InternationalJournalofBusinessandSocialScience

Vol.2No.1;January2011

ContraceptiveUseamongWomenofReproductiveAgeinKenyasCitySlums
TimothyC.Okech
PhDCandidate,SchoolofEconomics,KenyattaUniversity,Kenya
Email:tcokech@usiu.ac.ke
Dr.NelsonW.Wawire
SeniorLecturer,SchoolofEconomics,KenyattaUniversity,Kenya
Dr.TomK.Mburu
Lecturer,SchoolofEconomics,KenyattaUniversity,Kenya
http://www.ku.ac.ke/schools/economics/images/stories/research/contraceptive-use-among-women-ofreproductive-age-in-kenya-city-slums.pdf
Abstract
TheKenyagovernmentincollaborationwithotherstakeholdersinvolvedintheprovisionoffamilyplanning
serviceshaveputinplacevariousstrategiesandpoliciestoincreaseuptakeoffamilyplanningservices.These
areaimedatincreasingcontraceptiveprevalencerate(CPR),reductioninbothtotalfertilityrate(TFR)and
unmet need for familyplanning services. Despite the various strategies andpolicies, total fertilityrate still
remainshighat4.6percent,whileCPRandunmetneedforfamilyplanningareestimatedat46percentand24
percent,respectively.Thepurposeofthestudywastoexaminetheutilizationleveloffamilyplanningservices
andtoanalyzethedeterminantsofdemandforfamilyplanningservicesamongwomeninCityslumsinKenya.To
realizethisobjective,asurveydesignwasadopted.Thetargetpopulationconstitutedwomenincityslumsin
Kenya,whowereidentifiedthroughmultistagerandomsampling.Primarydatawascollectedfromthewomen
usingastructuredinterviewschedule. Afactsheet wasusedtosummarizethedatacollectedbeforeitwas
cleaned, coded and edited for completeness and accuracy. The study revealed low usage of contraceptives
comparedtothenationallevel.Useoftheservicesvariedintermsofdemographicandsocioeconomicfactorsof
thewomanandalsothewomansperceptionintermsofthefacility/providerfactorssuchquality,friendlinessof
staff and promotion. Various factors accounted for the low use of family planningservices. These included
partnersapproval,qualityoftheservices,friendlinessofthestaffadministeringtheservicesandthewomans
knowledgeaboutfamilyplanningservices.Otherfactorsincludedthewomansincomelevel,proximitytothe
providerandthereligiousbackgroundofthewoman.Toincreasetheuseoffamilyplanningservicesamong
womeninslums,activitiesofcommunitybaseddistributorsshouldberevivedandenhanced,promotionoffamily
planningeducationandactivitiesatthehouseholdlevelshouldbeaccordedpriority.Formationoflobbygroups
toenhanceculturalchange,awarenesscreationandcounsellingandintegratingfamilyplanningserviceswith
HIV/AIDSarerecommended.

Keywords:Familyplanning,women,reproductiveage,Kenya
Introduction
Manydevelopingeconomiesarecharacterizedbyrapidpopulationgrowththatispartlyattributedtohighfertility
rate,highbirthratesaccompaniedbysteadydeclinesindeathrates,lowcontraceptiveprevalencerateandhigh
butdecliningmortalityrate(Oyedokun,2007).InSubSaharanAfrica(SSA),therateofpopulationgrowthisone
ofthehighestintheworld,(2.8percent)comparedtotherestoftheworld(USAID/HPI,2007).Equally,the
numberofpeopleinneedofhealthandeducation,amongotherpublicgoodsislargeandincreasingwhichinturn
requireslargeamountsofresources,personnelandinfrastructure.Thisislikelytobeanimpedimenttowardsthe
realizationofthereductionofchildmortality,improvementofmaternalhealth,achievementofuniversalprimary
education, environmental sustainability and combating HIV/AIDS, malaria and other diseases as part of the
MillenniumDevelopmentGoals(MDGs)(HealthPolicyInitiative,2007).Toaddressthis,manycountriesinthe
SubSaharanAfrica(SSA)includingKenyafocusedtheirattentiononbirthcontrolmeasures,especiallytheuseof
family planning services.In Kenya, family planning services have been in use since 1957 when the Family
Planning Association of Kenya (FPAK) started operating family planning clinics within Ministry of Health
facilities.

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Thegovernmentrecognizedtheimportanceoffamilyplanningsoonafterindependence,andformallyaccepted
populationplanningandfamilyplanningaspartoftheNationalPlanningStrategies(RepublicofKenya,1965).
Toenhanceitscommitment,theGovernmentofKenyaestablishedtheNationalCouncilforPopulationand
Development(NCPD)in1982.Themandateoftheinstitutionwastoformulatepopulationpoliciesandstrategies
aimedatreducingKenyaspopulationgrowthrate.IntheKenyaHealthPolicyFramework(KHPF)of1994,the
Governmentidentifiedpopulationdevelopmentasaprioritystrategyforachievingbalancedsocioeconomic
development.Inthereport,reproductivehealthcomponentswereidentifiedasoneofkeystrategies.Specifically,
theGovernmentprioritisedreductioninfertilityrateaswellasincreaseintheproportionofhealthfacilities
providingintegratedreproductivehealthservicesincludingfamilyplanning(FP)servicesaskeypriorityin
populationdevelopment.Toreinforceitscommitmentfurther,thegovernmentlaunchedSessionalPaperNo.1of
1996onNationalPopulationPolicyforSustainableDevelopment,inwhichitrecognizedpopulationchallengesas
unmetneedforfamilyplanningandhighlevelofadolescentfertility.Asaresult,thegovernmentreiteratedits
commitmenttoincreasingavailability,acceptabilityandaffordabilityofqualityfamilyplanningservices.
Toensurequalityprovisionoftheseservices,thegovernment,throughtheMinistryofHealth(MOH),developed
guidelinesandstandardsforfamilyplanningserviceprovidersin1991.Theguidelineswerenotonlydevelopedto
assistfamilyplanningprovidersineducatingclients, but alsotodetermine andprovide the bestmethodfor
clientsneedsandtoinstructtheclientsintheuseofmethodandfollowup(RepublicofKenya,1991).The
guidelineswerehoweverreviewedin1997andconsequentlyincorporatedintheReproductiveHealth/Family
Planning Policy Guidelines and Standards for Service Providers (Republic of Kenya, 2007). In the policy
document,provisionofqualityandsustainablefamilyplanningserviceswasidentifiedasthemaingoalthat
wouldhelptoreducetheunmetneedsforfamilyplanning.Aspartofitscommitmentinaddressingpopulation
growth,theGovernmentintheNationalHealthSectorStrategicPlanII(NHSSPII)of20052010specifiedthe
Kenya Essential Health Package (KEPH). In the package, a wide range of population growth issues was
addressed. These range from maternal health infections, nutritional deficiencies, family planning and child
spacing.TheGovernmentfurtherreiterateditscommitmentincontainingpopulationgrowthintheVision2030
and National Population Census report of 2010 through various interventions including provision of family
planningservices(RepublicofKenya,2007b;RepublicofKenya,2010).

TrendsinFertilityRateandContraceptiveuseinKenya
ThepolicydevelopedbytheGovernmentsince1968remaineddormantuntilthefindingsfromtheWorldFertility
Survey(WFS)in1977showedthatKenyahadoneofthehighestfertilityratesintheworldof8childrenper
woman(WFS,1977).Thisstatisticservedtofocusbothpolicyandpublicattentiononfertilityissuesandto
reinvigoratethepopulationpolicy,withtheresultthatsubstantialnationalandinternationalsupportwasdedicated
to developing and strengthening a vigorous national family planning programme. The impact of this was
remarkable,asthefertilityratedeclinedfrom8.1childrenperwomanin1977to6.7,4.7and4.6in1989,1998
and2008respectively,(RepublicofKenya,2009).Indeed,thedeclineinfertilitybetween1977and1998,from
8.1to4.7birthsperwomanwasoneofthemostrapiddeclineseverdocumentedintheworld.Thisconsistent
declineinfertilityledtoprojectionsthattotalfertilityrate(TFR)woulddeclinegraduallytoabout3.5by2008.
Thisdeclinewasattributedtoincreasedcontraceptiveuseamongwomenagedbetween15and49years(Republic
ofKenya,2003).Ontheotherhand,thecontraceptiveprevalencerateincreasedrapidlyfrom9.7percentin1984
to39percentin2003.Thesustainedincreaseintheuseoffamilyplanningserviceswasamajorfactorinfertility
transition, providing women and couples with the means to help them plan pregnancies (Backer, 2003;
USAID/HPI,2007;RepublicofKenya,2007b).
AsoneofthefirstcountriesinAfricatodevelopaPopulationPolicyandestablishaFamilyPlanningProgramme
asthemainpolicylevertoreducethepopulationgrowthrate,Kenyahasbeenwellplacedtoinitiateafertility
transitionthroughgovernmentledactions(Koomeetal.,2005;Ianetal.,2009).Inthe1980sand1990s,Kenya
achievedarapidfertilitydecline,becauseoftheofficialcommitmentofthegovernment,substantialfundingand
technicalsupportfromarangeofbilateralandmultilateraldevelopmentpartners.

