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

*Significant at p < 0.05

Source: Fieldwork (2001).

Field results in Table 7 indicate that there is a significant difference in the reproductive health indicators (such as frequency of sexual intercourse, highest educational level and ability to pay for family planning services) based on residence of respondents in the areas of study. In urban areas, for example, people have higher levels of education compared to rural areas. Consequently, the highly educated are more aware of contraceptive methods, are more likely to use contraceptives and are more capable of purchasing them compared to people in the rural areas. Furthermore, people in urban areas are close to and able to pay for family planning services compared to those in rural areas. Therefore, the research null hypothesis that there is no significant difference in reproductive health indicators among respondents by their place of residence in the areas of study is rejected.

Another 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 socio-economic and demographic characteristics in the areas of study was equally tested. The results are shown in Table 8.

Table 8: Chi-Square Results Showing Relationship Between Reproductive Health Indicators and Socio-economic and Demographic Characteristics of Respondents

*Significant at p < 0.05

Source: Fieldwork (2001

The results in Table 8 show that there is a significant difference in reproductive health indicators and the socio-economic and demographic characteristic of respondents in the area of study. For instance, people with high levels of education delay the age of marriage and delivery of first child. Again, they are more likely to deliver in hospital unlike women who did not go to school. However, the only exception was the variable on marital status and the age when the first child was born, meaning that people can get children without necessarily being married. To this end, the research hypothesis that that there is no significant difference in reproductive health indicators among respondents by their socio-economic and demographic characteristics in the areas of study is rejected.

The mean distance to the nearest health facility in the area of study was 25km. The long distances to health facilities hinders some women from accessing reproductive health facilities and services like contraceptives, pre-natal, delivery and post-natal services. Tharaka District is hit hardest in the distribution of health facilities and services. Consequently, the Mari Manti District Hospital lacks facilities like emergency theatre and constant supply of modern contraceptives. To this end, the reproductive health needs of women as required by the ICPD are not adequately addressed.

Culture and the Reproductive Health of Women

Cultural beliefs and practices of various ethnic communities in Kenya greatly influence the reproductive health of women. This influence starts at conception and surrounds an individual's life until death. Culture explains why people get married, the age at which they marry, reasons for getting children, the number of children and determine sexual behavior within marriage, to mention but a few. 

Pregnancy taboos

In most communities in Kenya, pregnant women are culturally expected to refrain from eating some foods with a view to protecting the new life in them (Mbiti, 1969). Among the Akamba, of Eastern Province, for example, expectant women are denied access to the most nutritious foods in the community such as eggs, liver, fish and fresh milk (Katola, 1987). In the Maasai community, pregnant women are not expected to drink fresh milk. This prohibition is based on the belief that fresh milk will make the fetuses to become too big (Sindiga, 1996). In the process, Maasai women are denied the only source of proteins in their community, thereby leading to anemia and giving birth to under-weight children. 

When female respondents were asked if there are any types of food pregnant women are prohibited from eating, there was positive response from all the three districts of study. The prohibited foods were mostly proteins such as eggs, red meat, game meat, bananas, fresh milk, honey, fruits and soya beans. Reasons given by discussants in FGDs for such prohibitions included avoiding problems at delivery, preventing the mother from becoming too fat, ensuring that the baby is born with hair and can talk later on, to prevent heart-burns and to remove a bad scent from both the child and mother (Female FGD, Siaya Showground, 1-4-2001.

Protective medicine in pregnancy

African people believe that pregnant women and children are very vulnerable to mal-practices of the witch (Akiiki, 1992). For this reason, protective medicine is provided in many communities to protect expectant women from people with "evil eyes." According to discussants in Siaya District, “herbal medicines are widely used during pregnancy to protect the mother and child from bad omen” (Female FGD, Karapul Catholic Mission, 1-4-2001). In communities where the use of traditional medicine in pregnancy is widespread and intense, there is low attendance of pre-natal care (KDHS, 1998). Trangsrud and Thairu (1998) established that 27% of pregnant women make two to three visits and 4% do not receive the care at all. To this end, women with complications are sometimes not seen early enough to solve their problems. Sometimes, such women die especially when emergency obstetric services are unavailable given that many deliveries are done at home under the care of traditional birth attendants.

