The Impact of Culture Religion and Policy on the Reproductive Health of Women in Kenya

 Constance Rose Ambasa
Kenyatta University, Department of Religious Studies, 
P.O. Box 43844 Nairobi, Kenya. 
Email: cambasa@avu.org

Paper Prepared for CODESRIA’s 10^th General Assembly on “Africa in the New Millennium”, Kampala, Uganda, 8-12 December 2002. 

Abstract

The International Conference on Population and Development (ICPD) of 1994 in Cairo provided a broad definition of the reproductive health of women. In Kenya, research has mainly concentrated on the physical dimension of reproductive health such as family planning and adolescent sexuality. There has been an apparent neglect of other areas of reproductive health like religious and cultural embededness of reproductive health. A study was conducted to partly fill up this gap in knowledge by examining the influence of culture, religion and policy on reproductive health of women in Kenya. A questionnaire-based survey was carried out in three districts in Kenya: Kiambu, Siaya and Tharaka in which 547 respondents were interviewed. Focus Group Discussions (FGDs) were held separately for men, women and the youth. In-depth interviews also took place with key informants. The study established a variation in the status of reproductive health of women based on socio-economic and demographic characteristics. The status of reproductive health of women is influenced by culture through determination of the age of marriage, frequency of sexual intercourse, number of children, puberty rites and widowhood rites. Religion equally influences reproductive health of women through its teachings and policies. The study further established that the ICPD policy has been a catalyst in improving the reproductive health of women in Kenya. However, many bottlenecks exist at policy level that hinder effective implementation of the ICPD Programme of Action in Kenya.

Introduction

The last two decades have witnessed a growing concern world-wide by policy makers, implementers and scholars to improve the reproductive health of women (World Health Organization, 1999; United Nations, 1995; Family Care International, 1994). The International Conference on Population and Development (ICPD) that was held in Cairo in 1994, for example, rejected the then existing family planning programmes. Instead they were to be integrated into a broad range of other reproductive health services, such as pre-natal and post-natal care, medical attention at birth, cancer screening, access to safer abortion and protection from STIs and HIV/AIDS (Family Care International, 1994). The ICPD Programme of Action placed great emphasis on promotion of complete physical, mental and social wellbeing in all matters related to reproductive health system rather than merely concentrating on the absence of disease in the reproductive system (World Health Organization, 1999). These changes in policy on reproductive health have resulted into many programmes and interventions at the global level. However, despite these changes, achievements in reproductive health of women are uneven between and within countries.

The Government of Kenya (GOK) and Non-Governmental Organizations (NGOs) have made some efforts to improve the lives of women with respect to the stipulations of the ICPD (GOK and UNICEF, 1998; KDHS, 1998; GOK and UNICEF, 1992). Despite these efforts, there are still intractable problems in reproductive health of women. Previous studies on reproductive health in Kenya have missed out the cultural and religious dimensions and have mainly concentrated on the ‘physical’ indicators: contraceptive accessibility (Hammerslough, 1992); acceptance (Steiner, et al., 1995); communication (Westoff and Rodriques, 1995); counselling (Kim, et al., 1998); adolescent sexuality (Ilinigumugabo, 1995); HIV/AIDS (Forsythe and Rau, 1996) and abortion issues (Okumu and Chege, 1994). The cultural and religious dimensions could perhaps contribute towards unraveling the under-achievement in the policies and programmes on women’s reproductive health, especially the standards set by the ICPD. Thus, a study was undertaken to investigate the interaction between culture, religion, policy and the reproductive health of women in Kenya.

Theory and Conceptual Issues

An understanding of the reproductive health of women in Kenya rests on theories that explain gender differences in social relations. Bem’s theory of gender-polarizing lens (Bem 1993) was used to inform this study. Bem maintains that there are three gender lenses that perpetuate the oppression of women in all spheres of life. First, is the lens of androcentrism or male-centeredness whereby men and their experiences are perceived as the norm. Second, is the lens of gender polarization whereby the male-female differences are forged on every human experience. Third, is the lens of biological essentialism that has secularized God’s plans as the inevitable plan for humanity. Bem’s theory indicates that gender makes a great difference with social structures favoring males over females. This happens in most communities irrespective of whether they are patriarchal or matriarchal. Consequently, the placing of women at disadvantaged positions by most social structures affects the way people relate in all spheres of life, including reproductive health relationships. 