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Indeed, whentheresults ofthe1993Demographic HealthSurvey(DHS) were released,Kenyassuccessin

achievingaphenomenaldeclineinfertilitywaslaudedglobally,andmanynationalandinternationalobservers
feltthatsocialnormsinfavourofsmallfamiliesandincreaseduseofcontraceptionwerenowwellestablished
andirreversible(Ian etal., 2009).Overthedecadestartingfromthemid1990s,thenationalfamilyplanning
programme was substantially reduced following the withdrawal of funding from donors, and a reduction of
governmentfunding.Asaresult,thelargescalecommunitybaseddistribution(CBD)programmesthatallowed
lowcostcontraceptiveinformationandservicestoreachruralandperiurbancommunitiesdeclineddrastically.
Atthesametime,thenationwideinformationeducationandcommunication(IEC)campaignsadvocatingfor
smallfamiliesandtheuseofcontraceptioncollapsed.Bothofthesecomponentshadbeenintroducedasdemand
creationstrategiesforfamilyplanningservices.Thedrasticreductionininvestmentinthesestrategiesatthistime
reflectedthefalseperceptionthatthedemandforfamilyplanningwassufficientlywellestablishedinthegeneral
population,andthattheprogrammesfocusshouldconsequentlyhaveshiftedtoaddressingtheresultingunmet
need(Crinchton,2008).
Severalotherfactorsalsoinfluencedfundingofthefamilyplanningprogrammes.Someoftheserelatetopolicy
andprogrammaticdecisionsconcerningthefamilyplanningeffortinthe1990s.TheInternationalConferenceon
PopulationandDevelopment(ICPD)in1994affirmedtheimportanceofprovidingfamilyplanningwithina
rightsbasedframeworkandaspartofacomprehensivesetofservicestomeetindividualreproductivehealth
needsthatwouldalsoaddressbroaderdevelopmentconcerns(WestoffandCross,2006).Whilethisundoubtedly
broadenedtherangeandqualityofreproductivehealthservicesprovidedinKenya,theenergiesandresources
expendedonrealigningpolicies,programmesandservicesalmostcertainlydilutedtheattentionbeingpaidto
basicfamilyplanningservices.LongstandingdonorinvestmentinfamilyplanninginKenyahadbeenseento
produceamajorfertilitydecline,andmanydonorseitherredirectedtheirinvestmentsintoabroaderrangeof
maternalchildhealth(MCH)relatedservices.OthersincludedemergingprioritiessuchasHIV/AIDS,orinbasket
fundingtothegovernmenttosupportarangeofsocialinvestments(Ian etal., 2009).AccordingtoCrinchton
(2008),inthe1990s,theKenyaneconomywasalsocharacterizedbydeclininggrowthintheGrossDomestic
Product(GDP)andincreasesinthepopulationlivingbelowthepovertyline.Atthesametime,politicaltensions
increasedsignificantlyfollowingtheintroductionofamultipartypoliticalsysteminthe1992elections.Further,
the donor community reduced funding for Kenyas programmes including family planning services, due to
Kenyas poor macroeconomic policies. These factors attracted the attention of politicians as well as other
influentialleadersandindeedthegeneralpopulation.Intheend,thefamilyplanningsuccessstorysoonbecame
yesterdaysnews,andattentiontopopulationissuesingeneralandfertilitydeclineinparticulargraduallywaned.
Thepoliticalturbulenceofthe1990salsofacilitatedariseinpublicadvocacyagainstfamilyplanningfrom
conservative religious leaders and prolife groups. As a result, many politicians became more cautious in
makinganypublicstatementsaboutreproductivehealthgenerallyandfamilyplanninginparticular.Therewas
evidenceofadeclineininternationalandnationalsupportforthefamilyplanningprogrammesincethemidtothe
late1990s,whichmirrorsthedecreaseinoverallofficialassistancetoKenya.Thiswasestimatedtohavedropped
fromahighofabove$1billioninthelate1980stounder$400millionby2000(Crinchton,2008).Thetimingof
thisdecreasealsoparallelsthestallinfertilitydecline,althoughthemagnitudeoftheeffectofthisdecreasein
developmentassistanceisyettobefullyevaluated.
Anincreasefollowedbyadecreaseininstitutionalcommitmenttofamilyplanningprogrammesappearsalsoto
haveaffectedthestall,withthetimingofthesechangesincommitmentandcorrespondingprogrammeseffort.
Thiscloselymirroredthedeclineandthenstagnationinthefertilityrate(Ianetal.,2009).Ontherealizationthat
HIVandAIDSwerereachingpandemicproportions,thegovernmentofKenyadivertednationalandinternational
attentionandresourcesintofightingtheepidemic.Notonlydidthisreducethefundingallocatedforfamily
planningservices,butitalsoreducedthelevelsofnationalandinternationaltechnicalexpertiseavailable,and
importantly,tookwelltrainedhealthpersonnelandsupportsystemsawayfromreproductivehealthtoworkinthe
newlycreatedHIV/AIDSprogrammes.The1998DHSshowedafourpercentagepointincreaseincontraceptive
prevalencefrom26percentto39percentbetween1993to2003,whiletotalfertilitydeclinedsubstantiallyover
thesameperiodfrom5.4to4.7(RepublicofKenya,2003).

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ThesefindingsreinforcedtheimpressionthatthefertilitytransitioninKenyawaswellandtrulyestablished,and
thatthestrategiesthatwerebeingimplementedandlevelsoffundingavailableforbothcreatingandsupplying
demandwereappropriateforthecountryatthisstageoffertilitytransition.
Consequently,theresultsofthe2003DHScameasashocktonationalandinternationalobserversandaflurryof
activitiesensuedtotrytorepositionbothfamilyplanningandpopulationaskeyissuesworthyofattentionand
investment. The government, for example replaced the NCPD with a National Coordinating Agency for
PopulationandDevelopment(NCAPD),andtheMillenniumDevelopmentGoalsprovidedaplatformfortherole
ofpopulationgrowthinsustainabledevelopmenttoberevisitedandaddressed.Manydevelopmentpartnershave
soughtwaystoincreasetheirinvestmentsinsupportoffamilyplanningservices,buttheirgradualdisengagement
overthepreviousdecadehasmeantthatithasbeendifficulttomakeconvincingargumentstoincreaseallocations
forfamilyplanninginthefaceofotherdevelopmentchallengessuchastransportation,infrastructure,HIV/AIDS
andeducation.Notwithstandingthis,studiesbySharmaetal.(2005a)andSharmaetal.(2005b)havehowever
shownthat,paradoxically,itisthewealthiergroupswhobenefitfromgovernmenthealthcarespending,notthe
poor.Moreover,thepoormaynotbeawareofpoliciesdesignedtohelpincreaseaccesstoreproductivehealthcare
servicesingeneralandfamilyplanningservicesinparticular,suchasuserfeeexemptionschemesforthepoor,or
theymaybesubjecttoinformalfeeschargedbyproviders.