Socialization of the Children

The socialization of children influences the way they live later on in life. In most communities in Kenya, more value is placed on boys than girls right from the moment of birth. Boys are socialized to be in control of the public sphere and to aspire for greater opportunities in life whereas girls are trained to be submissive, honest, lead a life of sacrifice and to aspire to be good wives and mothers. Indeed, the picture that is imprinted on minds of children matures as they grow and this influences the reproductive health of women in most communities in Kenya. For instance, girls are given less nutritious meals in comparison to boys. This practice denies the girls nutrients they require for the reproductive conditions. Sometimes, girls are denied equal opportunities with boys for education. They end up with no economic empowerment to cater for their reproductive health.

Other practices that influence the reproductive health of women include puberty rites like female genital mutilation that is practised in Tharaka and Kiambu districts. The practice of child marriage, polygamy, domestic violence and widowhood rites also influence the reproductive health of women. Table 9 shows the Chi-square results of the research hypothesis that there is no significant difference between cultural practices (age at first pregnancy, age at first marriage, place of delivery, domestic violence, widowhood practices) and the reproductive health indicators among respondents in the areas of study. 

Table 9: Chi-square Results Showing the Relationship Between Cultural Practices and Reproductive Health Indicators Among Respondents

Significance level p > 0.05*

Source: Fieldwork 2001.

Results in Table 9 show that there is a significant difference between cultural practices and the reproductive health of respondents in the areas of study. For instance, there is more likelihood of experiencing STIs that lead to itching of the genitalia among people who practice widow cleansing than those who do not practice it. Therefore, the null hypothesis that there is no significant difference between cultural practices and the reproductive health indicators among respondents in the areas of study is rejected.

Religion and Reproductive Health of Women

Religious beliefs have great influence on the reproductive behavior of adherents. In Kenya, the predominant religions are Christianity, Islam and African Religion. African religion, for example, emphasizes many offsprings as a sign of God's blessings and for personal immortality. The distinct differences in the beliefs of the separate religions is reflected in their reproductive behavior such as beliefs concerning family planning, abortions, domestic violence, sexual behavior, widowhood status and HIV/AIDS. For instance, the emphasis on reproduction in African instituted churches leads to big families compared to areas with other religions. The influence of religion on reproductive health indicators is discussed below.

Family Planning Practices

Religious beliefs influence the practice of adherents in reproductive health. In the Roman Catholic Church and African instituted churches, adherents are expected to use natural family planning methods to plan their families. However, field results indicated that some respondents in the Catholic Church to not obey the church policy on contraceptive usage. 

Some of the respondents’ responses are provided below:

The Roman Catholic Church expects me to use natural family planning but this is impossible. I can not keep on worrying about the possibility of conception every time l have intercourse with my spouse given that withdrawal method is not reliable. This makes me sneak to the family planning centre for an injection (Githunguri Female FGD, Catholic Church 11-9-2001).

My husband drinks a lot of local liquor. When he comes back home, he expects to make love to me. I cannot get too many children yet the economy is bad. I have opted to go for a tubal ligation to avoid possibility of any pregnancy (Gatunga Female FGD, Catholic Church 18-3-2001).

However, a good proportion of respondents who were non-users did so based on convictions of the teachings in their churches. Among the Legio Maria church, for example, a respondent observed that:

Many of us in the church do not know how to use modern contraceptives such as condoms. The church does not encourage the use of such things. Even our wives are not encouraged to go to hospitals for delivery. Instead, we believe that the Almighty God who gave us life will take care of our wives even at the time of delivery (Male FGD, Siaya Show Ground, Legio 1-4-2001).

Members of Believers Independent Church strictly follow biblical teachings. nowhere in the Bible have contraceptives been recommended. Members are also told not to use them due to the many side effects like high blood pressure, heart failure, infertility, and miscarriages (Female FGD, Believers Independent Church, Siaya Showground, 1-4-2001).

Position of Church on Abortion

When asked what the position of the church is on abortion, respondents (96.5%) noted that it is murder and, therefore, a sin to God .This Christian belief has led to blanket condemnation of abortion by most Christians in Kenya. To this end, women who procure abortions are excommunicated from the church and stigmatized by the society without considering reasons that drive them to such an act.

HIV/AIDS and Religious Perspective

When asked how HIV/AIDS and people living with AIDS are perceived in their churches, respondents answered as shown in Table 10.