Bem’s theory of gender-polarizing lens is appropriated in this study to show how religion reinforces cultural practices in ethnic communities in Kenya, thereby keeping women in disadvantaged position in relation to reproductive health. Policy makers in the Government of Kenya (GOK) who are mostly men, also tend to put less focus on policies that could improve women’s lives as proposed in the international document of the ICPD. This reluctance is due to the desire by men to continue controlling power in both the domestic and public spheres as the female gender is subjugated. Religious teachings and policies that equally favor men due to the patriarchal setting of Christianity, Islam and African religion that are dominant in Kenya support the upper hand that men have in policy. This scenario complicates matters for women since their reproductive health problems tend to be perceived by men and religious bodies as the normal way of life for women. By so doing, both religion and culture could be contributing to the apparent failure to implement the ICPD Programme of Action in totality in Kenya that emphasizes reproductive health.

This study has adopted the variables on reproductive health found in David and Blake (1956) which were later on modified by Bongaarts (1978) who identified seven proximate determinants of fertility instead of the previous eleven. However, both models have two apparent limitations. First, they assume that fertility and other reproductive health issues only affect married women. This assumption is untenable in view of the many fairly documented cases of pre-marital sex and pregnancies not just in Kenya but other parts of the world. Second, they tend to ignore other factors such as religion and culture that equally seem to be influencing reproductive health of women in Kenya. Based on these limitations, the present research postulates that deeper insights could be gained into the status of reproductive health of women if the underlying factors are looked at under the framework of culture, religion and policy implementation.

Methodology:

A questionnaire-based survey was carried out in three districts in Kenya: Kiambu, Siaya and Tharaka districts. A total of 547 respondents were interviewed for this study, out of which 49.5% and 50.5 % were males and females respectively (Table 1). The sample size was used to make inferences on reproductive health indicators among women in Kenya. 

Table 1: Study Districts and Sample Size

Source: Fieldwork (2001).

Focus group discussions (FGDs) were also held to unearth hidden religio-cultural beliefs of the communities in the three areas of study. The FGDs comprised three categories of people based on age: men, women and the youth. In each visited site, FGDs were held based on religious affiliation: the Roman Catholic Church, one Protestant Church and an African Instituted Church. In-depth interviews with key informants also took place in the areas of study. Triangulation of data collection techniques was used to ensure validity and reliability of data. The collected secondary data were synthesized to form the theoretical basis of the study. Quantitative data from questionnaires were coded, edited, entered and a database created using the statistical package for social sciences (SPSS). The qualitative data from FGDs and in-depth interviews were analyzed qualitatively based on the themes of the study. Both sets of data were then integrated to form the basis for a final report

Results

Status of Reproductive Health of Women in Kenya

The status of reproductive health of women in Kenya is influenced by factors at two levels: proximate determinants of reproductive health and socio-economic conditions of the women. Some of the factors are discussed below.

Contraceptive Use by Married Women in Kenya

The 1998 Kenya Demographic Health Survey (KDHS) revealed that 41% of married women in urban areas use modern contraceptives compared to 29% in the rural areas (Table 2). Contraceptive usage at the macro-level is still low despite the introduction of new family planning techniques. Apparently, some obstacles exist that hinder wider usage of contraceptives among married women in Kenya. Micro level data analysis of fieldwork data in the studied areas indicate that 52.1 % of respondents are currently using a family planning method with a partner while 47.9% do not use any method. Although over a half of the respondents indicated that they use a family planning method, many of them noted in FGDs that they use natural methods such as withdrawal, calendar method, Billings Method and breast-feeding that are less effective in preventing conception. This implies that many women in the studied areas get unwanted pregnancies due to lack of effectiveness of the natural methods employed in preventing conception.

The study established that more women than men use contraceptives in the three districts of study (Table 2).

Table 2: (%) Use of Family Planning by Respondents

Source: Fieldwork (2001).