ImportanceofFamilyPlanning
AnanalysisofthecontributionoffamilyplanningtotheMDGsbyMorelandandTalbird(2006)showedthat
satisfyingunmetfamilyplanningneedsinKenyacouldavert14,040maternaldeathsand434,306childdeathsby
theMDGtargetdateof2015(RepublicofKenya,2007b).InUSAID/HPI(2007),itwasnotedthatthecost
savingsinprovidingservicestomeetMDGsoutweightheadditionalcostsoffamilyplanningbyafactorof
almost4to1.Specifically,thesocialsectorcostsavingsandfamilyplanningcostsinKenyafor20052015are
estimatedat$271millions,withmaternalhealthtaking$75million,whilewaterandsanitation,immunizationand
educationeachtaking$36million,$37millionand$115million,respectively.Thiscompareswiththetotalcost
offamilyplanningestimatedat$71million,whichimpliesthattotalsavingswillbe$200million(Morelandand
Talbird,2006;USAID/HPI,2007).
Promotionoffamilyplanningincountrieswithhighbirthrateshasthepotentialofreducingpovertyandhunger,
whileatthesametimeaverting32percentofallmaternaldeathsandnearly10percentofchildmortality.This
wouldcontributesubstantiallytowomen'sempowerment,achievementofuniversalprimaryschoolingandlong
termenvironmentalsustainability(Clelandetal.,2006).Ifaccesstofamilyplanningserviceswasincreased,the
unmetneedforfamilyplanningcouldbemet,therebyslowingpopulationgrowthrateandreducingthecostsof
meetingMDGsintermsofuniversalprimaryeducation,whichisinfluencedbythenumberofchildreninneedof
education(MorelandandTalbird,2006).Hawkins etal. (1995)observedthatfamilyplanningservicesoffer
various economic benefits to the household, country and the world at large. First, family planning permits
individualstoinfluencethetimingandthenumberofbirths,whichislikelytosavelivesofchildren.Secondly,by
reducingunwantedpregnancies,familyplanningservicecanreduceinjury,illnessanddeathassociatedwithchild
birth, abortions and sexually transmitted infections (STIs) including HIV/AIDS. Further, family planning
contributestoreductioninpopulationgrowth,povertyreductionandpreservationoftheenvironmentaswellas
demandforpublicgoodsandservices(Shane,1997;CincottaandEngelman,1997).
Othersubstantialeconomicbenefitscouldincludedemographic bonus ordividends.Demographic bonus exists
whenthereisashrinkingshareofthepopulationconsistingofdependentchildrenatthesametimeasagreater
shareconsistingofworkingageadults.AccordingtoDavidetal.(2002),whenthisoccurs,itboostsproductivity
andallowsaddedsavingsorinvestment.Davidetal. (2002)observedthatfamilyplanninghelpstoreducethe
numberofhighriskpregnanciesthatresultinhighlevelsofmaternalandchildillnessanddeath.Wawire(2006)
notedthathighpopulationgrowthisassociatedwithhighilliteracyratesandloweducationlevelthatmakeit
difficulttoimplementgovernmentprogrammes,giventheirbudgetaryimplications.AccordingtoWorldBank
(2003),theuseoffamilyplanningservicesisanimportantissueforadevelopingcountrylikeKenya.

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TheWorldBank(2003)notedthatthiswasduetothebenefitsgainedintermsofdevelopmentthroughreductions
infertilitylevels.Furthermore,theuptakeoffamilyplanningwidenedchoicesavailabletopeople,particularly
women,byallowingindividualsandsocietymoreopportunitiesforsocialandeconomicdevelopment.Singh et
al. (2004)revealedthatahighfertilityrate(whichinmanycasesisattributedtolowcontraceptiveprevalence
rate)impedeseconomicgrowth.
Singhetal.(2004)observedthatcountrieswithhighpopulationpressureorwithrapidlygrowingpopulations
maynotbeabletomeetthelargeeducation,labour,health,andinfrastructurerelateddemandsofthepopulation.
Leisinger etal.(2002)notedthatpopulationgrowthaffectstheenvironmentandraisesconcernsaboutfood
security,safedrinkingwaterandavailabilityofarableland.EastwoodandLipton(2001)observedthatreducing
fertilitycanhelpalleviatepovertyandstimulateeconomicgrowth.Theynotedthatreducingthebirthrateby5
birthsper1,000duringthe1980swouldhavereducedtheaveragenationalincidenceofpovertyfrom18.9percent
inthemid1980sto12.6percentinthemid1990s.Merrick(2002)forecastedthatdecliningbirthratescanresult
inanimproveddependencyratio,withanincreasingnumberofproductiveadultsrelativetothenumberofyoung
andelderlydependents.This,Merrick(2002)contended,wouldberealizedonlyifcountriesrespondedwith
appropriatefamilyplanningpoliciesandtheresourcesthatwouldhavebeenrequiredtomeettheneedsofalarger
numberofdependents.AccordingtoUSAID/HPI(2007),familyplanningcanslowpopulationgrowthandreduce
demographicpressure,whichcaninturnhelpcountriestoliftthemselvesoutofpoverty.Reducedpopulation
sizesmeanadecreasedburdenonnationalexpendituresforeducation,healthandothersocialservices,aswellas
less strain on the environment and natural resources. This further contributes directly to reduced infant and
maternalmortalityandmorbidity.

TheProfileofStudyArea
ThestudywasconductedinthecityslumsofNairobi,KisumuandMombasa.Theseslumsarecharacterizedby
highpovertylevels,lowlevelsofeducation,largehouseholdsizesthataffectaccesstobasichealthservices
includingfamilyplanningservices.AccordingtoUSAID/HPI(2007),womenfromthelowestsocioeconomic
status(SES)groups,includingslums,aretheleastlikelytousemoderncontraceptivemethods.In2003,for
instance,only12percentofwomenfromtheverylowSESgroupsusedmodernfamilyplanningmethods,while
45percentofwomenfromthehighSESgroupsdidthesame(RepublicofKenya,2003).USAID/HPI(2007)
notedthatSESaffectstheaccesstoanduseoffamilyplanningservices.Intermsofunmetneedforfamily
planningservices,womeninslumshavethehighestlevelsofunmetneedforfamilyplanning,estimatedat33
percentcomparedtoonly17percentinhighSESgroups.Itisestimatedthathalfofthe2.2millionKenyans
living with HIV live in slums (USAID/HPI, 2007). Similarly, young girls are also married off by their
parents/guardiansatatenderageinordertosecureaperceivedfinancialsupport.Bythetimetheyreach40years
ofageamajorityofthemwillhavegivenbirthtomorethansixchildren.Additionally,accesstohealthservicesin
slumsisanotherissueofconcerngiventhepovertylevels.Thus,theabilitytoaccessfamilyplanningservicesis
equallyaffected,leadingtoincidencesofhighchildmortality,poormaternalhealth,nonsustainabilityofthe
environmentandinabilitytocombatHIV/AIDS,malariaandotherdiseases.Inthefinalanalysis,theabilityto
achieveuniversalprimaryeducationas envisagedinvision2030is affected. Intheprocess, thiscontributes
towardshighlevelsofschooldropouts,highunemploymentlevelsaswellasprostitution.
Giventhelowlevelsofeducationamongwomeninslumstogetherwithhighlevelsofschooldropoutratesand
insufficient knowledgeof family planningservices, the utilizationof familyplanning is expected tobe low
comparedtothenationallevelestimatedat46percent(RepublicofKenya,2008).Householdsinslumsearntheir
livelihoodsthroughdifferentformsofeconomicactivities,whichincludeemploymentaswaiters,barmen,bar
maids,drivers,watchmen,shopassistants,casuallabourers(infactoriesandconstructionsites),artisans,small
businessowners,andotherincomegeneratingactivitiessuchasherbalists,entertainers,carriersofgoodsandany
otherassignmentwithmoneyattached(KarirahGitau,1999).This,accordingtoKarirahGitau,impactsheavily
ontheirabilitytoaccessbasicneedsincludingeducationandhealth(whichincludesfamilyplanningservices).
Mitullah(1997)reportedthatmostresidentsinslumshadprimaryeducationlevel(61percent)andsecondary
leveleducation(32percent)withabout7percenthavingnoformaleducation.Mitullahfurtherrevealedthatthese
householdsearn,onaverage,verylowincomesrangingbetweenKsh.1,000and28,000withamajorityearning
betweenKsh.5,000and7,500(Mitullah,1997).Suchlowincomeshaveanimpactonaccesstobasicneeds.

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Intermsofailments,APHRC(2001)notedthatintheslums,theincidenceofmalaria,waterbornediseasessuch
astyphoidandcholeraishigh.Thesehaveintheprocesscontributedtohighratesofchildmortalityandpoor
maternal health. Other common ailments according to APHRC (2001) include measles, flu, STIs including
(HIV/AIDS),andTB.APHRC(2001)contendedthatpoorenvironmentalconditionsincludingcrowding,lackof
accesstofamilyplanningservicesaswellaslackofcleanwaterhadaccountedfortheailments.
Givenallthesecharacteristics,thereislikelihoodthatcontraceptiveprevalencerateandunmetneedsintheslums
arelowerthanthenationalratesestimatedat46percentand24percent,respectively.Similarly,fertilityratesare
expectedtobehigherthanthenationalrateof4.6percent.Forthesereasons,thestudywasperceivednecessaryin
theseareastoinformthepolicyprocessonthewayforward.

