about starting a family so young, and neither does her mother. Kirangazi became a widow in 1993 when her husband, who worked as a police officer, was killed in the line of duty. She now works as a charcoal vendor in the area to provide for her family. Her six children all dropped out of school. They now earn low wages at menial jobs, except one son who is a mechanic. Together, she and this son support their other 22 relatives. Kirangazi, one of her sons and Mramba are also HIV-positive. She and her son believe they contracted it from taking care of Mramba. They receive health evaluations every four months, courtesy of Food for Prescription, a community outreach program that provides care for people living with HIV. It was initiated by the World Food Program and Pathfinder International and is implemented locally by the Ministry of Health and a local nonprofit organization, Strengthening Community Partnerships and Empowerment, SCOPE. Through the program, the family also receives food rations. They have been receiving cornmeal, lentils and cooking oil for the past nine months. Kirangazi is also part of a women's group that runs "sack farms." They grow vegetables in sacks filled with manure, other nutrients and soil. Between the sack farms and the community outreach program, she says that feeding her family has been manageable. She says she sees taking care of her family more as a cultural obligation than a burden. Local hospital officials in Kenya's coastal towns say that promoting reproductive health care is difficult because of cultural opposition, illiteracy and poverty. The tendency in these areas is for girls to drop out of school, marry young and have large families. Local hospitals, the government, nonprofit organizations and international partners have implemented various initiatives to erode cultural resistance to family planning. Although they cite some success, they acknowledge that it's an uphill battle. Nearly 70 percent of Kenyans in coastal areas lived in poverty in recent years, according to the 2005-2006 World Bank Survey on cases of rural poverty in Kenya. At the same time, the population growth rate for Kilifi has exceeded Kenya's annual population growth rate of 2.6 percent, according to 2010 World Bank statistics and the Kilifi District Strategic Plan 2005-2010. Some attribute the higher growth rate in coastal areas to the cultural norms there of marrying girls off young in exchange for a dowry that can help sustain their families. Less than 40 percent of students who enroll in first grade in the area graduate from high school, according to 2011 statistics from the Kenya Ministry of Education. About 61 kilometers, 38 miles, down a charred, sandy road from Kilifi lies a village called Bamba. On either side of the road, dead, dry and discolored crops droop under the heat. Women with long and exhausted faces carry jerricans filled with water on their heads. The only sign of water is the town's rusty pipes, which peer through the eroded landscape. There are no wells or rivers to be seen for miles. Dilapidated huts sparsely dot the area. The few that stand reveal holes in their walls, as dried and cracked mud holds the fickle frames of the hut. The roofs are one storm away from ruin. The solitary village center houses the sole hospital, Bamba Subdistrict Hospital, for a population of 45,800 people. The concrete facility has a staff of only 13 and a 12-bed capacity. The fertility rate here is about seven children per mother, according to the hospital's statistics. And most of the mothers are between 14 and 17 years old, says Neville Kombo, a nursing officer here. Reproductive health care in the area is quite a challenge. There are several reasons for this, including high illiteracy levels. "In some cases, women come to the facility and don't now how many months pregnant they are," she says. Robert Kariuki, another nursing officer in the facility, says one woman thought she was younger than her child. "One woman once came in with a child who looked no older than 2 years old," Kariuki says. "When I inquired how old her child was, she said 7 years old. When I asked her how old she was, she said 5 years." Kariuki says this makes it hard to treat patients properly. "Even being sure that the subscription you give the mother will be properly administered to the child is a concern," Kariuki says. Sammy Chai, a public health officer at the hospital, says that matters pertaining to reproductive health are made more complicated by the fact that they have fallen solely to women. Robert Mulewa, area chief of Bamba, echoes Chai's sentiments. He says that they discuss family planning during local barazas - village meetings - but that 80 percent of the attendees are women. But at the same time, men restrict women's power to manage these responsibilities. The women are willing to plan their families and use contraception, but the husbands don't want to, he says. "The men normally argue that God said we should fill the earth," he says. "And with that argument, they say that God knows how he will take care of the children." Philomena Omunga, the district reproductive health coordinator based at Kilifi District Hospital, calls it the "mwenye" - Swahili for "owner" - syndrome. She says that culturally, most women are required to be submissive and adhere to their husbands' needs and demands. And this makes most women reluctant to take contraception. "Mwenye nyumba [the owner of the house] isn't willing to take contraception," she says, explaining how this makes women reluctant, too. Abdalla Kadzitu Kenga, a Bamba village elder, says that traditional beliefs result in large families. "Culturally, women are required to bear children to keep the deceased fathers and uncles of their husbands 'alive,'" he says. Kenga says that is why polygamy is common in the community. In a case where a woman's father-in-law was the seventh son in his family, the woman would be required to bear an equivalent number of sons until she "bears" her father-in-law in order to keep him alive in spirit. In addition to the cultural challenges within the coastal communities of Kilifi area, there are many financial constraints. SCOPE estimates that the area has a per capita income of 700 shillings KES (${esc.dollar}7 USD). The two key economic activities in the rural