Table 10 Frequency Distribution of the Church's Views on HIV/AIDS as Reported by Respondents

Source: Fieldwork (2001)

According to Table 10, a half (50.4%) of the respondents noted that HIV/AIDS is perceived as punishment for sins in their Churches. This attitude was equally revealed in FGDs through the following voices:

If people leave immorality, there will be no of AIDS”(Male FGD, Believers Independent Church, Siaya Show ground, 1-4-2001). 

It is wrong for PLWD to come to church the last days when they realize that their lives are almost coming to an end. Yet when they were alive they were only leading life of sin (Female FGD, Marimanti MCK, 18-3-2001). 

About sixteen per cent observed that HIV/AIDS is a Biblical revelation indicating the signs of the times. The close link of HIV/AIDS with Biblical revelation about signs of the end has equally led to stigmatisation of people living with HIV/AIDS. Such stigmatisation could be reduced if people break the silence and secrecy that surrounds the pandemic. However, there seems to be change of heart among some respondents (21.8%) who noted that their church members perceive the pandemic like any other disease. This change of heart is influenced by the life of Jesus Christ who served the sick despite the nature of problem at hand. As a result of such a changed attitude, some churches are now operating programmes in support of people living with HIV/AIDS and orphans in Kenya. 

A Chi-square test was used to test the null hypothesis that there is no significant difference between religious practices and beliefs (approval of contraceptive usage, abortion, sexual practices, HIV/AIDS) and reproductive health indicators among respondents in the areas of study. The results for the test are presented in Table 11.

Table 11: Chi-square Results Showing the Relationship Between Religious Beliefs and Reproductive Health Among Respondents

Significance level p > 0.05*

Source: Fieldwork 2001.

Table 10 indicates that there is a significant difference between religious beliefs and practices and reproductive health indicators among the respondents. For instance, if a church condemns FGM, its members are likely to delay in engaging in sexual activity compared to a church that either keeps silent or encourages FGM. Based on the above results, the null hypothesis that there is no significant difference between religious practices and beliefs and reproductive health indicators among respondents in the areas of study is rejected.

Implementation of the ICPD Programme of Action in Kenya

This study established that the ICPD Programme of action has been a catalyst in improving the reproductive health of women in Kenya. There has been integration of family planning services into public health as well as expanding the family planning services to rural areas through use of community-based distributors. Again, there has been some improvement in safe motherhood through training of TBAs. Furthermore, there is free counselling and testing for HIV/AIDs though the response from the public is still poor. The government has imported many condoms with a view to preventing HIV/AIDS infections. In addition, legislation against FGM is now in place in Kenya. However, in practice, a lot of conscietization must be done so that people can understand why the practice should not continue in secret. The Affirmative Action Bill was passed in April 2000 but is yet to become law. The Equality Bill (October 2000), Domestic Violence Bill (November 2000), Criminal Law Amendment Bill and formation of the Family Court are still in the process of becoming laws with a view to improving the status of women in society. This will in turn translate into reproductive health benefits as stipulated In the Cairo Programme of Action of 1994.

However, there are still many bottlenecks in addressing all issues of the ICPD. For instance, it is not easy to legalise abortion and avail condoms to the youth in Kenya due to opposition from religious bodies, especially the Roman Catholic Church. According to the position of the church, legalising abortion is sanctioning murder whereas availing condoms to the youth encourages immorality. Although we do not condone immorality, this study established that the youth initiate sexual activities at 6 years of age. This reality of youth sexuality need to be confronted through practical means rather than the Roman Catholic Church polity that prohibits the use of condoms as well as refusal of Sex Life Education being taught in schools in Kenya. The policy of the Roman Catholic Church needs to be amended to allow the lesser evil of using contraceptives than to sanction the deaths of so many adolescents and married women who die in the process of aborting unwanted babies.

Other policy problems that affect the reproductive health of women in Kenya are due to economic factors. From the 1980s, Structural Adjustment Programmes (SAPs) were introduced in Kenya where by people were expected to pay for their medical expenses unlike in the past. Currently, the GOK only spends 7% of its National Budget on Health instead of the 15% that was agreed upon in the Abuja Declaration. The economic hardships facing many women have prohibited many of them from seeking medical help in the reproductive sector. Consequently, some women die out of conditions such as delivery that could have been prevented if they had sought medical care. The economic situation has been compounded by the globalisation process which has rendered many women poor and incapable of providing basic needs to their children. Due to lack of economic empowerment, some women engage in commercial sex to enable them sustain their families while neglecting their own health. Indeed, poverty and lack of socio-economic empowerment renders women to many reproductive health proplems such as contracting HIV/AIDS.