StatementoftheProblem
Asindicatedintheforegoingdiscussion,theKenyangovernmenthasputinplacevariousstrategiesandpolicies
to facilitate the use of family planning services as a step towards reducing the fertility rates, increasing
contraceptiveprevalencerate(CPR)andreducingtheunmetfamilyplanningneeds(RepublicofKenya,2003b;
RepublicofKenya,2007b;Ianetal.,2009;andRepublicofKenya,2008).Despitethesepolicymeasures,total
fertilityratestillremainshighat4.6percent,whileCPRforallmethodsisat46percent.Ontheotherhand,the
unmetneedsforfamilyplanningservicesaverageat24percent(RepublicofKenya,2007a;RepublicofKenya,
2009;Ian etal.,2009).ThehighTFRtogetherwithlowCPR,unmetneedsforfamilyplanningservices,low
deathrate(estimatedat14.02deathsper1,000women),highbirthrate(estimatedat39.73birthsper1,000
population)andlowinfantmortality(estimatedat59.26per1000livebirths)(RepublicofKenya,2009)couldbe
contributingtowardshighpopulationgrowth.Standardsoflivingtendtoworsenwhentherateofpopulation
growthexceedstherateofeconomicgrowth(FeyisetanandBamiwuye,1998).Atthehouseholdlevel,thehigh
fertilityratemaybecontributingtowardsdepletionofproductiveresourcesinthesociety,risingcostofliving,ill
health,poornutritionandlimitededucationalopportunities,ultimatelytrappingwomeninapovertycycle.Inthe
case of slums where poverty levels are high, the situation is likely to be worse. Although 2008 KDHS
demonstratedthateducation,maritalstatus,womansincome,andotherdemographicandsocioeconomicfactors
affectutilizationoffamilyplanningservices,thesignificanceofthesefactorsandproviderfactorshavenotbeen
determinedfortheurbanpoorwomenlivingintheslums.Thepurposeofthestudywastoanalysetheleveluseof
contraceptives amongst women of reproductive age within the city slums in Kenya while at the same time
examinethefactorsthatwascontributetowardstheutilizationofthecontraceptivesamongstthesewomen.

OverviewofPastStudies
Variousstudieshavebeenconductedwithregardtothedemandforhealthservicesingeneralandcontraceptives
inparticular.Ingeneral,therearesomeaspectsoftheexistingliteraturethatdeservescrutiny.Mostofthese
studieshaveusedeconometrictoolsthatareinadequateinaccountingforthecomplexityofrelationshipsbetween
family planning services due to the insufficiency of economic theory in the determination of the right
specification. For instance, majority of the variables did not have a direct theoretical relationship, hence
estimationcouldnothavebeenplausibleasitwasdoneinthestudies.Specifically,otherthanstudiesbyMwabu
(1984),Mwabuetal.(2003),Davidetal.(2002),Odweeetal.(2006)andAjakaiyeandMwabu(2007),noneof
theotherstudiesdevelopedatheoreticalmodelthatprovidedthesolidgroundforadoptingmodelsthatwere
estimated.Eventhoughthesestudiesdevelopedatheoreticalmodel,allofthemwereconcernedwiththedemand
forhealthcareandnotfamilyplanningservices.Similarly,noneofthestudiestargetedrespondentsdirectlyinthe
slums.Thiscomparestothecurrentstudywhererespondentsfromtheslumsweretargeted.Asrevealedinthe
literaturereview,mostofthestudiesonfamilyplanningservicessuchastheLewisetal.(1986),Mohamadetal.
(1988),Abdullah(1997),Mahidul etal. (1998)andKamal(1994)werenotonlydoneoutsideAfricabutalso
reliedonsecondarydatafromdemographichealthsurveys.
Atcountrylevel,althoughthereexistsafewstudies(Njogu,1991;Kyalo,1996;andAquanda,2005)regarding
contraceptiveuse,mostofthemreliedonsecondarydatafromthedemographichealthsurveys.Ontheother
hand,othercountrybasedstudiessuchasKorirandMwabu(2004),ObonyoandMuga(2005),Korir etal.(2004)
consideredpolicyissues,especiallyuserfees.Thecurrentstudy,however,wentbeyondbyincorporatingpolicy
aswellasdemographicandsocioeconomicvariablestudiesinordertoexaminehowthesevariablesinfluencethe
demandforfamilyplanningservicesincityslums.

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Intermsofvariablesconsidered,manyofthestudieswerelimitedandreliedheavilyondescriptivestatisticsin
theanalysis.Forinstance,althoughthestudybyClementsandNyovani(2004)consideredawidevarietyof
variablessuchaseducationlevelofboththewomanandherpartner,religion,thepartnersapproval,marital
statusandage,noeconometricmodelnortestswereincorporated.Thismakesthestudyinadequateespeciallyin
theworldofacademicrigour.LikethecaseofClementsandNyovani(2004),Betrandetal.(2005)considered
manyfactors,someofwhichwereincorporatedinthecurrentstudy.However,thestudycapturedboththesupply
sideaswellasthedemandsidetoevaluatefamilyplanningservices.Thecurrentstudy,however,onlyconsidered
thedemandsidevariablestoavoidtheeconomicproblemofdoublecausality.Onthebasisoftheliterature
reviewed,variousvariableswerefoundtoaffectdemandforfamilyplanningservices.Thisstudyconsidered
someofthesevariablesonarestrictivebasistoexaminehowtheyaffectdemandfortheservicesamongstthe
urbanpoorinthecityslums.Itisworthnotingthatnoneofthestudiesreviewedtargetedrespondentsinthecity
slums.

DataandMethods
Thestudyadoptedasurveydesigninordertoobtainthenecessarydata.Theselectionofthedesignwasdueto
twofoldreasons.First,itfacilitatedthecollectionoforiginaldatanecessarytorealizetheresearchobjectives.
Secondly,itwasalsoappropriateincollectingusefuldatathatcouldbequantifiedandreportedasarepresentation
oftherealsituationorcharacteristicinthestudypopulation.Thetargetpopulationwaswomeninslumsinthe
three cities of Nairobi, Mombasa and Kisumu who were identified through multistage sampling. The study
objectivewasachievedusingbothquantitativeandqualitativedata.Thestudyreliedonprimarydatacollected
usingastructuredinterviewschedulethatcontainedbothopenendedandclosedendedquestions.
Beforecollectingthenecessarydata,theresearchinstrumentwaspilottestedwithasmallrepresentativesample.
Thepretestoftheinstrumentwasnecessarytofindoutifthetoolcouldcollectthenecessarydata.Thiswas
becauseataglance,itwasnotonlypossibletoforeseeallthepotentialmisunderstandingsorbiasingeffectsofthe
questionsbutalsotofacilitateperfectionofconceptandwording.Acodebookwaspreparedforthevarious
responsesobtained.Thereafter,thedatawascleanedtoensurecompletenessoftheinformationbeforeitwas
convertedintothemodethatcouldpickthenecessaryinformationbasedontheresearchproblem.Thedata
collectedwasanalyzedfirstintermsofdescriptivestatisticstoexaminetheutilizationlevelbasedonthewoman
demographicandsocioeconomicfactorsaswellasfacility/providerfactors.Secondlyabinomiallogisticmodel
wasestimatedusingatwostepregressionintermsofprobabilityandfinallymarginaleffects.Variousdiagnostic
testsincludingnormalitytest,modelspecification,multicolinearityandheteroskedasticitywereundertakenonthe
specifiedmodel.

TheoreticalFrameworkandModel
Inthederivationofthemodel,anattemptwasmadetoprovideatheoreticalexplanationforcertainempirical
observationsaboutawomaninherbehaviourtoseekfamilyplanningservices.Itwasassumedthatawoman
facedinformationasymmetryandavarietyoffamilyplanningservices.Inthestudy,theutilityofarepresentative
consumer who in this case was a woman was expressed as a function of observable attributes of family
provider/facility,characteristicsofthewomanwhointendtoconsumefamilyplanningservices,andarandom
error.Inthestudy,theamountoffamilyplanningservicesconsumedisanargumentofaconsumersutility
function.Toavoidproblemsofmeasuringtheamountoffamilyplanningservicesconsumed,anindirectutility
functionofthefollowingformwasused.
Vij=V(Pij,Yi,Si,Fij,Po).......1
whereVijwasindirectutilitythatconsumeriderivedfromconsumingfamilyplanningservicesj,wherej=1,2,
,m; P wasavectorofpricesthatconsumer i facedforthefamilyplanningservices j,Yi wasincomeofthe
consumeri;Sijwaspersonalcharacteristicsofconsumerilikeage,education,religion,andmaritalstatus,among
others for family planning services j; Fij was facility/provider characteristics such as friendliness of staff at
facility, perceived quality of the services and accessibility of the facility, among others that provide family
planningservices j,andPo wasGovernmentpoliciesrelatingtofamilyplanningservicessuchaspromotionof
familyplanning,amongothers.

