Policy stalemate: To offer contraceptives to adolescents or not?

Everlyne, 15, lulls her twins to sleep. It is only 8am, but she is ready for the baby’s first nap of the day. 

She looks tired, not a surprise for a teen mother of twins aged one — and she is six months pregnant with a third child.

The warm rays of the morning sun wafting through the hole that plays the window in her mud-walled hut in Shiatsala village, Kakamega County may not portend bliss. 

At least not this morning. With not much food at home, Everlyne is still racking her brain on what to give her children for breakfast. “I will prepare porridge, I have some flour left,” she decides.

Before her pregnancy, Everlyne was one of the best pupils in her class in one of the primary schools in Kakamega County and the best performer in Christian Religious Education. 

However, a few months before sitting her final primary examination, her schooling was crushed. “This happened so fast,” she says. 

At a sports day event in a neighbouring school, she met a boy from Butere High School. They had an instant liking for each other, she recalls, and within the first week of their relationship, they had started having unprotected sex.

“At times he would use a condom but most of the time we had unprotected sex,” she says.

Worried about getting pregnant, Everlyne sought help. She walked to Kakamega Referral Hospital one Saturday to seek help with contraceptives. She did not want to get pregnant. She also did not want her mother to know that she was sexually active.

But a new policy on reproductive health as articulated by the national government does not allow any health care workers to give contraceptives to minors unless they are accompanied by a parent or a guardian. 

Health care workers at the hospital denied her the contraceptives she needed. In a matter of three months, she was pregnant. 

She kept this a secret for four months until authorities in her school found out she was pregnant and expelled her. 

The boyfriend, she says, denied the pregnancy and abandoned her. She was alone and stranded. 

She tried aborting the child. But just like in her search for contraceptives, she hit a wall. No facility could offer her the procedure. Abortion remains illegal in Kenya. 

She stayed home as the rest continued with their studies. But she was determined to keep fighting, so she went back to sit her examination when she was in her last trimester.  

Five months after delivering her twins, she got involved with yet another man who had promised to take care of her and her babies. She returned to the hospital with the hope that this time she could get a family planning method. Still, the system failed her. 

“When I went to the hospital, it was my hope that they would see the sense and give me the contraceptive. I had given birth and was having a relationship with another man. I tried explaining all this but no one was ready to listen to me,” she says.

She returned home without a solution. After six months of her involvement with the second man, she got pregnant again. Now she is waiting for her third child.

“You know, it is not that after giving birth I will stop having sex. I need contraceptives. I need to stop here and plan for my family. I want to be allowed to make the decision on when to have another baby,” Everlyne says.

Everlyne’s helplessness is a direct result of the new policy on reproductive health that pits the national government against the county governments on the provision of contraceptives to adolescents. 

The two levels of governments have been squabbling over whether the policy should stand, with counties arguing that some of its recommendations are tone-deaf to the realities of teen pregnancies in the country.

One in every four girls in Kenya aged between 10 and 19 is either pregnant or has given birth to a first child, according to National Council for Population and Development (NCPD)’s report in 2021.

The Health ministry was to launch the National Reproductive Health policy 2020/2030 in an elaborate ceremony in Nairobi, 370 kilometres  from Everlyne’s dusty hamlet.

The ministry sent out an invitation to the Council of Governors, which dismissed the invite. Then Council of Governors Chair Wycliffe Oparanya fired back a letter of his own asking the ministry to shelve the policy to allow “the county governments to study the document and make their recommendations.”

Health is a devolved function, with county governments expected to play a pivotal role not just in the implementation of policies but also in their design and formulation. But on this particular policy, county governments felt left out on the latter.

The result has been confusion across the country, with health officials in some counties refusing to deploy the policy and continuing to offer contraceptives to teenagers, and others withdrawing the services out of fear of retribution. 

The standoff has come at a steep cost to thousands of teenagers like Everlyne across the country, who have become the collateral damage.

It is in Kakamega Country where a health care worker was reportedly arrested for giving family planning to a girl below 18 years.  Health workers in the county have since vowed not to deal with a minor. The confusion caused by the policy has left many health workers in the county afraid of giving contraceptives to minors. Many of the health workers have focused their efforts on adults, leaving minors like Everlyne to their own  devices. 

This has led to an increase in the number of teenage pregnancies and unsafe abortions in the region, according to data from the Reproductive Health Department.

Comparing the 2020 and 2021 reproductive health data in Kakamega County from the Kenya Health Information System, one sees a notable drop in the number of young girls seeking the family planning services. 

In 2020, the number of 10 to 19 years girls assessing family planning methods in Kakamega County shot to 18, 635, with about 14, 768 attending their first antenatal clinics in various hospitals. This reduced by more than a half in 2021, when 8,726 were on family planning and 6,853 attended their first antenatal clinics. 

This, the Reproductive Health Coordinator Kakamega County Amelda Barasa attributed to the girls being denied services in most of the health facilities.

Before the policy, the National Adolescent and Sexual Reproductive Health Policy (2015) indicated that reproductive health services are basic human rights for all people and that adolescents and youth have the right to a full range of reproductive health information and services. 

