Prevalence and Determinants of Covert Contraceptive Use in Kenya: a Cross-Sectional Study

Background: Family planning (FP) is a key intervention for preventing unplanned pregnancies, unsafe abortions, and maternal death. Involvement of both women and their partners promotes contraceptive acceptance, uptake and continuation, couple communication and gender-equitable attitude. It is a key strategy for addressing about 17.5% of the unmet needs in FP in Kenya. This study assessed the prevalence and determinants of covert contraceptive use (CCU) in Kenya. Methods: We used data from the sixth and seventh rounds of the performance monitoring for accountability surveys. We dened CCU as ”the use of contraceptives without a partner’s knowledge”. We used frequencies and percentages to describe the sample characteristics and the prevalence of CCU and assessed the determinants using bivariate and multivariable logistic regressions. Results: Of the 3,892 married women using contraceptives included in this study, 62.9% were 20−34 years, 65.4% lived in rural areas, 51.3% had primary education and 82.4% had two or more children. The mean age at rst sexual encounter was 17.3 years (standard deviation: 3.0). The prevalence of CCU was 12.2% (95% CI: 10.4%−14.2%) and was high among 35−49 years (12.8%), uneducated (22.3%) and poorest (18.2%) women. Siaya (22.9%), Kericho (16.7%) and Kakamega (13.1%) counties had the highest prevalence of CCU. Injectables (53.3%) and implants (34.6%) were the commonest methods among women who practice CCU. County of residence, education, wealth, parity, and age at sexual debut were associated with CCU. Conclusion: About one in 10 married women in Kenya use contraceptive covertly, with injectables and implants being the preferred methods. Our study highlights a gap in partner involvement in FP and calls for efforts to strengthen their involvement to increase contraceptive use in Kenya while acknowledging the rights of women to make independent choices.


Introduction
Kenya has a high fertility rate at 3.9 births per woman [1], and a teenage pregnancy rate of 18% [1] and 120,000 unsafe abortions annually [2]. Family planning (FP) is a key intervention for preventing unplanned pregnancies, unsafe abortions, and maternal death [3]. In 2014, the modern contraceptive prevalence rate (mCPR) was 53%, with about one-fth of the FP needs still unmet [1]. The mCPR is expected to increase to 58% by 2020 [4].
In line with the sustainable development goal 3, Kenya is implementing FP programmes aimed at universal access to sexual and reproductive health services by 2030. Most interventions have been targeted towards women, who are the primary users of contraceptives. However, involving both women and their partners is a strategy that promotes contraceptive acceptance, uptake and continuation [5,6], couple communication and gender-equitable attitude [7]. Male involvement in FP has remained relatively low in Kenya [8], with the lack of their involvement resulting in opposition to self or partner's FP use [5,8,9]. In South Africa [9] and Nigeria [5], male opposition to contraceptives has been attributed to their low level of knowledge on FP, physical violence and dominance.
Earlier studies have found an association between women empowerment and autonomy and their use of contraceptives [10][11][12]. High education and wealth empower women to decide on their reproductive health including the uptake of FP. However, women have resorted to using contraceptives without their husbands/partners knowledge due to their opposition to contraceptives [5,8,9], fear of reprisal from the partner [13] and religious beliefs [14]. In sub-Saharan Africa, between 2.6% and 20.2% of women use contraceptives covertly [15]. Covert contraceptive use (CCU) is common in male-dominated settings where women lack the autonomy to make choices on their health [16].
To address the unmet need for FP, Kenya is promoting partner involvement in FP. However, there is a paucity of evidence on the involvement of male partners in FP. An earlier study found that nine per cent of married women in Kenya use contraceptives without their partners' knowledge [15]. While CCU increases overall contraceptive prevalence rate, it could indicate barriers women encounter in deciding and using FP methods. Hence, there is a need to ascertain the extent of CCU in Kenya and its determinants to inform FP interventions and policies. This study assessed the prevalence and determinants of CCU in Kenya.