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Giventhechoicemodel,itwasnecessarytoinvokeRoysidentityasimpliedinVarian(2002)inordertoobtain
theamountoffamilyplanningservicesimpliedbythemaximizationoftheindirectutilityinequation.
In{P/1P}=Xij................2
wherePwastheprobabilityofusinganymethodofcontraception.Inthiscase,aconsumermightbeusingornotusing
contraceptives;Inisthenaturallogarithmicfunction,isavectorofregressioncoefficientstobeestimated;whileXij
isavectorofexplanatoryvariablesthataffectutilizationoffamilyplanningservicesjbyhouseholdi.
Basedonthetheoreticalframeworkafunctionalequationwasdevelopedwithdependentvariablebeinguseof
familyplanningservices(USfp)astheproxyfordemand.Theexplanatoryvariableswerecharacteristicsofthe
woman (HHcrt); characteristics of the family planning services provider (Pfpcrt); and government policies
(Govp).Thesevariableswerechosentoreflectthefactorsthatmightbeassociatedwithfamilyplanningusein
Kenyascityslums.Thecharacteristicsofthefamilyplanningservicesprovidersandgovernmentpolicieswere
selectedasindirectexplanatoryvariables.Theindividualconsumercharacteristicsincludedage(ag),numberof
livingchildren(nlc),levelofeducation(led),desireforchildren(dmc),maritalstatus(mrts),partnerseducation
(pted),approvalbypartner(pap),religiousbackgroundofthewoman(rlg)andaverageincomeofthewoman
(avinc).Thecharacteristicsofthefamilyplanningservicesproviderincludedqualityoffamilyplanningservices
(qfps), proximity of the family facility (pxif) and friendly staff at facility (fsp). Government policies were
restrictedtopromotionoffamilyplanningservices(prfs)anduserfees/price(pri).Therestrictionwasnecessary
inordertolimittheanalysisontheknowledgeofthewomanregardingfamilyplanningservices.Thusequation
consideredwas:

USfp=f(ag,nlc,pted,mrts,led,dmc,pap,rlg,avinc,qfps,pxif,fsp,prfs,....................8

EmpiricalResults
a)DescriptiveStatistics
In terms of descriptive statistics, overall utilization level is provided followed by reasons for use and the
commonly used methods. Thereafter, utilization of family planning services in terms of demographic,
socioeconomicandfacilityfactorsareprovidedinthatorder.
i) Utilization
While51percentoftherespondentswerecurrentlyusingfamilyplanningservices,theremaining49percentwere
not. Those using the contraceptives cited various reasons ranging from managing the family to preventing
sexuallytransmitteddiseases.Whereas20percentoftherespondentswereusingfamilyplanningtomanagethe
family,30percentwereusingfamilyplanningforpurposesofpreventingpregnancy.Thisresultpointsoutthat
themajorreasonswhywomeninslumsusecontraceptivestopreventpregnancyandcontractionofSTIs.Onthe
otherhand,nonuseofcontraceptiveswasattributedinfrequentsex,notmarried,desireforchildren,cultural
norms,pregnant,religionandlackofsupportfromthepartner.Intermsofmethods,thestudyrevealsthatthe
mostcommonlyusedcontraceptiveswerecondoms(35%),pills(33%),injection(19%),andIUD(4%)
ii) DemographicandSocioEconomicFactors
Thefirstobjectiveofthestudywastoexaminedemographicandsocioeconomicfactorsthataffecttheuseof
familyplanningservicesbywomenincityslums.Variousdemographicandsocioeconomicfactorsconsidered
includeageofthewoman,religionofthewoman,levelofeducationofthewomanandpartner,maritalstatus,
numberoflivingchildren,desireformorechildren,partnersapproval,employmentstatusandaveragelevelof
income.Informationobtainedwasanalysedassummarizedintable1.
Useoffamilyplanningwasfoundtobehighestamongwomenagedbetween2039yearscomparedtothose
below20yearsandabove39years.Whereas49percentofthewomenthatwereusingcontraceptiveswereaged
2029years,41percentwereagedbetween3039years,whilenowomanaged50yearsandabovewasfoundto
beusinganyformoffamilyplanningservices.Ontheotherhand,4percentand6percentofthewomenwho
wereusingfamilyplanningserviceswerelessthan20yearsandbetween4049yearsofage,respectively.

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Asshowninthetable,majorityofthoseusingcontraceptiveshadpostprimaryeducation,whiletheleastusersof
familyplanninghadnoformaleducation.Inpercentageterms,whereas49percentoftheusersoffamilyplanning
services had secondary education, 28 percent had university education while only 15 percent had primary
educationwith6percentreportingnoformaleducation.Intermsofreligiousbackgroundofthewoman,outofthe
51percentthatwereusingcontraceptives,52percentwereProtestants,35percentMuslimswhileonly13percent
wereCatholics.ThisisanindicationthatuseofcontraceptivesvaryacrossreligionwithCatholicsusingtheleast.
Table1:DemographicandSocioEconomicFactors
DemographicandSocioEconomicFactors
1.

WomansAgeGroup

2.

WomansLevelofEducation

3.

PartnersLevelofEducation

4.

Religion

5.

MaritalStatus

6.

PartnersApproval

7.

PartnersLevelofEducation

8.

NumberofLivingChildren

9.

DesiretohaveChildren

10. EmploymentStatus
11. WomansLevelofIncome

12. KnowledgebyRespondents
Source:SurveyData,2010

30

a.Above50Years
b.Lessthan20Years
c. 2029Years
d. 3039Years
a. 4049Years
a. None
b. Primary
c. Secondary
d. PostSecondary
a. None
b. Primary
c. Secondary
d. PostSecondary
a. Catholics
b. Protestants
c. MuslimandOthers
a. Married
b. Single
a. Yes
b. No
c. None
a. None
b. Primary
c. Secondary
d. PostSecondary
a. None
b. Between13
c. Between46
d. Between79
e. Above9
a. UsingFP
b. NotUsingFP
a. Casuals
b. Employed
c. Others
a. None
b. Lessthan5,000
c. Between500110,000
d. Between10,00115,000
e. Between15,00120,000
f. Above20,000
UsingFP
NotusingFP

No.
of
Respondents
0
20
245
205
30
30
75
245
140
20
95
235
150
65
260
175
315
185
280
115
105
20
95
235
150
10
75
150
180
85
55
445
115
240
145
15
35
60
95
140
155
140
360

