**3. Results**

health. According to the 2014 Kenya demographic and health survey, the level of contraceptive use among currently married women aged 15–49 years was modest at 47% while unmet need for family planning was also among the highest in the country at about 26% [17]. Furthermore, the county has a perpetual burden of high unintended pregnancy and overall high HIV prevalence estimated at 26%, which is the highest in Kenya [24]. Third, the county was easily accessible to the research team, having previously conducted operations research on access to comprehensive reproductive health and HIV information and services for mar-

The study involved structured interviews with 2424 women who were identified in two stages. In the first stage, 12 sub-locations (the smallest administrative unit in Kenya) were randomly sampled from the list of sub-locations in each sub-county. All households in the sampled sublocations with currently married women aged 15–49 years were identified with the help of village elders, and all individuals in those households were listed to generate the sampling frame. A total of 3118 women aged 15–39 years were then randomly sampled from among 5424 in the sampling frame that were within that age range and were married at the time of listing (1040 each in Ndhiwa and Rachuonyo north and 1038 in Rachuonyo south sub-counties). The upper age limit was informed by plans to interview the women again in future and the desire for such follow-up interviews to find when they are still within the reproductive age cohort.

Out of the women who completed interviews, 2294 (95%) reported having ever used a contraceptive method while 1563 (64%) were using a method at the time of the survey. Slightly more than a third (39%) of past users reported being dissatisfied with at least a method. Those who reported dissatisfaction with a method were asked about the reasons for each of the methods they were dissatisfied with. A total of 166 out of 896 women (18%) who reported dissatisfaction with methods mentioned failure of at least one method. This chapter focuses on women who reported during interviews that they got pregnant while using a contraceptive method. Although reasons for dissatisfaction were not asked to women who were using female sterilization, four women who were using the method mentioned to interviewers that they experienced method failure. In addition, whereas the study tool was not specifically designed to capture reasons for method failure, the research teams collected additional information on such reasons from 69 of the 166 women and prepared reports on the same. We used the infor-

Analysis entailed descriptive statistics (frequencies and percentages) and estimation of multivariate logistic regression model examining variations in the likelihood of experiencing method failure among dissatisfied users of contraceptives. The outcome of the model is whether a study participant reported experiencing failure of any method and was coded zero for 'no' and one for 'yes'. The independent variables included the sub-county, age (coded zero for under 25 and one for 25 years and above), education level (no formal schooling or primary incomplete, primary complete, and secondary and above), religious affiliation (protestant/other Christian or otherwise), number of times married (once or more than once), living arrangements with partner (living away or with respondent), and number of living children

mation from the reports to supplement the data captured by the study tool.

ried adolescent girls [25].

158 Family Planning

**2.2. Analysis**

#### **3.1. Characteristics of women experiencing contraceptive failure**

Close to half (43%) of the women reporting contraceptive failure were from one sub-county (Ndhiwa). Similarly, half (50%) of the women experiencing method failure were aged between 20 and 29 years, 6% were aged below 20 years while the rest were aged 30 years and above (**Table 1**). In addition, most of the women (96%) were married as opposed to cohabiting, most (88%) had been married once, and about three-quarters (78%) were living with their partners at the time of the survey. More than half (60%) had completed primary, secondary, or higher level education. More than half (56%) had given birth to four or more children and almost a similar proportion (52%) had four or more living children (**Table 1**).

#### **3.2. Extent of contraceptive failure**

Although only about one in five (18%) of the women who were dissatisfied with contraceptive methods mentioned failure as the reason, most of the women reported knowing other friends who got pregnant while on methods. For instance, one woman who got pregnant while on implants reported during interviews that four of her friends who obtained the method from the same health facility on the same day also got pregnant while on the method around the same time that she did. Another respondent who got pregnant while on implants reported that whereas her husband supported and even accompanied her to get the method, he was very disappointed when she got pregnant and did not want to hear about family planning anymore. A woman who got pregnant while on injectables mentioned knowing about 10 other friends who became pregnant while using the method. One who got pregnant while on female sterilization reported that she experienced ectopic pregnancy while on the method, went through Cesarean section, and had to go through another tubal ligation. Another who was on sterilization reported that she had an operation after experiencing ectopic pregnancy, which led to cancer and that she was on treatment for the disease at the time of interview.

