1 Role of family planning in reducing unwanted pregnancies and unsafe abortions: synthesis of global and Kenya specific evidence Violet I. Murunga and Nyokabi R. Musila Presented at the Population Association of Kenya, 4 th Population Conference Nairobi, Kenya (October 23-25, 2012)

Outline Unsafe abortion in SSA and in Kenya Role of FP in reducing unsafe abortion Factors promoting unsafe abortion in Kenya Recommendations

Key messages Unsafe abortion is a major cause of maternal mortality Women usually choose to induce abortion because of unwanted pregnancy Unsafe abortion is preventable and can be reduced by increasing contraceptive use among women who want to postpone or stop child bearing

Unsafe abortion in SSA Unsafe abortion estimates, SSA, 2008 *Number of unsafe abortion (millions) *Induced abortion rate (per 1000 woman of 15-44) Number maternal deaths due to unsafe abortion % of maternal deaths Africa ,00014 Eastern Africa ,00018 Middle Africa ,40012 Northern Africa ,50012 Southern Africa Western Africa ,70012 Source: WHO 2008; 2012* update

Evidence shows that the number of unsafe abortions remains high in SSA 2012 Adding it Up report by the Guttmacher Institute/UNFPA – In 2012 there will be an estimated ~19 million unintended pregnancies (39% of all pregnancies) in SSA resulting in 6 million abortions Unsafe abortion contributes to maternal morbidity and mortality; – MDG5 target in SSA trailing other regions – Preventable through increasing use of FP

Abortions are common in Kenya 2002 national estimates - 300,000 (both induced & miscarriages) abortions occur in Kenya annually → *46 abortions for every 1,000 women of reproductive age (Ipas 2004)

Morbidity and mortality attributed to unsafe abortion in Kenya is unknown No national estimates in Kenya Pilot study in Nakuru Provincial General Hospital - unsafe abortion accounted for 1 out of 4 (25%) maternal deaths in 2002 (Herndon et al 1998) Small-scale study – ~6 out of 10 (60%) gynecologic emergency hospital admissions are due to abortion complications (Gebreselassie et al 2005) 8

FP reduces unwanted pregnancies The most common reason for inducing abortion is unintended pregnancy. A review of 32 studies in 27 countries examining the reasons (Bankole et al 1998) In almost half of 23 studies (in 20 countries), about 50% or more of women gave the birth-timing and family-size control cluster of reasons as their most important reason Notably, there are other factors in a woman's life that make the timing of the pregnancy undesirable which were also examined in the study

Majority of unintended pregnancies occur among women with unmet need for modern FP Source: Guttmacher Institute and UNFPA (2012). Adding it Up report. Estimated 80 million unintended pregnancies in 2012

Meeting unmet need for FP would reduce the number of unintended pregnancies and abortions  number of unintended pregnancies in SSA countries from 19 million to 4 million (78% reduction) – Reduce abortions from approx. 6 million to approx. 1 million

Kenya has high unmet need for FP and unintended pregnancies  unmet need in Kenya – 1 out of 4 women (25%) & has remained at this level since 1998  levels of unintended pregnancies and unsafe abortions – >40% of births in Kenya are unplanned; a Kenyan woman gives birth to one child more than she wants Source: KDHS

Barriers to accessing FP services Youth; sexually active unmarried women; rural women; poor and uneducated women – Stigma associated with premarital sex. (Adaji et al 2010) – Pregnancy most 2 nd most common reason for adolescent girls dropping out of sec. school(KHRC 2010); abortion regarded the only way to avoid expulsion (Mitchell et al 2006) – Sex education fragmented in schools(Agbemenu and Shlenck 2011); religious and cultural taboos (Chrichton et al 2011)

Postabortion care is inadequate Legal restrictions on abortion Abortion in Kenya is still operating under the previous guidelines; act of parliament still pending Post abortion care (PAC) PAC is inadequate - nurses and midwives can legally provide PAC but in many instances only doctors are adequately trained; many small facilities not equipped; Cost (ksh 1,000-10,000) – Sources: Center for Reproductive Rights 2010; Gebreselassie et al 2005; & KHRC 2010)

Recommendations Reduce unmet need for FP and eliminate barriers to obtaining FP services – Government scaling up targeted educational campaigns using media and parliamentarians & targeting the county system – Sustained advocacy is needed to increase resource allocation for FP given that investment will actually reduce overall healthcare costs 15

Recommendations cont’d Improve sex education in schools – Government introduced National Lifeskills Eduacation (LSE) in – After successful advocacy efforts, MOE is rolling out a comprehensive sexuality education in the curriculum persists 16

Recommendations cont’d Expand PAC services. – The government recently launched standards & guidelines for reducing morbidity and mortality from unsafe abortion in Kenya emphasizing expansion of PAC services – need to ensure implementation Increase access to and utilization of safe abortion services Educate both potential users and providers; train more providers and build capacity of health facilities

Thank You 18