Data source and study population
We utilised data from sixth [17] and seventh [18] rounds of Kenya's performance monitoring for accountability (PMA) surveys. The surveys used a multi-stage strati ed cluster design that involved urban-rural and 11 counties (Nairobi, Bungoma, Kericho, Kiambu, Kili , Kitui, Nandi, Nyamira, Siaya, Kakamega and West Pokot) as strata, 151 enumeration areas (EA) sampled from the KNBS master sampling frame, 42 randomly selected households in each EA. All consenting females 15 to 49 years in the selected household were interviewed. Round 6 included 6,106 households and 5,876 females (99% response rate) while round 7 had 6,097 households and 5,671 females (99.1% response rate). Data were collected by trained interviewers using standardised questionnaires in November and December of 2017 and 2018 [17,18].
Measures CCU was de ned as "the use of contraceptives without a male partner's knowledge" [19]. It was measured based on the question: "Does your partner/husband know that you are using family planning?" among women currently using FP and in-a-union.

Statistical analysis
We described the sample characteristics and the prevalence of CCU using frequencies and percentages.
Determinants of CCU were assessed using bivariate and multivariable logistic regressions. All independent variables were included in the adjusted model. Stata 13.0 was used for analyses [26], which were adjusted for the sampling design and strati cation based on survey weight provided in the datasets. Statistical signi cance was set at p = 0.05.

Sample characteristics
Out of the 11,753 sampled women, 3,943 were in-a-union and currently using contraceptives. A total of 3,892 women were included in the nal analysis after excluding 51 women (1.3%) who did not respond to the question of partner knowledge on contraceptive use. A majority of the nal sample were 20−34 years (62.9%), lived in rural areas (65.3%) mainly Bungoma (11.6%) and Kitui (11.4%) counties, and had primary education (51.2%) and two or more children (82.3%). The mean age of rst sexual encounter was 17.3 years (standard deviation: 3.0) ( Table 1). Injectables (43.7%) and implants (35%) were the commonest method of contraceptives used.

Determinants of covert contraceptive use
Siaya county, rural residence, education, wealth, and age at sexual debut were associated with CCU in the bivariate analysis. In the multivariable logistic regression, counties, rural residence, education, wealth, parity, and age at sexual debut were associated with CCU (Table 1). Uneducated women and those with primary education had 3.8-and 1.9-folds increase in odds of CCU respectively, compared to those with tertiary education. Women from households with the poorest, poorer, and middle wealth quintiles had 2.7, 1.8-and 2.4-times increased odds of CCU compared to those from the richest quintile. Compared to women in Nairobi county, those in Kitui, Bungoma, Nyamira, West Pokot, Kili and Nandi counties had between 58% and 77% reduced odds of CCU. Women with two or more children and those with four or Page 5/14 more children had 51% and 38% reduced odds of CCU compared to those with no children. The odds of CCU reduced by a factor of 0.94 for every year increase in age at sexual debut (Table 1).