In Kiambu District, for example, 68.1% of female respondents use contraceptives compared to 21% of male respondents. These results corroborate other studies in Kenya that men are reluctant to use contraceptives (KDHS, 1998; Fapohunda and Rutenberg, 1999). Given that men determine the family size in most Kenyan communities (Rono, 1998), it follows that many women have less control over their sexuality. Consequently, they bear many children to satisfy the desired family sizes of their spouses. This is one area where the reproductive health rights of women in Kenya are violated since the powerful men downplay women’s wishes. The results in Table 2 also show disparities in the use of family planning in the three districts of study. Kiambu District with 68.1% female users is a head of Tharaka (55%) and Siaya (43.1) districts. These results agree with the national contraceptive usage levels that equally indicate regional disparities. Nationally, the use of modern contraceptives is highest in Central Province (61.1 per cent) and lowest in the Coast Province at 20 per cent (KDHS (1998: 46).

In Eastern and Nyanza Provinces where Tharaka and Siaya Distrcts are found respectively, lower usage of contraceptives by married women could be attributed to low levels of formal education (GOK and UNICEF, 1992). Field data indicated that women with high educational levels are more likely to use contraceptives than those with low educational levels (Table 3). Use of modern contraceptives increases from 16 per cent among married women with no education to 46 per cent among women with some secondary education.

Table 3: Contraceptive Use (%) by Educational Levels in Kenya

Source: KDHS (1998: 46).

Regarding preference of contraceptives in Kenya, macro level analysis reveals women prefer injectables in both rural and urban settings (KDHS 1998: 46). Pills and female sterilization take the second and third places, respectively. Micro-level analysis equally established a higher preference for injectables in the areas of study. This method is preferred because it is hidden and, therefore, good for women whose spouses do not approve the use of modern contraceptives. The other preferred methods in order of preference were: pills (19.9%), condoms 11.3%, Breast-feeding (10.2%), Tubal ligation (6.8%), implants (6.3%) and others (Field data, 2001).

Although condoms rank third (11.3%) in order of preference, they are not widely used in the areas of study. When male respondents were asked whether or not they would use condoms, a large proportion (76.1%) was unwilling to use them compared to 23.9%, who did not mind using them (Table 4).

Table 4: Frequency Distribution of Male Respondents on Views on Condom use

Source: Fieldwork 2001.

The above results corroborate other findings in Kenya that men are unwilling to use contraceptives (Ilinigumugabo 1995; Bauni and Jarabi, 2000). Reasons given in FGDs for failure to use condoms included the following:

Condoms have small invisible holes and this makes them inefficient in prevention of pregnancies. The same happens to STIs and HIV/AIDS. They are not safe (Female FGD, Karapur Catholic Mission, 1-4-2001).

They reduce sexual pleasure (All male FGDs).

They stick in the vagina (Male FDG, Randang Market 29-3-2001).

The church prohibits their use since they encourage immorality (All Catholic and African Instituted churches in the study).

I have never seen a condom although l have heard about it. Such things cannot be brought here at Rang’ala Mission Hospital because our Church does not allow their use (Male respondent Rang’ala Hospital 31-4-2001).

It is unnatural God wanted the sexual act to be real (Male FGD, Legio Maria Siaya Showground 1-4-2001).

Condoms are for prostitutes but not church going people (All Male FGDs).

They are cumbersome to wear. In fact, you cannot easily tell which side should be up (Male FGDs, Siaya District).

The qualitative results indicate that although knowledge on condoms is widespread, the acceptability is still low due to misconceptions that surround their use. The fact that about 24% of the male respondents did not mind using condoms means that tremendous change of attitude has been achieved among respondents with regard to condom use. The main reason for this change is the fear of contracting HIV/AIDS given that many men engage in extra marital affairs in Kenya (Ilinigumugabo, 1995). Indeed, some respondents in FGDs pointed out this reality through the following words: ‘Condoms are good for they prevent diseases.’ It should be noted that condom use in Kenya has increased slightly compared to previous times due to the awareness that has been created with regard to their efficacy in preventing HIV/AIDS infections. However, there were some cases where people had never seen condoms and lack knowledge on how to use them. Such a situation is deplorable among a people who seem to engage in multiple sexual relationships. 

