**2. Data and methods**

#### **2.1. Data**

improvements in women's and children's health through appropriate spacing of births which in turn contribute to reductions in maternal and child mortality that could arise from having short birth intervals; enhanced educational and employment opportunities for women due to the ability to control their fertility; and environmental sustainability that results from creating a balance between population and available resources [3–7]. Although efforts to improve contraceptive uptake have led to increased use of modern family planning methods in some parts of the developing world, many countries are still characterized by high levels of unmet need for contraception and unintended pregnancies [8, 9]. It was, for instance, estimated that in 2012, 222 million women in developing countries had an unmet need for modern contraceptives, with the prevalence of unmet need being highest in most parts of sub-Saharan Africa [5]. In addition, 40% of 213 million pregnancies that occurred globally in 2012 were unintended, with Africa recording the highest rate of unintended pregnancies per 1000 women

Unintended pregnancies result from non-use of contraception, use of ineffective methods, contraceptive discontinuation or switching for reasons other than wanting a pregnancy, and contraceptive failure [8, 9, 11]. With respect to contraceptive failure, which is the focus of this chapter, available estimates show that about a third of unintended pregnancies in developing countries result from method failure [12, 13]. Evidence further shows that contraceptive failure rate (number of failures per 100 episodes of use) within the first year of use is lowest for permanent methods such as female sterilization, followed by longer-acting methods such as implants, intrauterine devices (IUDs), and injectables while short-acting methods such as pills and male condoms have the second highest failure rates after traditional methods including withdrawal, periodic abstinence, and rhythm [12, 13]. Contraceptive failure may negatively affect the success of family planning programs especially in developing countries where uptake of modern methods is further hampered by limited method mix, weak service delivery systems, health concerns about possible side effects, as well as societal opposition to

Consistent with global efforts to improve family planning uptake in developing countries, national estimates show that the contraceptive prevalence rate (CPR) in Kenya—the proportion of currently married women using any method of contraception—more than doubled from 27% in 1989 to 58% in 2014 [16, 17]. Use of modern methods nearly tripled over the same period from 18% in 1989 to 53% in 2014 [16, 17]. The 2014 CPR level raised excitement among the donor community, policy makers and program implementers since it surpassed the target of 56% that the country had set to achieve by 2015 as part of the Millennium Development Goals (MDGs). The achievement was attributed to a combination of factors, including deliberate efforts to reposition family planning after a decade of focus on HIV/AIDS; implementation of a national program on AIDS, Population and Health Integrated Assistance (APHIA) funded by the United States Agency for International Development (USAID) that focused on health systems strengthening; increased health sector funding for family planning; improvements in the capacity of healthcare workers to provide services; streamlining the procurement and distribution of commodities through the Kenya Medical Supplies Agency (KEMSA); and using innovative service delivery models such as mobile outreaches, in-reach/choice camps in

facilities, community-based distribution, and integration of services [18].

aged 15–44 years [10].

156 Family Planning

and misconceptions about contraception [6, 14, 15].

Data are from a cross-sectional study that was conducted between November and December 2016 among currently married or cohabiting women aged 15–39 years in three rural subcounties of Homa Bay County, namely, Ndhiwa, Rachuonyo north and Rachuonyo south. The county, located along the shores of Lake Victoria in western Kenya region, was purposefully selected based on three factors. First, Homa Bay County is one of the counties with rapidly growing population. According to the 2009 Kenya population and housing census, the county was home to 963,794 people at the time of the census [22]. The population was projected to rise to about 1.2 million persons by 2017, of which, 564,843 were projected to be males while 612,338 females [23]. This growth is largely a result of high fertility, which is estimated at 5.2 children per woman, compared to a national average of 3.9 children per woman [17]. Second, the county continues to experience challenges with respect to reproductive 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 married adolescent girls [25].

(less than four and four or more). The analysis adjusted for clustering of individuals residing in the same village, and the results are presented as odds ratios (OR) with 95% confidence

Contraceptive Failure among Women in Homa Bay County of Kenya…

http://dx.doi.org/10.5772/intechopen.72161

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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

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.

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.

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

similar proportion (52%) had four or more living children (**Table 1**).

**3.2. Extent of contraceptive failure**

**3.3. Variations in contraceptive failure**

intervals (CI).

**3. Results**

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

#### **2.2. Analysis**

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 (less than four and four or more). The analysis adjusted for clustering of individuals residing in the same village, and the results are presented as odds ratios (OR) with 95% confidence intervals (CI).