areas of Kilifi are charcoal burning and quarry mining. In Tezo, another village in Kilifi, the situation is similar. Patrick Masha, 51, a charming, sweet-talking and youthful-looking assistant chief, says that residents here prefer large families as well. He says that educating the community on family planning is a challenge because, as a leader, it tends to be hard to lead by example. "I have three wives," he says. "My first has seven children, my second wife has four children and my third, 10 children." He says the key difference is that he can afford to take care of them all, but many others with large families cannot. "I can afford to take care of my children," he says with a cheeky smile and his eyes lighting up. "But I keep reminding members of my community to have children that they can afford to take care of." Masha says he would like to have even more children, but he can't. "I would have had more [children]," he says. "But I got ill - diabetes." Masha says that contraception here is not common. He jokes that the most common contraceptive used in the area is alcohol. "Men get drunk," he says with a chuckle. "When men are drunk, they can't perform at home." One school in Tezo, Ngala Primary School, has a student population of nearly 400 students. Most students start school about three to four years later than usual, so those who drop out between fourth grade and eighth grade tend to be between 14 and 17 years old. Isaiah Chemosong, a senior teacher at the school, says that an average of seven students drop out of school between these grades. "A student who dropped out of school and got married recently was 14 years old," he says. "She now has a newborn child called Mapenzi." Despite all the odds, SCOPE has come up with an interesting strategy to promote reproductive health education and family planning services in the area. Bob Charo, a voluntary testing counselor with SCOPE, says that members of the community list several reasons for being wary of contraceptives. "Some say that women get a smelly discharge when they use condoms," he says. "Others say contraception causes heavy menses in women, or it makes women fat. One person once told me that a child was born holding an intrauterine contraceptive device, IUCD." He says that people are interested in learning about contraception and family planning, but that there's a stigma attached to it in the community that complicates this education. "We discovered during our door-to-door visits that people were willing to discuss the matter," he says. "But they didn't want to be seen attending these services during the day." Charo says that, to change this, one solution has been conducting one-on-one sessions during weddings and funerals. SCOPE provides financial support for weddings and funerals for members of the community. In turn, the families allow the organization to pitch a tent and station attendants there to provide information. "One by one, community members come to the tent and ask questions," he says. "At weddings when people are in high spirits, we discuss the need for contraception and family planning and offer condoms to those who need them." He says they operate similarly at funerals. The federal and local government have also implemented numerous initiatives to address reproductive health and family planning here, with varying success. Masha says that condoms used to be available at local government health centers, but that the program has since stopped because of a lack of results. "The children would go to the toilets and pull out condoms and use them as balloons," he says. But accessibility to contraceptives and medical care has been made possible in select regions in Kenya through a Kenya government partnership with the German government. The program, referred to as Output-Based Aid, OBA, provides care through health vouchers. This partnership began in 2006 covering four key areas: family planning, childbirth, antenatal care and gender-based violence. The health vouchers program currently works in health facilities in two slum areas in Nairobi and three rural districts, including Bamba, where the program began in June 2011. Women simply walk into the designated health centers that offer these vouchers and purchase them for amounts ranging between 100 and 200 shillings KES (${esc.dollar}1 to ${esc.dollar}2 USD). Then, when in need of any services, they can walk into the facility, present their card and receive full treatment for no additional cost. The government fully reimburses the health facilities involved in this program for their services. Omunga says the program has had a noticeable impact. "Within just three months since commencement of the OBA program, the rate of issue of family planning cards alone has risen by 41 percent." Omunga attributes this rise to the fact that the women taking up contraception can opt for a less conspicuous contraception, such as Depo-Provera, an injection. Husbands who disapprove of contraception will never know or suspect their wives are using the injection because of its discreetness. Clinical staff at the Bamba Subdistrict Hospital say they also have made some gains. Out of the estimated 100 clients that they receive in a month, 52 percent currently receive family planning support. And the most popular form of contraception, as in Kilifi, is the injectables. "Between 2009 and 2011, we have managed to set up two community units that provide on-the-ground education and sensitization in the community," Chai says. "We hope to set up more." The units refer to personnel who travel around the area. Dr. Sarah Onyango, the senior reproductive health specialist with USAID, a U.S. government agency that provides economic aid and humanitarian assistance, in East Africa says that region-specific programs can continue to soften the cultural opposition to family planning. Onyango says that a model that was adopted in West Africa, where similar challenges existed, can also apply in coastal Kenya. "In West Africa, what they did was encourage families to space their children as opposed to pushing for a fewer number of children," she says. "And naturally, the more you space your children, the fewer you have. Sensitization on reproductive health needs to be culturally relevant to each communty. You can no longer have a blanket approach."