WOMEN'S EXPERIENCES OF INDUCED ABORTION IN MOMBASA CITY AND THE KILIFI ...

255 Pages·2014·3.02 MB·English

TITLE

WOMEN’S EXPERIENCES OF INDUCED ABORTION IN
MOMBASA CITY AND THE KILIFI DISTRICT, KENYA

Louisa Njeri Ndunyu
M.A Population Studies (University of Nairobi, Kenya)

Submitted in fulfillment of the requirements for a PhD (Population Studies) in the
School of Built Environment and Development Studies,
University of KwaZulu-Natal, 2013

Date: 29 November 2013
Supervisor: Prof. Eleanor Krassen Covan, PhD
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DECLARATION

I, Louisa N. Ndunyu, declare that the work presented in this doctoral thesis is my own, and that it has not
been submitted in any other form to another university.

Where use has been made of any work done by other persons it has been duly acknowledged and
referenced in the text.

Candidate: Louisa Ndunyu Signature Date: 29-11-2013

Supervisor: Prof. Eleanor Krassen Covan Signature Date: 29-11-2013
ACKNOWLEDGEMENTS

 I wish to use this opportunity to express my sincere gratitude to many people and institutions for
supporting this study. Due to ethical obligations and their large numbers, I cannot mention all by
name. However, I wish to highlight in general the following:

 Prof. Eleanor Krassen Covan, my divine supervisor at the ‘eleventh hour’, for renewing my hope,
inspiring and supporting me in the run to the finish of this project; for the extraordinary
supervision and mentoring, I am truly privileged and obliged.

 Dr. Kerry Vermaark, for your commitment and support in the administrative processes to ensure
the successful submission of this thesis, I am grateful.

 Prof. Eleanor Preston-Whyte for journeying with me; for the confidence you put in me and for
dedicated supervision of this study from the mid-year 2007.

 Prof. Julian May, School of Development Studies, University of KwaZulu-Natal for trusting me
and providing consistent support throughout my studies.

 Prof. Vishnu Padayachee, Head of School, Development Studies and the entire administrative
staff for efficient management of research funds, library and workstation assistance.

 Prof. Francie Lund, thank you for encouragement and creating a ‘home away from home’
environment.

 My employer, Maseno University, for granting me initial study leave that facilitated this
investigation.

 This investigation received financial support from the Special Programme of Research,
Development and Research Training in Human Reproduction, World Health Organization,
(WHO). To them I am truly indebted. In particular, my thanks go to Dr. Iqbal Shah, Coordinator
Scientist, Department of Reproductive Health and Research, for facilitating efficient transfer of
funds and his willingness to review my manuscripts for conference presentations; Dr. Ina
Warriner and Ms. Nicky Sabatini Fox for their efficient communication.
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 Further funding was granted by the African Doctoral Dissertation Research Fellowship (ADDRF)
offered by the African Population and Health Research Centre (APHRC) in partnership with the
International Development Research Centre (IDRC) and Ford Foundation. To them I extend
sincere gratitude.

 The entire APHRC team, I say thank you for your support and ‘family’ environment. In particular
the Director, Dr. Alex Ezeh for granting me a work station at the APHRC as an ADDRF fellow in
the year 2008. Dr. Chimaraoke Izugbara, thank you for the academic support, and together with
Dr. Caroline Kabiru, you have enriched this study through skills acquired and networks created at
the training workshops, conferences and other meetings courtesy of the ADDRF fellowship. I
gratefully acknowledge Dr. Yazoume for introducing me to data analysis using MS Access; Mr.
Anthony Maina and Mr. Morris Mbogo for invaluable technical assistance with IT.

 The Ethical Review Board of the Kenyatta National Hospital/University of Nairobi, in particular,
Prof. Elizabeth Bukusi of the UoN/KEMRI; the administration of the CPGH, the KDH, MDH and
HCs; and the local administration, for permission to do research among patients in health
facilities and households.

 The research team, including the women studied, interviewers, field assistants, nurses,
counselors, community resource persons, translators, and fellow researchers who double checked
the transcriptions. Thank you for your participation.

 Reproductive health organizations and experts in Mombasa and the Kilifi districts, for corporate
and individual technical support and information during the field exercise and dissemination. The
Officer Commanding Police Division, (OCPD), Mombasa, is here acknowledged.

 KEMRI, Kilifi, in particular Dr. Evasius Bauni, and the then Mombasa District Hospital in Port
Reitz, for the maps used in this study, thank you.

 Qualitative experts: Ms Parsy Clarke, retired ICT Division, University of KwaZulu-Natal for
providing me with qualitative material for analysis and proof-checking text data; facilitators of
various qualitative methods courses organized by the Reproductive Health Research Unit (2007);
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the joint APHRC/UAPS (2005); and the joint School of Development Studies, UKZN/Groningen
University (2005), I here acknowledge the skills you imparted on me.