Another policy problem faced by women is with regard to handling of abortion cases in Kenyan hospitals. Many patients are condemned and stigmatised for abortion even if the act was spontaneous. Such stigmatisation makes some women not to seek medical help when they abort leading to high mortality rates. Such a situation could be change if the medical profession modifies its policy on abortion by making it less stigmatising. The same case applies to he stigmatisation of people suffering from STIs and HIV/AIDS.

Conclusion

This study established that there is a variation in the status of reproductive health of women in Kenya based on socio-economic and demographic characteristics of the respondents. Many women in rural areas get unwanted pregnancies due to lack of information and access to family planning services. The majority of these women deliver in unsafe environments under the care of traditional birth attendants (TBAs). Yet most TBAs are not well equipped to handle emergencies that could arise during childbirth. Consequently, many women die due to inadequate care during delivery. The situation is compounded by deaths from unsafe abortions, especially among adolescents, due to lack of information and access to family planning services. This scenario explains why there are high maternal mortality rates in the areas of study. The results of this study also show that culture influences the status of reproductive health of women in the three districts of study. Culture and religion also influence the reproductive health of women in Kenya. It was established that the ICPD has been a catalyst in improving the reproductive health of women in Kenya. However, there are many cultural, religious and policy setbacks that hinder proper implementation of the ICPD Programme of Action.

Recommendations

This study recommends the following with a view to improving the reproductive health situation of women in Kenya.

• The Roman Catholic Church should revisit the position of the Holy See with regard to the prohibitive position on the use of contraceptives. A similar call is extended to the hierarchy of most African instituted churches in Kenya that have stringent polity on the use of contraceptives and medical attention.

• The government must confront the issue of offering good health services to abortion victims rather allowing the health providers to stigmatise them. Such a move will encourage many girls and women to seek post-abortion care rather than ending their lives prematurely in an attempt to abort, as is the current situation. 

• There is need for greater awareness campaigns in the rural areas on the usefulness of condoms in preventing HIV/AIDS, STIs and pregnancies. This awareness should go hand in hand with the eradication of the stigma and misconceptions that surround the use of condoms. The government should equally provide free female condoms to women to empower them to control their sexuality the way male condoms are freely distributed

There is need to provide infrastructure and health facilities in rural areas to enable people to get higher access to health institutions and services.

There is need to empower women on the socio-economic and political fronts to enable them lead better lives. Women should be integrated into the decision-making process to ensure that they vote for bills that would improve their lives. Such empowerment will culminate into improving the reproductive health situation.

References

Bauni, E K & Jarabi, B.O. (2000) Family Planning & Sexual Behavior in Studies in Family Planning, 31(1): 69-80.

Bauni , E.K. (1990) "The Changing Sexual Pattern of the Meru People of Chogoria Region, Kenya": A paper Prepared For The Semonar on Anthropological Studies of Sexual Behaviour Relevant to HIV Transmission" Southern Justland Denmark.

Bongaarts, J. (1978) A Framework for Analysing the Proximate Determinants of Fertility. Academic Press Inc. NewYork.

Davis, A. K. & Blake, J. (1956) "Social Structure: An Analytical Framework," Journal of Economic Development and cultural Change. pp 211-235 vol. 4, April.  

Family Care International (1994), "The International Conference on Population and Development, Action for 21st Century Reproductive Health and Rights for all: Summary Report of Recommended Actions on Reproductive Health and Rights of the Cairo ICPD" Sept, 1994.

Fapohunda, B. & Rutenberg, N. (1999), Expanding Men's Participation in Reproductive Health in Kenya in African Population Policy Research Center, Nairobi.

Forsythe and Rau (1996) AIDS in Kenya: Socio-Economic and Policy Implications, U.S. Agency for International Development AIDSCAP/Family Health International

Government of Kenya and UNICEF (1992) Situation Analysis of Children and Women in Kenya. Ministry of Planning and National Development, Human Resources and Social Services Department, Nairobi.

