Bamba, Kenya – Zippora Masha invites her guests into her spacious mud-walled home, where educational posters, brought home by her husband, a teacher, line the walls. Her oldest daughter, 5, is at school, but her youngest, a healthy, chubby toddler, snoozes on her hip.
Although her own education ended in third grade, she hopes her children will go further in school so they can get good jobs. She wants to have six children – her husband prefers five – and with his approval she has used a contraceptive implant to space their children.
“He feels that if we plan our family we will be able to better educate and take care of our children,” the 27-year-old explains through an interpreter, adding with a laugh that her mother-in-law would prefer them to have a child every year.
Less than a mile away, down a road that looks more traveled by goats than cars, a very different picture emerges.
Riziki Karisa meets her guests under the shade of a neighbor’s tree, the only one in sight amid fields of brittle, parched corn. A half dozen curious children watch from the front of the house as Riziki, holding her crying toddler, tells her story.
Growing up in a rural, remote area of Kilifi County in coastal Kenya, Riziki never had the chance to go to school. At 30 years old, she is the mother of nine children, with one more on the way. She and her husband spend their days gathering firewood from a local forest to make charcoal, which they sell for a minimal income. Most days, there is enough food for only one meal, if that, and the children often miss school.
She knows about contraception, and in fact has asked her husband repeatedly if she can use it – permission she believes she needs based on the cultural norms and practices of her community. But so far, he has refused, even though his mother supports it.
“He enjoys seeing them playing,” she explains, referring to their children. And in this part of Kenya, where the “Mwenye Syndrome” is common – the belief that husbands “own” their wives – his view prevails.
Reaching women in those underserved areas is a passion for Dr. Aisha Mohamed, the new manager of the Family Planning, Reproductive and Maternal Health Unit for the Kenyan Ministry of Health. A native of Kilifi, she knows too well how the Mwenye Syndrome prevents women from living healthy, self-directed lives and fuels the cycle of poverty for their children.
Sitting in her conference room in Nairobi, Mohamed points at a graphic that shows the areas of highest need — coastal and northern Kenya, where geography, security concerns and cultural issues have made service delivery challenging.
With a masters in public health and a recently completed MBA from the University of Leicester in England, Dr. Mohamed is focused on leading change. As a mother, a Muslim and the first female leader of the family planning program, she speaks from a unique perspective.
“I come from a community where women are not generally empowered to make decisions,” she explains. “When I talk about family planning, I understand the cultural and religious issues.
“And as a woman, I can create the bridge to discuss issues that may be difficult for men to address.”
Improving access to contraception for women in underserved areas of Kenya is the focus of a new pilot project implemented by the global health non-profit Population Services International (PSI) and its local affiliate, PS Kenya. The project is supported through a seed investment from Maverick Collective, a philanthropic and advocacy initiative of PSI that aims to end extreme poverty by driving investments in girls’ and women’s health and rights. Maverick Collective members are individual philanthropists who use their financial and intellectual resources to create change in collaboration with PSI.
The project has a key advocacy goal: changing Kenya’s policy to allow community health extension workers (CHEWs) to insert contraceptive implants, which provide women with reliable contraception for up to five years. Currently, the policy requires that implants be inserted by medical professionals only, which dramatically limits access, especially for women in remote areas. The project will involve training CHEWs to safely deliver a variety of methods, including implants, and will include behavior change communication and education components.
The three-year project will pilot the new task-sharing approach in one sub-county of Kilifi, while using a similar sub-county as a control site. It is the first time this approach has been tested in Kenya, although similar projects in Nigeria and Ethiopia have shown some success.
The numbers show why new approaches make sense. While Kenya has made huge strides in its contraceptive prevalence rate (CPR) – in fact surpassing its national goal and hitting 62 percent CPR in 2016 – there are large pockets of unmet need. In Kilifi County, for example, the CPR is just 34 percent and only three in 10 women are using modern family planning methods. Teen pregnancy is also higher than the national average, with 22 percent of teens getting pregnant.
Back in Bamba, there are signs that change is possible.
During a community focus group, more than a dozen women freely share their joys and worries, as well their views on contraception. It is surprising how much the women know about different methods, and how open they are talking about the subject. One woman even rolls up her sleeve and shows her implant, vouching for its effectiveness.
But other women say they have problems convincing their husbands, or their mothers-in-laws, or that their religion — Islam and the “Miracle Church” are specifically mentioned — won’t allow it. The most fundamental decision involving their bodies — whether or not to have children — is not their own.
One young woman speaks up repeatedly in support of contraception and women’s empowerment. Despite her youth, the women listen to her with respect.
One of six children raised by a widow, Elizabeth Kombe is one of the rare women in town who completed high school. She started college but dropped out because she could not cover the tuition. She is unmarried, unusual at her age, and struggles to support herself. She receives a small stipend for volunteering at the local orphanage.
Ever since she attended a family planning training offered by World Vision four years ago, she has taken up the cause, using her voice to try to influence her peers.
“It enables people to take care of their children,” she explains, staying to chat after the lively community meeting has concluded. “They can provide food, education and health for their children and give them a future.”
She promises to keep speaking up, and in fact, offers to organize the women in the Bamba focus group to meet again to continue learning and supporting each other. Her dream?
“I would like to see this group trained to go the community and spread the gospel of family planning.”
Banner Photo: © Population Services International / Photographer: Jackie Presutti