 Ms. Princess Nhlanqulela, UKZN, who tirelessly processed the transcripts in to Word documents.

 Colleagues of the consortium for abortion research in Africa, thank you for valuable discussions
and facilitating dissemination of this study. Special thanks to Dr. Ann Moore, Guttmacher
Institute, for granting me the DELL laptop that I now use to complete this study as the battery in
my original computer failed me. My daughter Kazuri for sacrificing her laptop after the battery in
the DELL laptop recently expired!.

 My colleagues in the PhD office F200, School of Development Studies, thank you for making
this academic endeavour a bearable journey by your lunch hour and tea-break companionship,
global political discussions, jokes, ‘braais’ and football games by the beachfront, and being a
valuable sounding board for my ideas. Dr. Janet Muthoka of the Gender Studies, UKZN thanks
for reviewing the narratives, affirming the gender themes and the fruitful discussions we had.

 My friends and colleagues: Ms. Olympia Jelagat Okal, your dedication in keeping me connected
to my employer and encouraging my family while I was away in Durban, is fully appreciated.
Together with Dr. Pauline Andang’o, your support and encouragement during a difficult writing
period as I struggled to teach in Kisumu and be there for my family in Nairobi, receive my many
thanks.
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 My long-suffering family: my daughter Kazuri and son Steven who bravely and selflessly
allowed me to study in South Africa leaving them behind; they have grown and advanced to the
university in the years I have spent completing this study; my mother who has grown frail; and
my brother, Christopher, his wife Luiza and their four children namely, Alvin, Ethel, Triza and
Tracy for graciously embracing my children in the years I was in Durban, I am greatly indebted.

To God be the Glory,

Louisa .N. Ndunyu
Maseno University, Kenya

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DEDICATION

This thesis is dedicated to the women of Mombasa and the Kilifi districts for their courage to
share and lay public their private lives with the hope that it will make a contribution towards
improvement of Kenyan women’s lives.

The experiences of these women left a remarkable change in me and I hope the reader will be
similarly influenced by these accounts.

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ABSTRACT

The primary objectives in this study were to gain a deep level of understanding of Kenyan
women’s experiences of seeking abortion, both safe and unsafe, and to explore how social and
legal issues impact their choices and the routes they take to obtain abortion. I explored the
contexts and interpreted 49 in-depth narratives of women’s emic experiences of abortion in
Mombasa city and the Kilifi district, Kenya, using a qualitative form of inquiry conducted
between April and July 2005. Ethical Review Committees granted ethical clearance to this study.
This emic work revealed gender inequity consistent with developing feminist theory and thus
how women conceive gendered relationships is introduced in this analysis of women's narratives.
The findings provide new insights as well as useful confirmatory knowledge, gleaned from
detailed empirical evidence within Kenyan women’s social contexts. The women have revealed
the evidence through their narratives; such an approach is largely missing in existing abortion
literature.
The prominent finding is that women do not abort motherhood, but they do abort particular
pregnancies to protect motherhood; to avoid a difficult motherhood likely to compromise the
quality of care they envisage for their potential and existing children. This includes ensuring the
best nurturing environment, paternal and religious identity, social legitimacy. The abortion
decision is difficult to make and thoroughly considered. The married women make a consultative
decision with their ‘breadwinners’ having the upper hand.
Legal barriers cannot bar abortion but entrench inequities in abortion care access, heighten
secrecy, stigma, and hamper prompt comprehensive post abortion care seeking. Thus, financial
resources, peers, geographical remoteness, and knowledge significantly influence the type of
abortion accessed. Consequently, unsafe abortion threatens motherhood of the most vulnerable
groups of women.
The foremost recommendation is that public health law must ensure healthy, enjoyable, dignified
motherhood for the women; hence safe early abortion (first trimester) must become accessible to
alleviate existing health care inequities.