#### **3.3. Variations in contraceptive failure**

Variations in method failure by type of method showed that it was highest for rhythm (38%), followed by pills (30%), injectables (17%), and withdrawal (15%, **Figure 1**). In contrast, method failure was low for condoms and implants (4% each) while none of the dissatisfied IUD users mentioned failure of the method as a reason. Results not shown indicate that only 62 women reported using female sterilization. Assuming that the four women who mentioned to interviewers that they experienced failure of the method reported correctly, then this represents about 6% of users of female sterilization and 2% of those who reported failure of any method.

#### 160 Family Planning


Results from the multivariate logistic regression analysis showed that there were statistically significant differences in the likelihood of experiencing contraceptive failure by study site (**Table 2**). In particular, the likelihood of experiencing method failure was significantly lower in Rachuonyo North and Rachuonyo South sub-counties than in Ndhiwa sub-county (OR: 0.61; 95% CI: 0.40–0.92 for Rachuonyo North, and OR: 0.43; 95% CI: 0.28–0.66 for Rachuonyo South). A test of whether the difference between Rachuonyo North and South was statistically significant showed that it was not (p = 0.13), indicating that the significant differences were mainly between Ndhiwa and the other two sub-counties. There were, however, no statistically significant variations in the likelihood of experiencing method failure by the other

**Characteristics Percent Number of women**

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 2–3 39.2 65 4–5 36.8 61 6 and above 15.7 26 Total 100.0 166

**Table 1.** Distribution of contraceptive users who experienced method failure.

Failure of injectables and pills was partly because of challenges with adherence to the methods. Some women reported that they forgot to return to the facilities for the methods on the dates of appointments. In some cases, they resorted to obtaining the methods from other

16.9

0 5 10 15 20 25 30 35 40

Percent

15.1

38

29.5

background characteristics considered (**Table 2**).

4.2

**Figure 1.** Contraceptive failure by type of method. Note: N = 166.

3.6

0

Rhythm

Injectables

Withdrawal

Condoms

Implants

IUD

Pills

**3.4. Reasons for contraceptive failure**


**Table 1.** Distribution of contraceptive users who experienced method failure.

Results from the multivariate logistic regression analysis showed that there were statistically significant differences in the likelihood of experiencing contraceptive failure by study site (**Table 2**). In particular, the likelihood of experiencing method failure was significantly lower in Rachuonyo North and Rachuonyo South sub-counties than in Ndhiwa sub-county (OR: 0.61; 95% CI: 0.40–0.92 for Rachuonyo North, and OR: 0.43; 95% CI: 0.28–0.66 for Rachuonyo South). A test of whether the difference between Rachuonyo North and South was statistically significant showed that it was not (p = 0.13), indicating that the significant differences were mainly between Ndhiwa and the other two sub-counties. There were, however, no statistically significant variations in the likelihood of experiencing method failure by the other background characteristics considered (**Table 2**).

#### **3.4. Reasons for contraceptive failure**

**Characteristics Percent Number of women**

 Ndhiwa 42.8 71 Rachuonyo North 32.5 54 Rachuonyo South 24.7 41

 15–19 6.0 10 20–24 19.9 33 25–29 30.1 50 30–34 28.3 47 35–39 15.7 26

 Cohabiting 3.6 6 Married 96.4 160

 None/some primary 40.4 67 Completed primary 34.3 57 Secondary and above 25.3 42

 Catholic 10.2 17 Protestant/other Christian 88.0 146 Muslim/other 1.8 3

 Once 88.0 146 More than once 12.1 20

 Living away 21.7 36 Living with respondent 78.3 130

 0–1 6.6 11 2–3 36.8 61 4–5 33.7 56 6 and above 22.9 38

0–1 8.4 14

Sub-county

160 Family Planning

Age group (years)