Discussion
The present study found a 12.2% prevalence of CCU among married women in Kenya. The prevalence was high among older, uneducated, poorest, and rural women, and among women who neither had children nor desired for more children. The commonest methods of contraceptives used covertly were injectables and implants. Education levels, wealth, county of residence, rural residence, parity and age at sexual debut were associated with CCU.
The prevalence of CCU in SSA ranges from 2.6-20.2% [15]. In our study, about one in ten women used contraceptives covertly, which signi ed an increase in the prevalence of CCU from 9% in 2008 [15]. Our prevalence was higher than in Ethiopia (8.7%) [27] but lower than in Uganda (22.1%) [23] and Ghana (53%) [28]. However, the study in Ghana included both married and unmarried women using contraceptives [28]. The practice of CCU could be due to societal perception of women using contraceptive as being promiscuous [6,14,28,29], patriarchy [9,29], fear of intimate partner violence [13,30,31], disagreement on the number of children [29], religious beliefs [14] and limited male involvement [6,32]. CCU could re ect women empowerment and autonomy in decision making [31] but could also indicate male dominance in decision making and create a barrier to increasing contraceptive coverage [9].
Similar to previous studies in Ethiopia [27], Ghana [28], Kenya [1,15] and Nigeria [5], injectables and implants were the commonest methods of contraceptives used overtly and covertly by married women. Injectables and implants are easy-to-use, effective, concealable [31], modern reversible contraceptives lasting three months, and three or ve years, respectively [3]. Injectables are also widely available and accessible in most health facilities and pharmacies hence promote CCU [31].
Women empowerment is associated with modern contraceptive use [11]. Autonomy and decision-making give women control over their body and reduce potential resistance against contraceptive use from their partners [15,33,34]. Improved autonomy and independence in decision making may increase partner involvement in FP but may also promote independent use of contraceptive and lack of partner involvement hence increasing the likelihood of CCU [15,[33][34][35].
High education and wealth improve women autonomy and decision making increasing the likelihood of use of modern contraceptive [22,35,36]. In our study, low levels of education and wealth were associated with increased odds of CCU, which con rms previous ndings in SSA [15,21]. The prevalence of CCU among the poorest women was thrice that of the richest women. We also found that an increase in age at sexual debut is associated with reduced odds of CCU indicating that women who delay their sexual debut have a high likelihood to use contraceptives with their partner's knowledge. This could be attributed to higher levels of education and income which increases their autonomy and decision making [35]. Girls' education delays early marriages, reduces the age at sexual debut and improves girls' and women's selfesteem [37], which is likely to improve communication with their partners.
Married women with children are more likely to be involved in decision making about the desired number of children and birth spacing [23,35] hence the reduced odds of CCU among women with two or more children compared to those with none. This is consistent with a study in Ghana where women with no children were more likely to use contraceptives covertly compared to those with children [28]. We also found that women in rural areas were more likely to practice CCU compared to those in urban areas, though not statistically signi cant. Married urban women are more involved in decision making on children and FP due to their high level of knowledge on contraceptive and gender-equitable attitude [38].
On the contrary, we found that women from the rural counties of Kitui, Nyamira, West Pokot, Kili , Bungoma and Nandi were less likely to use contraceptives covertly compared to women in urban cosmopolitan Nairobi county. The reason for this is not clear but it may be due to perceived male dominance, cultural practices and reduced women autonomy.
Our study is one of the rst to explore the practice of CCU in Kenya. We used nationally representative cross-sectional data from 11 out of the 47 counties of Kenya, which makes our nding generalisable to the country. However, based on the nature of the data we could not infer causation. Also, some key determinants of CCU such as duration of the marriage, years of schooling, decision making and exposure to media were not collected. The study also focuses on women-in-a-union and excludes women not-in-aunion who we could ascertain whether they had a partner(s) hence we may have underestimated the prevalence of CCU.

Conclusion
Our study shows that about one in 10 married women in Kenya use contraceptive covertly, with injectables and implants being the preferred methods. CCU was associated with education levels, wealth, county of residence, parity, and age at sexual debut. CCU could re ect both increased or decreased women autonomy and independence in decision making. While it is important to promote open contraceptive use among married couples, women should be supported to use contraceptives in whichever way they prefer. Importantly, FP programmes should promote couples communication and foster male involvement in FP to improve overall contraceptive use. Further research is needed to explore the reasons for CCU in Kenya.
List Of Abbreviations aOR: Adjusted odds ratio; CCU: Covert contraceptive use; cOR: Crude odds ratio; FP: Family planning; PMA: Performance Monitoring for Accountability; mCPR: modern contraceptive prevalence rate; SD: Standard deviation; SSA: Sub-Saharan Africa

Declarations
Ethics approval and consent to participate The study used secondary data from the Performance Monitoring for Accountability (PMA2020) surveys that were approved by the Kenyatta National Hospital-University of Nairobi Ethics Research Committee [39].

Consent for publication
Not applicable Availability of data and materials Data used in this study can be accessed from the Performance Monitoring for Accountability (PMA2020) website at https://www.pma2020.org/request-access-to-datasets

Competing interests
The authors declare that they have no competing interest.

Funding
This work did not receive any funding.
Author Contributions CA conceptualized and acquired data for the study. CA, JOO and SMG designed the study, analysed the data, discussed, and agreed on the results and wrote the initial draft. All the authors critically reviewed, experience. Gates Open Research 2020, 4(30):30. Figure 1 Method of contraceptive used by women with or without partners' knowledge

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