Sexual Behaviour

Women in Kenya begin sexual activities earlier than men who sometimes begin five years later (KDHS, 1998: 72). The medium age at first sexual intercourse in Kenya is 17 years (KDHS, 1998: 72). . Micro level analysis shows that most respondents begun engaging in sexual intercourse when in the 16-20 age bracket (Table 5). The mean age at first sexual intercourse for respondents in this study was 17.25 with the youngest respondent having initiated sexual intercourse at the age of 5 years. This minimum age of 5 years gives an indication of what the situation is like in Kenya. Indeed, studies have shown that girls and boys begin engaging in sexual unions at early ages of 8 years and 10 years, respectively (Okumu and Chege, 1994. According to Murgor (1997: 104), the age at first intercourse among respondents in his study ranged from 8 to 19 years. By age fifteen, 60% of his respondents had already experienced their first sexual encounter. These findings of early commencement of sexual intercourse were corroborated by the qualitative data of this study. 

Table 5: Frequency Distribution of Age at First Intercourse of Respondents

Source: Fieldwork 2001.

In Siaya District, it was established that:

The youth begin engaging in sex at early ages like 10yrs. However, they do not use condoms at this age due to lack of knowledge about them. When they become adolescents, it becomes difficult to access condoms in health institutions because they are supplied to married people. Again, many girls fear that the condoms could stick in their vaginas (Youth FGD, Nyangánga 29-3-2001).

A similar case of early commencement of sexual activity was reported in Kiambu District. For instance, when the research team visited the Headmaster of Githunguri Primary School, he informed us that:

Yesterday, two six year old pupils were found making love in a classroom. One of the children belongs to a businesswoman, who like other parents, is too busy looking for money that she is not aware of what her children do. The other child belongs to a single mother. The boy is used to watching his mother engage in sexual relationship with men since they live in a bed-sitter. In such cases, the growing children get exposed to sexual matters at early stages and attempt to practice what they see their parents doing with their friends in school. The lack of proper parental guidance is leading to early initiation into sexual activities in this area (H/M Githunguri Primary School, O.I. 21-9-2001).

STIs and HIV/AIDS

Kenya is one of the countries in Sub-Saharan Africa with high prevalence rates of HIV/AIDS (Forsythe and Rau, 1996). Since the presence of STIs is a pointer to the possibility of HIV infection, respondents were interviewed on whether or not they have had such a problem (Table 6).

Table 6 Frequency Distribution of Itching of Genitalia Among Respondents

Source: Fieldwork 2001.

Table 6 indicates that Siaya District with 46.6% and 22.8% among male and female respondents respectively was a head of other districts, which reported relatively lower cases of itching of the genitals. Studies (Bauni and Jarabi, 2000: 71; Forsythe and Rau, 1996) have shown that the presence of STIs within a population increases susceptibility to and chances of infection with HIV. The same studies have indicated that incidences of HIV/AIDS prolong the duration of STIs symptoms and infection. Results in Table 6 show that Siaya District has the highest prevalence of STIs. By implication, the district leads in HIV/AIDS infections in comparison to other districts of study. Reasons for this scenario include the cultural practices of polygamy, cleansing of widows through sexual act and placing widows under guardianship institutions. When responses of males and females are compared, more men than women have experienced itching of the genitalia. This could be attributed to the freedom given to men to engage in sex at will to proof male prowess. Furthermore, female respondents may have failed to answer the question appropriately given that symptoms for STIs in the majority of women are hidden. 

The research hypothesis that there is no significant difference in reproductive health indicators (contraceptive usage, abortion rates, maternal mortality rates, child mortality rates, postpartum infecundability, marital status, sexual behaviour, STI rates, age at first marriage, age at first sexual contact, distance to health facilities, availability of health facilities and services, financial ability, education) among respondents by their place of residence in the areas of study was tested. Results of the Chi-square test are presented in Table 7.

Table 7: Chi-Square Results Showing Relationship Between Reproductive Health Indicators and Place of Residence Among Respondents