Percentage
(%)
0
4
49
41
6
6
15
49
28
4
19
47
30
13
52
35
63
37
56
23
21
4
19
47
30
2
15
30
36
17
11
89
23
48
29
3
7
12
19
28
31
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Use of contraceptives was foundto vary across marital status withmarried womenusing the services most
comparedtosinglewomen.Inthestudy,marriedwomenwerefoundtobeusingcontraceptivesthemostdueto
high incidences of sexual activities compared to single women. In this case, it was revealed that use of
contraceptiveswasaimedathelpingtospacechildrenandpreventunwantedpregnancy.Regardingpartners
approval,56percentofthewomensoughtapprovalbeforeusingcontraceptives,while23percentdidnotbother.
Theremaining21percentoftherespondentswerehoweveruncertainanindicationthattheywereeithernot
havingaregularsexualpartnerwhomtheycouldseekapprovalfrom,orthattheywerenotsexuallyactive.The
highpercentageofthosewhosoughtapprovalfromapartnerclearlyindicatestheimportanceofapartners
consentinmakingafinaldecisiononuseoffamilyplanningservices.Womenwithmorelivingchildrenwere
usingfamilyplanningservicesmorecomparedtothosewithfewerchildren.Outofthewomenthatwereusing
familyplanningservices,36percenthad46children,followedbythosewithbetween13livingchildrenat30
percent.
Ontheotherhand,17percentofthoserespondentsusingfamilyplanningserviceshadbetween79living
children,while15percenthadnolivingchild.Thisrevealsthatthehigherthenumberoflivingchildren,themore
thedesiretousefamilyplanningservices.Thisisbecausewithmorechildrenmightnotbehavingdesirefor
childrenasthedesirehasalreadybeensatisfied.Thedesireformorechildrenwasattributedtomanyfactors,
includingaculturalperceptionthatmorechildrensignifiedasourceofwealth.Forinstance,thosewhohadgirls
onlyneededboystosatisfytheirparentinlaws,whopreferredboys.Ontheotherhand,thosewhoreportedno
desireforchildrencitedhavingenoughchildren,notbeingmarriedandeconomicfactors,especiallylackof
necessaryresourcestotakecareofthechildren,tohavecontributedtolackofdesireforadditionalchildren.Out
ofthosewithadesiretohavemorechildren,only11percentwereusingfamilyplanningservices,while89
percentwerenot.Intermsincome,outofthetotalnumberusingcontraceptives,31percenthadanaverage
monthlyincomeofKsh20,000andabovewhile28percenthadanaveragemonthlyincomeofbetweenKsh.
15,000to20,000.Ontheotherhand,7percentofusershadanaveragemonthlyincomeoflessthan5,000.Those
withnoincomewere,however,theleastusersoffamilyplanningservices.Theresultsthusrevealthatinthe
absenceofanincomesource,usageoffamilyplanningwoulddecline.Amongrespondentswhohadknowledge
aboutfamilyplanningservices,72percentwereusingfamilyplanningservices,whiletheremaining28percent
werenotusingtheservices.
iii) FacilityFactorsdeterminingtheuseFamilyPlanningServices
Thesecondobjectiveofthestudywastoexaminefacilityfactorsthataffecttheuseoffamilyplanningservicesby
therespondentsincityslums.Variousfacilityfactorswereidentifiedandconsideredinthestudy.Theseincluded
familyplanningprovider,qualityoffamilyplanningservices,availabilityoffamilyplanningservices,userfees
chargedforfamilyplanningservices,andproximityofthefamilyplanningfacility.
Outofthe51percentthatwereusingcontraceptives,49percentobtainedtheservicesfromhealthfacilities,15
percentobtainedfrompharmacies,whileapaltry6percentobtainedfrombothworkplaceandmobilehealth
facility.Ontheotherhand,30percentcouldnotspecifythesourceoftheservices.Theseresultsclearlypointout
thatgovernmentandotherstakeholderssponsoredlargescaleprovisionoffamilyplanningservicesmightnotbe
workingeffectively,especiallyintheslums.Regardingqualityofthecontraceptives,whereas40percentofthe
respondentswereuncertainaboutthequalityoffamilyplanningservicesprovided,41percentagreedthatquality
wasgood,while19percentwereoftheopinionthatqualitywasnotgood.Thereisapossibilitythatwomenwho
were uncertain about the quality could be among those who were either unaware of the availability family
planningservicesornotusingtheservices,andthereforehadnowayofgaugingthequalityoffamilyplanning
services.Giventhemultiplesourcesoffamilyplanningservicesinslums,qualityoftheserviceswasboundtobe
compromised,especiallyinslumswheremonitoringbyhealthofficialswaslikelytobelimitedifatallitexisted.
Outofthe41percentthatagreedthatqualityoftheserviceswasgood,86percentwereusingtheservices,while
theremaining14percentwerenotusingtheservices.Theresultsrevealsthatalthoughqualityisanimportant
considerationinmakingadecisionregardingfamilyplanningservices,otherfactorscouldalsoaccountfortheuse
oftheservicesamongtheserespondents.Intermsofavailability,about60percentoftherespondentswerein
agreement that family planning services were available, while the remaining 40 percent were uncertain or
disagreedaltogether.

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Whereasavailabilityoffamilyplanningservicescouldbeattributedtothefactthattherearemultiplesourcesof
familyplanningservices(includingshops,healthfacilitiesandworkplaces),uncertaintyabouttheservicescould
havebeenattributedtolackofawarenessandusebytherespondents.Thispercentageisworryingandtherefore
mayneedtobeaddressedbythestakeholdersinvolvedinfamilyplanningprogrammes,especiallyinslums.
Withregardtouseoffamilyplanningservicesinrelationtodistance,41percentoftheusersofcontraceptives
livedwithinadistanceoflessthanonekilometre,27percentlivedbetween1and5kilometreswhile8percent
livedbeyondadistanceof10kilometres.Thisclearlypointsoutthatdistanceaccountpartlyfortheuseof
contraceptivesamongstwomenintheslums.Regardingperceptiononthefriendlinessofstaff,68percentofthe
respondentswhowereusingcontraceptivesperceivedthestafftobefriendlywhile19percentperceivedthestaff
tobeunfriendly.Theremaining13percentwereuncertainabouttheirperceptionregardingthestaff.Intermsof
cost,outofthetotalnumberofusingcontraceptives,45percentoftherespondentsindicatedthatthecostofthe
serviceswasfree,32percentfoundtheservicesaffordable,while6percentfoundtheserviceexpensive.The
remaining17percenthadnoideawhethercostoftheserviceswasexpensiveornot.Thisfindingrevealsthatthe
costoffamilyplanningserviceisanimportantdeterminantoftheuseoffamilyplanningservices.
Table2:FacilityFactorsanduseofContraceptives
FacilityFactorsanduseofContraceptives
FamilyPlanningServiceProvider

Qualityoffamilyplanningservices

AvailabilityofFamilyPlanningServices

ProximityoftheFamilyPlanningproviderand
proximitytotheprovider

UseofFamilyPlanningServicesandFriendliness
ofStaff
UseofFamilyPlanningServicesandCost

AvailabilityofFPWorkers

32

Healthfacility
MobileHealthWorkers

Number
of
respondents
245
15

Percentage
(%)
49
3

Pharmacy

75

15

Workplace

15

Others

150

30

Useoffamilyplanning
services
Notusing

430

86

70

14

Disagreed

65

13

Uncertain

140

28

Agreed

295

59

Lessthan1

220

44

15

135

27

510

105

21

Beyond10

40

UnfriendlyStaff

95

19

Friendly

340

68

Uncertain

65

13

Affordable

160

32

Expensive

85

17

Free

225

45

NoIdea

30

StronglyAgreed

80

16

NoneAvailable

65

13

Uncertain

140

28

Available

295

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Although50percentoftherespondentsagreedthattherewaspromotionoffamilyplanningservicesintheslums,
theremaining 50percent were either uncertain or disagreed. The high percentage of respondents who were
uncertainorindisagreementcouldexplainwhymajorityofthemobtainedthefamilyplanningservicesfrom
either shops or pharmacies.Further, lack of awareness could be attributed to lack of access to information
regardingtheservices.Theinabilitytoaccesssuchimportantinformationisboundtheaffectthewomansability
to make an informed decision on uptake of family planning services. Lastly, whereas 59 percent of the
respondentswereinagreementthatfamilyplanningworkerswereavailable,28percentoftherespondentswere
uncertainabouttheavailabilityoftheworkers.Ontheotherhand,13percentoftherespondentswereofthe
opinionthatfamilyplanningworkerswerenotavailable.Thisfindingsupportsthepreviousfindingswhere38
percentoftherespondentswereuncertainaboutthepromotionoffamilyplanningservicesbyfamilyplanning
workers