Marital status

Highest education level

Religious affiliation

Number of times married

Children ever born

Number of living children

Living arrangement with partner

Failure of injectables and pills was partly because of challenges with adherence to the methods. Some women reported that they forgot to return to the facilities for the methods on the dates of appointments. In some cases, they resorted to obtaining the methods from other

**Figure 1.** Contraceptive failure by type of method. Note: N = 166.


sufficient information about other methods when they sought care at health facilities. Others mentioned the costs associated with obtaining implants (equivalent of \$1) as a deterrent to honoring scheduled appointments and ensuring continuous use without interruptions.

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Contraceptive failure occurs to women and couples who are already making efforts to prevent mistimed or unwanted pregnancy. Contraceptive failure is likely to lead to disillusionment with methods or abandonment of contraception, with possible consequences of a rise in unintended pregnancies and the potential for increased incidents of induced abortion, which if conducted in unsafe conditions are likely to contribute to increased incidents of maternal morbidity and mortality [11, 12]. As the results of this chapter show, some study participants who experienced contraceptive failure reported that they or their partners were disappointed that the methods did not work for them. However, the findings indicate that contraceptive failure resulted from deficiencies either on the part of the user or the provider. In particular, failure of methods such as injectables, pills and condoms was mainly due to challenges with adherence (such as not regularly taking pills or not honoring scheduled appointments for injectables) and inconsistency of use (especially of condoms) on the part of the users. The finding suggests the need for expanding the range of contraceptive methods and providing adequate information and counseling for women and couples to enable them make informed

The findings further show that failure of more effective methods such as implants and female sterilization was partly due to limited provider capacity to offer the methods and partly due to inability to afford the costs of continuing the use of implants. Provider deficiency could be due to lack of appropriate skills, workload or lack of relevant equipment. For instance, the methods require highly skilled personnel to administer that might be lacking in the rural community where the study was conducted. It could also be that even if the providers had the requisite skills, staffing challenges facing lower level facilities especially in remote settings may negatively impact the quality of care provided in such outlets where in most cases, only one or two providers are available to offer all forms of healthcare including curative, preventive, promotive and reproductive health services. Lack of appropriate equipment is another challenge that could impede providers' ability to administer the methods even if they have the relevant skills. Whatever the reason, provider deficiency was evident from women's reports that they got information about the methods from friends who had used them, and that they were not given sufficient information when they sought services at health facilities. The finding suggests the need for addressing health systems challenges that affect the provision of the more effective long-acting and permanent methods such as implants and female sterilization in such rural settings. Although the cost of continuing use of implants also emerged as an issue, the global Implant Access Initiative that aims to make the method available at low cost has enabled family planning programs to increase its availability, which has contributed to increased use of the method in settings such as Kenya [18, 26]. The reach of the initiative might, however, be hampered by uncertainties about its sustainability and

decisions regarding methods that are appropriate and easy for them to use.

**4. Discussion**

**Table 2.** Odds ratios from multivariate logistic regression model examining variations in the likelihood of experiencing contraceptive failure.

sources such as private pharmacies, community health volunteers or community-based distributors for fear of reprisals from health facility providers because of missed appointments. Some reported that they went back to health facilities even after missing appointments but that they were not screened for pregnancy before being given the methods again, which could suggest that they might have already been pregnant at the time. Some women who were on pills reported that they forgot taking the method on certain occasions, while others suspected that the pills did not dissolve but were instead piling in the stomach. Another participant who was on pills reported using strong antibiotics at the time she got pregnant, which she suspected might have interfered with the efficacy of the method and thus exposed her to the risk of pregnancy.