It indicated that a continuous supply of essential medical commodities including contraceptives, condoms, pregnancy testing kits, and post-abortion care kits was necessary to the group.

“Before the policy, when a girl came to the facility, we would not deny them services even though we would advise them on some other contraceptives, including condoms, but as long as we conducted a screening and found them eligible, we would give the service,” says Ms Barasa.

However, this has changed with many healthcare providers choosing to even lie that the methods are not available.  

Data from the Performance Monitoring for Action Kenya 2021 report reveals that about six in every 10 adolescents nationally did not use a contraceptive method during the last sex they had and only 14 per cent of all adolescents (15-19 years) are using modern contraceptives methods.

“Until the policy is revised, we are not going to give this service to the girls and we have started seeing an impact of that from our numbers but still we have to respect the policy,” says Ms Barasa.

However, some counties have taken a different stand on the policy, and have continued to offer contraceptives to adolescents. Kilifi County, for example, has adopted a different approach. 

“Looking at it from the health rights angle, it is not right to deny them the services because they need them. We have girls as young as 10 years old getting pregnant,” says Mr Kenneth Miriti, Kilifi County Reproductive Maternal Neonatal Adolescent Sexual Reproductive Health coordinator.

The policy, he says, locks out the most vulnerable and the biggest population in need of contraceptive services.

“What we are likely to witness if the policy is implemented is the increase in teenage pregnancies, unsafe abortions and maternal deaths. The repercussions are huge,” he says.

Kenya Health Information Service report released in June 2021 says about 15,000 adolescents aged between 10 and 19 in Kilifi were on contraceptives and about 7,000 adolescents of the same age group got pregnant.

“If you look at the population that needs the contraceptives and you deny them the methods, then it means that we are likely to record backtracking of the gains made. Adolescents are the biggest consumers of family planning services in the county,” he told Healthy Nation.

The Kilifi data shows that 53 percent of consumers of family planning methods are aged 10 to 49, with a majority — 28 per cent — being adolescents.

Mr Miriti says his county will disregard the policy and will continue to give contraceptives to girls without parental consent as long as the girls have been screened and are eligible. 

“If a 10-year-old girl comes to the labour ward, we won’t release them without giving a method of family planning because it is part of the service package. We have decided to treat the matter differently.”  Adolescent pregnancy, whether intended or unintended, increases the risk of maternal mortality and morbidities including complications of unsafe abortion, prolonged labour, delivery, and post-natal period.

Mr Miriti’s sentiments are supported by Ms Sharlette Anzazi Gongole, the nurse in charge of Mnarani Dispensary in Kilifi County, who is supporting close to 50 teenage girls with family planning methods.

“Giving a method is not an encouragement for them to be reckless but prevention of future unwanted pregnancies. We are also telling them more about condom use,” says Ms Gongole.

In February 2022, about 20 girls between the ages of 10 and 19 were on contraceptives at Mnarani Dispensary,  with 30 others of ages 20 and 24 also on contraceptives.

“There is a dire need for the girls to be given contraceptives and other interventions to stay safe,” Ms Gongole told Healthy Nation.

Ms Monica Kerrigan of the Family Planning 2020, a consortium of family planning and reproductive health organisations, said it was sad that countries are ignoring the right of young people to information and ultimately family planning services.

“Let them make their own decisions,” she said.

Kenya has made notable strides to improve the uptake of modern contraceptives. In 2020, Kenya attained a contraceptive prevalence of 61 per cent, surpassing the target of 58 per cent. This led to the revision of the rate to 66 per cent by 2030 and 70 by 2050, according to a survey, conducted by Performance Monitoring for Action.

The demand for modern contraceptive methods increased from 74 to 76 per cent, with married women using modern contraceptives more than their unmarried counterparts at 58 per cent in 2019 and 62 per cent in 2020, as compared to 56 and 61 per cent, respectively. However,  the Youth Family Planning Policy  Scorecard by the Population Reference Bureau states that the legal stance on parental and spousal consent for youth accessing family planning services remains a barrier and may slow down the gains.

The new policy drawn by the national government backs a conservative approach to contraceptives, stating that a child’s right to health care is the responsibility of the parent. 

The policy, according to health experts interviewed by Healthy Nation, was informed by a statement made by President Uhuru Kenyatta on July 27, 2020, ordering a crackdown on private clinics offering emergency contraceptives to underage girls.

The President alleged that health care workers were inculcating a culture of sexual promiscuity for sex pests and providing “sexual insurance” for minors. 

However, this contradicts commitments that the President made during the 2019 United Nations International Conference on Population and Development Programme of Action to advance women’s rights, choices and wellbeing.  

The commitments included ensuring that all citizens attain the highest possible standard of health through elimination of preventable maternal and newborn deaths, mother-to-child transmission of HIV, teenage pregnancies and reducing new adolescent and youth HIV infections by 2030.

“This isn’t where girls my age should be, taking care of two babies. If I was allowed to have a method of my choice, I would be in class with my peers,” says Everlyne.

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