RegressionResults
Use of family planning services was the dependent variable and was used as a proxy for demand for
contraceptives. This took the value of one (1) if contraceptives were used and zero (0) if otherwise. The
explanatoryvariables considered were ageof the woman, marital status, number of living children, average
monthlyincome,educationallevelofthewomanandpartner,partnersapproval,proximityoffamilyplanning
provider,priceoffamilyplanningservices,knowledgeofcontraceptives,friendlinessofthestaff,availabilityof
contraceptives, quality of contraceptives and religious background of the woman. In order to determine the
explanatoryvariablestouse,correlationanalysiswasundertakentoestablishthedegreeofcorrelationbetween
theexplanatoryvariablestoavoidtheproblemofmulticolinearity.However,explanatoryvariablesarerarely
uncorrelatedwitheachotherandsomulticolinearityisamatterofdegree.Thedegreeofcorrelationbetweenthe
explanatoryvariableispresentedintheappendices.Allthevariableswithacorrelationof0.50andabovewere
identified and only one of the variables was selected for use in the regression. For instance, the degree of
correlationbetweenageofwoman(age)andnumberoflivingchildren(nlc)was0.64.Numberoflivingchildren
waspickedandageofwomandroppedfromtheregression.Thecorrelationbetweenproximitytothefamily
planningfacilityandpriceoffamilyplanningserviceswas0.50.Giventhatgovernmenthealthfacilityoffersthe
servicesfreeofcharge,proximitywasconsideredanidealproxyforpriceofthecontraceptives.Thefurtheraway
fromthefacilityarespondentisthehigherwouldbetransportcostortransactioncostofaccessingthefacility.
Thepartnersapprovalwaspreferredoveravailabilityofcontraceptives.Thechoiceofthevariablewasalso
influencedbythefactthatmaritalstatusandpartnerseducationhadacorrelationof0.50.Sincepartnersapproval
isalreadyincluded,itwasidealtoincludemaritalstatus.Theexplanatoryvariablesthatwereincludedinthe
regressionwereincome,proximity,maritalstatus,femaleeducation,knowledgeofthecontraceptives,partners
approval,numberoflivingchildren,religion,friendlinessofstaffandqualityofcontraceptives.Theresultsofthe
binomiallogisticregressionarepresentedintable3.
Table3:ResultsofLogisticRegressionAnalysis
DependentVariable
No.ofObservations
ExplanatoryVariable
MaritalStatus
Religion
PartnersApproval
No.oflivingchildren
Quality
Proximity
Friendly
Income
WomenEducation
KnowledgeofFP
C
PseudoR
2

LRchi (10)

UseofFamilyPlanningServices
500
Coefficient
Z
P>|z
0.107
0.29
0.775
1.955*
5.24
0.000
7.362*
6.61
0.000
0.119
0.97
0.332
1.023*
2.58
0.010
0.221*
2.73
0.006
1.125*
2.56
0.010
0.011**
2.01
0.045
0.003
0.05
0.958
1.369**
2.22
0.026
2.945
2.83
0.005

[95percentConf.Interval]
0.628
0.843
2.685
1.224
5.177
9.545
0.122
0.361
0.245
1.801
0.380
0.062
0.264
1.985
0.000
0.023
0.130
0.125
0.162
2.575
4.984
0.906
2.945
0.6843
468.56

Source:DerivedfromDataAnalysis
*Implysignificanceat1percentlevelwhile**implysignificanceat5percentlevelofsignificance

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Fromthetable,allthecoefficientsoftheexplanatoryvariableshadtheexpectedsignexceptwomeneducation.
Similarly,sevenexplanatoryvariableshadcoefficientthatwerestatisticallysignificantwhiletheremainingthree
hadcoefficientsthatwerestatisticallyinsignificant.Theinterpretationofthecoefficientvaluesiscomplicatedby
thefactthatestimatedcoefficientsfromthemodelcannotbeinterpretedasthemarginaleffectonthedependent
variableasaresult,therewasneedtoestimatethemarginaleffectsasshownintable4.
Table4:ResultsofLogisticRegressionAnalysisforMarginalEffects
DependentVariable

UseofFamilyPlanningServices

No.ofObservations

500

ExplanatoryVariable

dy/dx

Std.error

P>|z|

[95percent
Interval]

MaritalStatus

0.016

0.057

0.28

0.776

0.095

0.128

0.640

Religion

0.278*

0.086

3.25

0.001

0.446

0.110

0.556

PartnersApproval

0.829*

0.028

29.04

0.000

0.773

0.885

0.420

Nooflivingchildren

0.018

0.019

0.95

0.343

0.019

0.054

2.364

Quality

0.166**

0.079

2.08

0.037

0.009

0.322

0.622

Proximity

0.033**

0.016

2.14

0.033

0.063

0.003

3.158

Friendly

0.193**

0.093

2.09

0.037

0.012

0.373

0.701

Income

0.002***

0.001

1.74

0.081

0.001

0.004

24.824

WomanEducation

0.001

0.009

0.05

0.958

0.019

0.019

10.123

KnowledgeofFP

0.257***

0.139

1.85

0.064

0.015

0.529

0.806

Conf.

Source:DerivedfromDataAnalysis
*Implysignificanceat1percentlevelwhile**and***implysignificanceat5and10percentlevel
ofsignificance,respectively

DiscussionandConclusion
As presented in table 2, all the explanatory variables had coefficients with expected signs except woman
education, which was shown to negatively influence the use of family planning. The coefficient of woman
educationwas,however,notstatisticallysignificantat1percentaswellas5percentand10percentlevelof
significance.Sevenvariables,namelymaritalstatusofthewoman,partnersapproval,numberoflivingchildren,
qualityoffamilyplanningservices,friendlinessoffamilyplanningservicesproviders,proximitytotheprovider,
incomeofthewomanandknowledgeofwomanonfamilyplanningserviceshadcoefficientswithpositivesigns.
Thisimpliesthattheyincreasethelikelihoodoftherespondentusingfamilyplanningservices.Ontheotherhand,
religiousbackgroundofthewoman,proximitytotheproviderandeducationlevelofthewomanhadnegative
coefficients.Thisimpliesthattheyreducethelikelihoodofrespondentsusingfamilyplanningservices.
The coefficients of religion and partners approval were statistically significant at 1 percent whereas the
coefficientsofqualityoffamilyplanningservices,proximitytotheproviderandfriendlystaffatfacilitywere
statisticallysignificantat5percent.Ontheotherhand,thecoefficientsofincomeandknowledgeoffamily
planning were statistically significant at 10 percent level. Marital status and number of living children had
coefficientsthatwerenotstatisticallysignificant.Themostimportantdeterminantofthelikelihoodofrespondents
intheslumsusingfamilyplanningserviceswaspartnersapproval,whosemarginaleffectwas0.83.Thismeans
thattheprobabilityofarespondentusingfamilyplanningserviceswas83percentwhereconsentfrompartner
wasgrantedcomparedtowherenoconsentwasgranted.Thesignificanceofthiscouldbeattributedtothefact
that for a womantousefamilyplanning services, partners approval was critical. Otherwise if foundusing
withouttheconsentofpartneritcouldbemisinterpreted,therebycausingmisunderstandinginamarriage.

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Thesecondmostimportantdeterminantwasreligion,whichtookthevalueofoneifCatholicandzero,otherwise.
Themarginaleffectwasnegative0.28,implyingthattheprobabilityofawomanusingfamilyplanningservicesif
sheisaCatholicwas28percentlowercomparedtootherswithdifferentreligiousbackgroundsuchasProtestant
andMuslims.Thisisbecausecatholicfaithdiscouragesitsfaithfulsfromusingcontraceptivesasbirthcontrol
measures.Faithfulsareinsteadencouragedtorelymoreonobservationofmenstruationcyclesandnaturalsafe
daysofawoman.Thisfindingclearlyindicatesasignificancedifferenceintheuseoffamilyplanningservices
betweenCatholicsandotherreligions.Knowledgeoffamilyplanningserviceswasfoundtobethethirdmost
important determinant of likelihood to use of family planning services with a marginal effect of 0.26. The
likelihoodofusingfamilyplanningserviceswouldbe26percenthigherforwomanwithknowledgeoffamily
planningservicesthanthosewithout.
Thisclearlysuggeststhatforincreaseduptakeoffamilyplanningservices,promotionthatfacilitatesawareness
abouttheavailablefamilyplanningservicesandtheirpossiblesideeffectsandbenefitsisparamount.Friendliness
offamilyplanningstaffhadamarginaleffectof0.19,implyingthatthelikelihoodofrespondentsusingfamily
planningserviceswas19percenthigheriffamilyplanningstaffwasfriendlythanwhentheywerenot.The
significanceofthisdeterminantcouldbeexplainedbythefactthatprovisionofcertaintypesoffamilyplanning
services requires performance of some procedures by the person administering the services, for example
injectables,hormonereleasingimplantsanduseofIUD.Withregardtoqualityoffamilyplanningservices,the
marginaleffectwas0.17.Thisimpliesthattheprobabilityofawomanusingfamilyplanningserviceswas17
percenthigherforrespondentswhoperceivedtheservicestobeofhighqualitythanforthosewhoperceived
otherwise.Thepositiveimpactofqualitycouldbeattributedtothefactthatintheprocessofmakingadecisionon
usingfamilyplanningservices,perceivedqualityoftheserviceisgivenahighconsiderationassupportedby
theorywherebytasteandpreferenceisanimportantfactorinmakingdemanddecision.Proximitytofamily
planningservicesproviderhadamarginaleffectofnegative0.03,implyingthatthefurtherawayfromthefamily
planningservicesprovider,thelowerthelikelihoodofseekingtheservicesby3.3percent.
Thenegativeimpactofdistancefromtheserviceprovidercouldbeattributedtothefactthatwhentheprovideris
farawayfromthewoman,thereisboundtobesomeimbeddedcostsintermsoftransportandtransactioncostsas
well as waiting and travelling time, which may discourage a person from seeking the services. The last
statisticallysignificantvariablewasincome,whichhadamarginaleffectof0.002,implyingthatanincreasein
averageincomeofawomanbyKshs.1,000increasedthelikelihoodofusingfamilyplanningservicesby2
percent.Maritalstatusandnumberoflivingchildrenhadeachamarginaleffectofabout0.02,althoughtheywere
notstatisticallysignificantateither1percent,5percentand10percent.Thepositiveinfluenceofmaritalstatuson
thelikelihoodofusingfamilyplanningservicescouldbeattributedtothefactthatcouplesmightdecideto
postponeraisingchildrenbyresortingtouseoffamilyplanningservices.Thevalueofthemarginaleffectsimply
meansthatamarriedwomanis2percentmorelikelytousefamilyplanningservicesthanasinglewoman.
Finally,thepositiveinfluenceofthenumberoflivingchildrenonthelikelihoodofusingfamilyplanningservices
couldbeattributedtothewomansdesireforchildrenhavingbeensatisfied.Mahidu etal. (1998)forinstance
foundthatoncetheteenagewomenandnewlywedshadachild,contraceptiveuseprevalencerosetoalevel
comparabletothatofwomenintheirtwenties.