Reasons for failure of implants and female sterilization—which are highly effective methods and are less dependent on client adherence—were, however, not straightforward. Women who got pregnant while on implants suspected that they were provided with expired commodities. Some reported that the implants might have disappeared in their bodies and thus became less effective. Another who got pregnant while on implants and was HIV-positive reported that she was told by a healthcare provider that antiretroviral drugs (ARVs) may reduce the efficacy of the method and that she suspected that it is what happened in her case. Those who got pregnant while on female sterilization reported that they were told by healthcare providers that the procedure entailed turning the uterus inside out, which made them believe that the process is reversible. In most cases, women reported that they got information about the methods they chose from friends who had used them, and that they were not given sufficient information about other methods when they sought care at health facilities. Others mentioned the costs associated with obtaining implants (equivalent of \$1) as a deterrent to honoring scheduled appointments and ensuring continuous use without interruptions.

### **4. Discussion**

sources such as private pharmacies, community health volunteers or community-based distributors for fear of reprisals from health facility providers because of missed appointments. Some reported that they went back to health facilities even after missing appointments but that they were not screened for pregnancy before being given the methods again, which could suggest that they might have already been pregnant at the time. Some women who were on pills reported that they forgot taking the method on certain occasions, while others suspected that the pills did not dissolve but were instead piling in the stomach. Another participant who was on pills reported using strong antibiotics at the time she got pregnant, which she suspected might have interfered with the efficacy of the method and thus exposed her to the

**Table 2.** Odds ratios from multivariate logistic regression model examining variations in the likelihood of experiencing

**Covariate Odds ratio 95% CI**

 Rachuonyo North 0.61\* [0.40–0.92] Rachuonyo South 0.43\*\* [0.28–0.66] Age group (25 and above = 1) 1.31 [0.82–2.08]

 Primary complete 1.21 [0.81–1.80] Secondary and above 1.28 [0.84–1.95] Religious affiliation (Protestant/other Christian = 1) 1.11 [0.64–1.92] Number of times married (More than once = 1) 1.21 [0.71–2.07] Living arrangements with partner (Living with respondent = 1) 0.91 [0.59–1.39] Number of living children (Four or more = 1) 1.19 [0.80–1.77]

Number of women 896

Reasons for failure of implants and female sterilization—which are highly effective methods and are less dependent on client adherence—were, however, not straightforward. Women who got pregnant while on implants suspected that they were provided with expired commodities. Some reported that the implants might have disappeared in their bodies and thus became less effective. Another who got pregnant while on implants and was HIV-positive reported that she was told by a healthcare provider that antiretroviral drugs (ARVs) may reduce the efficacy of the method and that she suspected that it is what happened in her case. Those who got pregnant while on female sterilization reported that they were told by healthcare providers that the procedure entailed turning the uterus inside out, which made them believe that the process is reversible. In most cases, women reported that they got information about the methods they chose from friends who had used them, and that they were not given

risk of pregnancy.

contraceptive failure.

\* p < 0.05. \*\*p < 0.01.

Sub-county (ref = Ndhiwa)

162 Family Planning

Education level (ref = None/primary incomplete)

Contraceptive failure occurs to women and couples who are already making efforts to prevent mistimed or unwanted pregnancy. Contraceptive failure is likely to lead to disillusionment with methods or abandonment of contraception, with possible consequences of a rise in unintended pregnancies and the potential for increased incidents of induced abortion, which if conducted in unsafe conditions are likely to contribute to increased incidents of maternal morbidity and mortality [11, 12]. As the results of this chapter show, some study participants who experienced contraceptive failure reported that they or their partners were disappointed that the methods did not work for them. However, the findings indicate that contraceptive failure resulted from deficiencies either on the part of the user or the provider. In particular, failure of methods such as injectables, pills and condoms was mainly due to challenges with adherence (such as not regularly taking pills or not honoring scheduled appointments for injectables) and inconsistency of use (especially of condoms) on the part of the users. The finding suggests the need for expanding the range of contraceptive methods and providing adequate information and counseling for women and couples to enable them make informed decisions regarding methods that are appropriate and easy for them to use.