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TABLE OF CONTENTS
ACKNOWLEDGEMENTS ............................................................................................... iii
DEDICATION ................................................................................................................... vi
ABSTRACT ...................................................................................................................... vii
TABLE OF CONTENTS ................................................................................................. viii
LIST OF TABLES ............................................................................................................. xi
LIST OF FIGURES .......................................................................................................... xii
LIST OF BOXES ............................................................................................................. xiii
LIST OF APPENDICES .................................................................................................. xiv
LIST OF ABBREVIATIONS ........................................................................................... xv
CHAPTER ONE ................................................................................................................. 1
1.0 GENERAL INTRODUCTION ..................................................................................... 1
1.1 Introduction ............................................................................................................... 1
1.2 Problem Statement .................................................................................................... 6
1.3 Study Objectives ..................................................................................................... 15
1.4 Theoretical Perspective ........................................................................................... 16
1.5 Overview of Chapter Contents................................................................................ 18
CHAPTER TWO .............................................................................................................. 21
2.0 REVIEW OF THE LITERATURE ............................................................................ 21
2.1 Introduction ............................................................................................................. 21
2.2 Research on Unsafe Abortion: A Global Review ................................................... 23
2.3 Characteristics of Women at Risk of Unsafe Abortion .......................................... 24
2.4 Reasons for Abortion .............................................................................................. 26
2.5 Abortion-Seeking Behaviours ................................................................................. 31
2.6 Consequences of Abortion ...................................................................................... 34
2.7 Perceptions of Abortion and of the Abortion Law.................................................. 40
2.8 Policy Implications ................................................................................................. 43
CHAPTER THREE .......................................................................................................... 47
3.0 METHODOLOGY ..................................................................................................... 47
3.1 Introduction ............................................................................................................. 47
3.2 Study Design ........................................................................................................... 47
3.3 Data Collection Procedures..................................................................................... 50
3.4 Data Analysis and Interpretation ............................................................................ 65
3.5 Validity and Reliability ........................................................................................... 68
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3.6 Respondent Bias...................................................................................................... 68
3.7 Challenges Presented by the Study ......................................................................... 69
3.8 Lessons Learned/Conclusion .................................................................................. 70
CHAPTER FOUR ............................................................................................................. 73
4.0 STUDY SETTING: MOMBASA CITY AND THE KILIFI DISTRICT .................. 73
4.1 Introduction ............................................................................................................. 73
4.2 Geography ............................................................................................................... 73
4.3 Population ............................................................................................................... 74
4.4 Economy and Poverty Status .................................................................................. 75
4.5 Socio-Cultural Values ............................................................................................. 78
4.6 The Public Health System ....................................................................................... 81
4.7 Conclusion .............................................................................................................. 83
CHAPTER FIVE .............................................................................................................. 87
5.0 PROFILES OF THE DIVERSE CONTEXTS IN WHICH WOMEN ABORT ... 87
5.1 Introduction ............................................................................................................. 87
5.2 Abortion amongst Women in Unstable Relationships ............................................ 89
5.3 Abortion amongst Women in Stable Relationships .............................................. 103
5.4 Abortion among women in no relationship- the raped ......................................... 106
5.5 Summary and Conclusions ................................................................................... 108
CHAPTER SIX ............................................................................................................. 110
6.0 ROUTE TO INDUCED ABORTION ACCESS ...................................................... 110
6.1 Introduction ........................................................................................................... 110
6.2 The Decision ......................................................................................................... 110
6.3 The Context of Abortion Access........................................................................... 114
6.4 Access to Abortion Care ....................................................................................... 119
6.5 Conclusion ............................................................................................................ 126
CHAPTER SEVEN ....................................................................................................... 129
7.0 SAFE ABORTION EXPERIENCES .................................................................... 129
7.1 Introduction ........................................................................................................... 129
7.2 Characteristics of women seeking safe abortion ................................................... 130
7.3 Institutional Settings ............................................................................................. 130
7.4 Technical Competence .......................................................................................... 135
7.5 Technological Aspects .......................................................................................... 138
7.6 Abortion Aftermath ............................................................................................... 140
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7. 7 Family Planning Counseling ................................................................................ 142
7.8 Conclusion ............................................................................................................ 144
CHAPTER EIGHT ....................................................................................................... 146
8.0 UNSAFE ABORTION EXPERIENCES .............................................................. 146
8.1 Introduction ........................................................................................................... 146
8.2 Characteristics of women seeking unsafe abortion ............................................... 147
8.3 Informal Institutional Settings .............................................................................. 147
8.4 Technical Competence .......................................................................................... 154
8.5 Technological Aspects .......................................................................................... 155
8.6 Complications of Unsafe Abortion: “It aborted but with many problems” .......... 161
8.7 Participants’ perspectives on unsafe abortion ....................................................... 165
8.8 Conclusion ............................................................................................................ 167
CHAPTER NINE .......................................................................................................... 168
9.0 POST ABORTION CARE ..................................................................................... 168
9.1 Introduction ........................................................................................................... 168
9.2 Management of complications .............................................................................. 169
9.3 Post abortion family planning counseling............................................................. 176
9.4 Links to other reproductive health services .......................................................... 180
9.5 Conclusion ............................................................................................................ 185
CHAPTER TEN.............................................................................................................. 187
10.0 CONCLUSIONS..................................................................................................... 187
10.1 Introduction ......................................................................................................... 187
10.2 Recapitulating on the Aims of the Study ............................................................ 188
10.3 Conclusions ......................................................................................................... 190
10.4 Policy implications (for the study informants) ................................................... 196
10.5 Policy implications for Public Health practitioners ............................................ 198
10.6 Areas for further research ................................................................................... 200

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