Conclusion
Variousfacilityfactorswereconsidered,amongthemqualityoffamilyplanningservices,availabilityoffamily
planningservices,proximityofthefamilyplanningfacilityandfriendlinessofstaff.Notableviewsprovidedwere
uncertaintybyrespondentsabouttheavailabilityofthefamilyplanningservicesaswellastheavailabilityof
familyplanninghealthworkers.Thisnotonlypointsouttheinadequacyoffamilyplanningservicesbutalsothe
familyplanningworkersintheslums.Amongthestatisticallysignificantdeterminantsoflikelihoodofusageof
familyplanningservicesbyorderoftheirmarginaleffectwerethepartnersapproval,religion,knowledgeof
familyplanningservices,friendlinessoffamilyplanningstaff,qualityoffamilyplanningservices,proximityto
thefamily planningfacility and income. All explanatory variables positively influenced the usage of family
planningservicesexceptreligionandproximitytothefamilyplanningfacility.Thestudyrevealedthatthefarther
awaythewomenwerefromthefamilyplanningfacilities,thelowerthelikelihoodofusingtheirservices.

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InternationalJournalofBusinessandSocialScience

Vol.2No.1;January2011

Intermsoftheexplanatorypowerofthemodel,68percentofthevariationofthelikelihoodoftheusageof
familyplanningserviceswascapturedbytheexplanatoryvariablesincludedinthemodel.Utilizationoffamily
planning services has been the concern of not only the government but also other stakeholders including
researchers.Inthisstudy,ithasbeenestablishedthatonlyafewcouplesinthecityslumsusefamilyplanning
services.Ithasfurtherbeenestablishedthatvariousdemographic,socioeconomicandproviderfactorsaffectuse
offamilyplanningservicesamongstwomeninslums.Theseincludebyorderoftheirmarginaleffectspartners
approval,religion,knowledgeoffamilyplanningservices,friendlinessoffamilyplanningstaff,qualityoffamily
planningservices,proximitytofamilyplanningfacilityandincome.

Recommendations
Inlightoftheresearchfindings,demandforfamilyplanningservicesinKenyaingeneralandamongwomenin
Kenyascityslumsinparticularisaffectedbyvariousfactors.Inordertoenhancetheuptakeoffamilyplanning
servicesasaboldsteptowardsmeetingthechallengesenvisagedintheKenyasVision2030andtherealization
oftheMDGs,thefollowingarerecommended.ThegovernmentthroughtheMinistryofHealthtoreviveand
supportfamilyplanningeducationatbothhouseholdandcommunitylevelthattargetsthewomanandherpartner.
Thiscouldbeundertakenthroughprintandmassmedia,chiefsbarazas,marketplacesaswellasnewslettersand
posters.Additionally,theMinistryofHealthshouldencouragetheuptakeofcontraceptivesathouseholdlevelby
enhancing continuous promotion of family planning services and provision of free condoms. This could be
realisedbysupportingfamilyplanningoutreachactivitiesbythehealthworkers.Thisisexpectedtocontribute
positivelytowardsenhancingawarenessoffamilyplanningservicesandthebenefitsandsideeffects.Enhancing
standardsandregulationtoensurethatcontraceptivesprovidedareofgoodquality.Inaddition,publichealth
facilitiesmayneedtouserevenuegeneratedthroughfacilityimprovementfunds(FIF)toimprovethequalityof
FPservices,includinginfrastructure,toencourageutilizationoftheservicesatfacilitylevelbytheproviders.
Revamping and supporting Community Based Distribution of Family Planning services by the government,
NGOs,andtheCBOsisinevitable.TheNGOsandCBOsneedtorevampandsupporttheservicesofcommunity
baseddistributorssothatcontraceptivescouldreachtheunderservedwhoarethemajorityinslums.Lastly,the
MinistryofHealthincollaborationdevelopmentpartnersinvolvedintheprovisionoffamilyplanningservices
needtoenhancelargescaletrainingofserviceprovidersinqualitycare,clientfollowup,communicationskills,
counselling,referralandfeedbackandprovisionofawidechoiceofmethods.Withgoodcustomercare,clients
whoseekcontraceptiveswillhaveconfidenceinthestaffwhichintheprocesswillattractmoreuserswhileatthe
sametimeencouragingfurtherusageonthosecurrentlyusingthem.However,forthisprogrammetobeeffective,
donorsupportiscritical.
Creationofadvocacygroupsatcommunitylevelishighlyrecommended.Thiswillnotonlyarticulatetherights
oftheclients,inthiscasethewomanwhoseekcontraceptives,butwillleadtoculturalandattitudechange
towardstheservicestherebyencouragingtheiruptake.Intheend,thisisexpectedtocontributepositivelytowards
a reduction in the total fertility rate as well as decline in population growth rate. NGOs, CBOs, and other
institutionsinvolvedinfamilyplanningneedtoinitiateandpromotetargetingprogrammesfortheuptakeofthe
servicesintheslums.
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Appendix1
TableA3:PairwiseCorrelationMatrixforExplanatoryVariables
Price

Pappr

1.000
0.482
0.077
0.045

1.000
0.060
0.120

0.102

0.153

0.051

0.601

0.060
0.079

0.599

DChild
Peduc

Mstat
1
0.058
0.248
0.354
0.449

0.044

0.057
0.041

0.045
0.498

Relign

0.019

0.057

Weduc

0.005

0.063

0.002

Frind
Incm

0.041
0.231

0.220
0.780

0.248
0.117

MStat
Price
Pappr
Age
LChild
Quality
know
Proxity

42

0.205
0.130
0.231

0.059

Age

1.000
0.639

0.050

0.060

Lchild

Quality

know

ProxityDChildPeducRelignWeduFriendIncm

1.000
0.073

1.000

0.114

0.186

1.000

0.102

0.162
0.178

0.034

0.139

0.052

0.091

1.000

0.109
0.301

0.021
0.036

0.038
0.012

0.050
0.025

1.000
0.095

1.000

0.043

0.015

0.001

0.137

0.028

0.071 1.000

0.034

0.021
0.247

0.037

0.015

0.008

0.063

0.041

0.198 0.013

1.000

0.040
0.215

0.200
0.007

0.223
0.054

0.241
0.002

0.066
0.610

0.027 0.074
0.613 0.052

0.044 1.000
0.097 0.0511.000

CentreforPromotingIdeas,USA

www.ijbssnet.com
Appendix2
NormalityTestResults

250

Series: Standardized Residuals

Sample 2 500
Observations 497

200

Mean
Median
Maximum
Minimum
Std. Dev.
Skewness
Kurtosis

150
100
50

Jarque-Bera
Probability

0
-2

0.028049
0.015523
10.43142
-2.200969
0.857685
5.263660
51.87198
51756.22
0.000000

10

Appendix3
TestforHeteroskedasticityusingResidualGraph

1.0

0.5

0.0

-0.5

-1.0
50

100

150

200

250

300

350

400

450 500

USFP Residuals

43