The findings further show that failure of more effective methods such as implants and female sterilization was partly due to limited provider capacity to offer the methods and partly due to inability to afford the costs of continuing the use of implants. Provider deficiency could be due to lack of appropriate skills, workload or lack of relevant equipment. For instance, the methods require highly skilled personnel to administer that might be lacking in the rural community where the study was conducted. It could also be that even if the providers had the requisite skills, staffing challenges facing lower level facilities especially in remote settings may negatively impact the quality of care provided in such outlets where in most cases, only one or two providers are available to offer all forms of healthcare including curative, preventive, promotive and reproductive health services. Lack of appropriate equipment is another challenge that could impede providers' ability to administer the methods even if they have the relevant skills. Whatever the reason, provider deficiency was evident from women's reports that they got information about the methods from friends who had used them, and that they were not given sufficient information when they sought services at health facilities. The finding suggests the need for addressing health systems challenges that affect the provision of the more effective long-acting and permanent methods such as implants and female sterilization in such rural settings. Although the cost of continuing use of implants also emerged as an issue, the global Implant Access Initiative that aims to make the method available at low cost has enabled family planning programs to increase its availability, which has contributed to increased use of the method in settings such as Kenya [18, 26]. The reach of the initiative might, however, be hampered by uncertainties about its sustainability and controversies around the association between hormonal contraception and increased risk of HIV acquisition [18, 27, 28].

the program at the local levels. Interventions could include expanding the mix of available methods, provision of adequate information, improving counseling, as well as addressing health system factors that impede the provision of quality care such as limited staff skills, staff availability, inadequate supplies, and lack of or faulty equipment for administering long-

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The study that provided data for this chapter was funded by UKaid from the Department for International Development (DfID) through STEP UP (Strengthening Evidence for Programming on Unintended Pregnancy) Research Programme Consortium. The opinions expressed in this chapter are, however, solely those of the authors and do not necessarily

[1] Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A, Innis J. Family planning: The unfin-

[2] Cates W, Karim QA, El-Sadr W, Haffner DW, Kalema-Zikusoka G, Rogo K, Petruney T, Averill EMD. Family planning and the millennium development goals. Science. 2010;

[3] Rebecca A. The role of family planning in poverty reduction. Obstetrics and Gynecology.

[4] Miller G. Contraception as development? New evidence from family planning in

[5] Singh S, Darroch JE. Adding It Up: Costs and Benefits of Contraceptive Services— Estimates for 2012. New York: Guttmacher Institute and United Nations Population

[6] Tsui AO, McDonald-Mosley R, Burke AE. Family planning and the burden of unin-

reflect the views of the funding agency or STEP UP partners.

Francis Obare\*, George Odwe and Wilson Liambila

Population Council, Nairobi, Kenya

\*Address all correspondence to: fonyango@popcouncil.org

ished agenda. Lancet. 2006;**368**(9549):1810-1827

Colombia. Economic Journal. 2010;**120**(545):709-736

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acting and permanent methods.

**Acknowledgements**

**Author details**

**References**

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2007;**110**(5):999-1002

Fund (UNFPA); 2012

Previous studies showed that contraceptive failure was more prevalent among younger than older users, which could be an indication of incorrect use of methods among these sub-groups [29, 30]. The findings of this chapter, on the other hand, show that there were no significant variations in reporting contraceptive failure by age among participants in the study. This could largely be due to the study's focus on married or cohabiting women—one of its limitations—which might have left out many unmarried young women at risk of experiencing contraceptive failure. However, evidence on variations in contraceptive failure by level of education is mixed, with some studies finding higher failure rates among less educated than more educated users, while others found no difference between the two sub-groups [29–31]. The findings of this chapter are consistent with those of previous studies that did not find significant differences in contraceptive failure by levels of education. The significant differences in contraceptive failure between sub-counties included in the study are, on the other hand, consistent with those of other studies that found sub-national variations in method failure, which could be an indication of disparities in provision of quality care [29].
