Provider-imposed restrictions on contraceptive use in Western Kenya

Abstract

Objective: Contraceptive providers unnecessarily restrict contraceptive use or inappropriately apply medical eligibility criteria for a variety of reasons, including knowledge gaps, personal bias, or fear of legal or social consequences. As prevalence of these restrictions is unknown, this analysis aims to document current patterns of provider-imposed restrictions on contraceptive methods at public facilities in Western Kenya and assess novel questions on medical restrictions.

Study design: We surveyed 345 family planning providers across all 137 public healthcare facilities in Kisumu County, Kenya in 2022. The survey asked about non-clinically-indicated provider restrictions placed on six contraceptive methods, including sociodemographic and medical restrictions on contraceptive use. We use descriptive statistics to present the self-reported proportion of providers who impose incorrect sociodemographic or medical restrictions and use Chi-squared tests to explore associations with provider gender, age, time since last family planning training, and facility level.

Results: We find that providers commonly imposed sociodemographic restrictions on female permanent contraception and intrauterine devices, with fewer providers inappropriately restricting women seeking oral contraceptive pills, implants, injections, or male condoms. Few providers reported accurately applying weight, blood pressure, or breastfeeding related medical eligibility criteria, with many inappropriately restricting hormonal methods. Weight was the most common reason for restriction, with 50% of providers reportedly applying inappropriate weight-based restrictions to oral contraceptive pills, 60% to injectables, and 40% to implants.

Conclusions: Provider bias and inappropriate medical restrictions limit women's contraceptive choice in Kenya. More research is needed to address inappropriate provider restrictions, especially around patient age, weight, and partner consent.

Implications: We find that providers are applying biased and/or inappropriate medical restrictions to contraceptive methods in Kisumu, Kenya, especially around patient weight. More research is needed to understand why many providers are applying medical eligibility criteria incorrectly, and how this impacts women's contraceptive choices.

Keywords: Contraceptive service delivery; Family planning; Kenya; Medical eligibility criteria; Provider bias.