Government of Kenya and UNICEF (1998) Situation Analysis of Children and Women in Kenya. Ministry of Planning and National Development, Human Resources and Social Services Department, Nairobi.

Hammerslough, C.R. (1992) Proximity to Contraceptives Services And Fertility Transition in Rural Kenya. International Family Planning Perspectives 18:54.

Katola, T.M. (1987) "The Akamba Concept of Taboo with Particular Reference to Machakos District" M.A. Thesis, Kenyatta University.

Ilinigumugabo, A. (1995), Psychosocial and Health Consequences of Adolescent Pregnancies Among Out of School Adolescent Girls in Four Rural Communities in Kenya. Center for African Family Studies (CAFS) Research Report Series No. 1.

Kim, Y. M., et.al. (1998), Informed Choice and Decision-Making in Family Planning Counseling in Kenya in International Family Planning Perspectives, 30 (1): 4-11 and 42.

Mbiti, S.J. (1969) African Religions and Philosophy, Heinmann, London.

Murgor, B.K. 1997, "The Effects of Reproductive Knowledge on Behaviour Among Pregnant And Nursing Adolescents in Eldoret Municipality", Master of Arts Degree, Kenyatta University

Njau W and Njeru E. H.N. (1997) "Women and Violence in Nairobi and Kajiado Districts of Kenya", A final report submitted to FIDA (Kenya), Nairobi.

Njau, W. (1994) Review of literature on Adolescent/ Youth Sexual and Reproductive Health, Centre for the Study of Adolescence (CSA), Nairobi.

Okumu M. Y. and Chege, N.I. (1994) "Female adolescent Health and Sexuality in Kenyan Secondary Schools: A Survey Report African Medical Research Foundation, AMREF, Nairobi.

Owino, W. and Korir, J (1997) Public Health Sector Efficiency in Kenya: Estimation and Policy Implications. IPAR Discussion Paper Series, Institute of Policy Analysis Research, DP No. 007/1997. Nairobi.

Republic of Kenya, (1998) Demographic & Health Survey, National Council for Population & Development, CBS, Office of the Vice President & Ministry of Planning & National Development, Government Printers, Nairobi.

Republic of Kenya, (1994) Kenya Health Policy Framework Paper, Ministry of Health. Government Printers, Nairobi.

Republic of Kenya, (1994) Demographic & Health Survey (1993) National Council for Population & Development, CBS, Office of the Vice President & Ministry of Planning & National Development, Government Printers, Nairobi.

Republic of Kenya, (1994) Contaceptive Prevalence Survey, Population & Development, CBS, Office of the Vice President & Ministry of Planning & National Development, Government Printers, Nairobi.

Rono, P.K. (1998) Family Size Preferences And Attitudes Towards Contraceptive Use Among Men: The Case Of Kaptumo Community In Nandi District of Kenya: An Analysis of Patriarchal Implications on Fertility Regulation, Union of African Population Studies (UAPS) Study Report Number 34.

Sindiga, I. (1996), Population Change Among the Maasai, Organization for Social Science Research in Eastern and Southern Africa (OSSREA), Research Report Series No. 5.

Steiner, M., et.al (1995), Acceptability of Spermicidal Film and Foaming Tablets Among Women in Three Countries in International Family Planning Perspectives. 21:104-107

Trangsrud, R. and Thairu, A. (1998) ,Safe Motherhood in Kenya: Lessons from an Assessment of Maternity Care, Ministry of Health (MOH) and UNICEF Project Report.

GOK and UNICEF, (1992), Children and Women in Kenya: A Situation Analysis, UNICEF Kenya Office, Nairobi, Kenya.

GOK & UNICEF, (1998) Children and Women in Kenya: A Situation Analysis , UNICEF Kenya Office, Nairobi.

United Nations (1995), Fourth World Conference on women, Beijing China, 4-15th Sept. 

Westoff, C.F. and Rodriguez, G (1995) The Mass Media and Family Plannin in International Family Planning Perspectives, 21:26-36.

World Health Organization, (1999), Women and Health: Beijing Platform For Action: A Review of WHO's Activities, WHO, Geneva.

ACKNOWLEDGEMENTS

I am indebted to the Organisation of Catholics For A Free Choice (CFFC) for awarding me a research grant that made this study possible. Special thanks are extended to all respondents from the study areas for their willingness to share with us views, knowledge and experiences in the areas of reproductive health.