Sabrina Boyce, March 2, 2017
"Most women I know in this neighborhood who are using [birth control] pills hide them in a neighbor's bush so that their husbands don't find out they are using them." - Family planning clinic provider, Kibera slum community, Nairobi
In December 2016, Dr. Silverman and I traveled approximately 10,000 miles to Nairobia, Kenya to visit community-based family planning clinics and deepen our understanding of the autonomy women and girls in Kenya have to control if and when they get pregnant. In Kenya, unintended pregnancy is common. A full one-half of unmarried women and more than 4 in 10 married women in Kenya who are pregnant report their current pregnancies as mistimed or unwanted. Unintended pregnancy is an important problem, as it is major contributor to girls leaving school (an estimated 13,000 girls dropping out of school every years in Kenya for this reason) and a major factor in maternal mortality, particularly via unsafe abortion.
Women in Kenya also experience high rates of violence from male intimate partners (IPV), with other 40% of women ages 15-49 reporting ever having experienced either physical or sexual violence from a male partner. Common to many contexts, women in Kenya who report IPV are significantly more likely than other women to report that a recent pregnancy was unintended.
As the anecdotal quote from a Nairobi family planning clinic staff member alludes (referenced above), Dr. Silverman and I learned that girls' and women's ability to prevent pregnancy in Kenya, just like in many other parts of the world, may often be limited by male partners' behaviors aimed at interfering with their attempts to contracept. This type of interference could include either coervion from her male partner to become pregnant against her wishes or interference with her use of contraception, and is referred to as reproductive coercion (RC). Reproductive coercion has been shown to be strongly associated with risk for unintended pregnancy among adolescent and young women in other contexts, a risk that persists even when the woman is not experiencing IPV. Additionally, when a woman is experiencing both IPV and RC, the risk for unintended pregnancy even higher than the risk seen for women experiencing IPV alone. Given the high prevalence of IPV and the likely role of RC as a major driver of continued high levels of unintended pregnancy and subsequent unsafe abortion among women and girls in Kenya, there is a great need for development and testing of promisng intervention models that may reduce RC in this and other low and middle income countries (LMIC), particularly models that may be scalable and sustainable in such contexts.
These important potential risks related to IPV and RC led Dr. Silverman to partner with International Planned Parenthood Federation (IPPF), Family Health Options Kenya (FHOK, the IPPF national affiliate in Kenya), and Population Council to adapt and evaluate a promising clinic-based intervention, ARCHES (Addressing Reproductive Coercion in HEalth Settings), for use in family planning clinics in Kenya. ARCHES is designed to reduce IPV, RC, and related unintended pregnancy among women and girls attending family planning clinics. This clinic-based model, developed in the U.S. by Dr. Silverman and Dr. Elizabeth Miller (University of Pittsburgh) and their colleagues, in partnership with Planned Parenthood Federation of America and Futures Without Violence, involves training in existing lay sexual and reproductive health (SRH) providers to provide a brief intervention to identify RC and promote related harm reducation strategies that minimize their risk for unintended pregnancy. In the US, two NIH-funded cluster randomized control trials (RCTs) of the ARCHES model involving over 4,000 women and girls have demonstrated that a single clinical visit that follows the ARCHES guidelines can result in reduced incidence of RC from male partners, increased self-efficacy to reduce their risk of IPV and unintended pregnancy (e.g., self-efficacy to use a form of family planning that would minimize the risk of male partner interference), as well as increased knowledge and use of community-based IPV resources. Dr. Silverman and our partners hope that this model could not prove helpful to women and girls in Kenya, but that it could be tailored to be a sustainable and scalable model to reduce RC and unintended pregnancy in other LMIC contexts.
This project in Kenya is part of GEH's larger strategy to move forward evidence-based, sustainable, and scalable interventions that increase reproductive autonomy to improve the lives and health of women and girls globally. Dr. Silverman has worked extensively on understanding women's experiences of reproductive coervion and improving women's reproductive autonomy in a variety of global regions, including current projects in India and Niger. Such research is now being used more broadly to standardize measures of reproductive coercion and inform intervention development across international reproductive autonomy promotion efforts.
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