African Population Studies Union for African Population Studies ISSN: 0850-5780 Vol. 12, Num. 2, 1997

Determinants of Adolescent Reproductive Problems in Kenya: Evidence from Health Service Data

Kennedy N. ONDIMU

Department of Geography, Egerton University Njoro, Kenya

Code Number: ep97014

ABSTRACT

Recent studies on adolescent reproductive health in Kenya indicate high incidence of maternal mortality and morbidity. The medical service records available for 1,756 women aged 10 to 20 years in seven randomly selected health facilities were analysed to identify major reproductive health problems of adolescents in Kenya. Of the total sample, 31.5 per cent had high blood pressure, 29.2 per cent had prepartum and postpartum haemorrhage, 28.6 per cent experienced obstructed labour, 27.2 per cent had low birth weights and 14.2 per cent of births delivered to these mothers died. The incidence of these health problems varied by socio-economic and demographic characteristics of the mothers. Recommendations to address these problems include encouragement of female education, introduction of family life education in school curricula, increasing access to ante-natal services in villages, expansion of free and better equipped referral medical facilities, provision of family planning services and general socio-economic reforms in the rural areas.

RÉSUMÉ

Les récentes études sur la santé de la reproduction chez les adolescentes au Kenya indiquent une forte incidence de la mortalité et la morbidité maternelles. Les archives du service médical disponibles pour 1756 femmes âgées de 10 à 20 ans dans sept formations sanitaires sélectionnées au hasard ont été analysées pour identifier les principaux problèmes de santé de la reproduction au Kenya. Sur l’ensemble de l’échantillon, 31,5 % avaient une hypertension artérielle, 29,2 % avaient une hémorragie avant et après l’accouchement, 28,6% ont connu un travail difficile, 27,2% avaient un enfant de poids en deçà de la normale à la naissance et 14,2% des enfants mis au monde par ces femmes sont morts. L’incidence de ces problèmes de santé a varié suivant les caractéristiques socio-économiques et démographiques des mères. Au nombre des recommandations en vue de trouver des solutions à ces problèmes figurent l’encouragement à l’éducation des femmes, l’introduction de l’éducation à la vie familiale dans les programmes scolaires, un plus grand accès aux soins prénataux dans les villages, le développement d’infrastructures médicales d’accueil gratuites et mieux équipées, l’accès aux services de planification familiale et l’application de réformes socio-économiques dans le monde rural.*

INTRODUCTION

Adolescence is a time when great physical, educational and social changes take place in a person. In the case of girls, it is also the time when most of them are given out for marriage even before their first experience of menstruation (Senderowitz and Paxman 1985). Pregnancy among adolescents is a growing health concern in many African countries (Kulin, 1980). This is because childbearing has been associated with many social and health risks that are sometimes very serious, and therefore, need targeting from both the curative and preventive health strategies. For instance, adolescent child bearing has been identified to be the major cause of interrupted and discontinued education (Kenya, 1988 ; AMREF, 1994). Early pregnancies have also been associated with higher than usual risk of morbidity during child birth and high incidences of maternal and perinatal deaths (Makinson, 1985; Senderowtiz and Paxman, 1985; Geronimus, 1987 and UN, 1989).

Various reasons have been put forward to account for high incidences of teenage pregnancies. These include; lack of knowledge on contraceptives (Ajayi et al., 1991), early marriage accompanied by need to prove one’s fertility (Barker and Rich, 1972) and the erosion of traditional practices coupled with lack of family control in urban areas (Feyisetan and Pebley, 1989). Pregnancy related deaths and disabilities are therefore increasingly being seen as a measure of neglect of the basic needs and rights of women. Meanwhile, as a result of high fertility and declining mortality, the population of Kenya, which will reach 30 million by the year 2000, is characterised by a young population. Over 50 per cent of Kenya’s population is less than 15 years of age, 59 per cent is less than 50 years (Kenya, 1994).

DATA SOURCES AND METHODOLOGY

This study is based on health services data derived from maternity record and birth notification cards found at seven randomly selected centres that represent both rural and urban areas. These cards contain vital reproductive health information on maternal age, birth weight, size and height of the mother, marital status, parity, education level, nature of birth and place of residence of mothers. The card also indicates whether or not the mother had been attending prenatal clinics and the type of personnel consulted for prenatal care. The records covered one calendar year ending December, 1994.

Health facilities have been found to be the most convenient places to locate women with complications (Barreto et al, 1992). If the referral system is working efficiently, most high risk women who present themselves for prenatal care are referred for hospital delivery. Evidence from the Kenya Demographic and Health Survey (KDHS) of 1993 indicate that up to 95 per cent of pregnant women in Kenya receive antenatal care from trained medical practitioners (Kenya, 1993). It was therefore assumed that if any problem is detected, it must be referred to more specialized personnel for attention. The hospitals that were selected for this study therefore had a maternity section with wards for in-patients.

This study also considered the fact that the outcome of a pregnancy is not by chance but is determined by circumstances of a woman’s life especially the economic and environmental condition in which she lives as well as her social status. In order to cater for different socioeconomic, we further subdivided the hospitals into three categories according to ownership. These are : government mission and privately owned. The government hospitals enjoy subsidies in terms of personnel and drugs and they offer free services. Most people who utilize the government hospitals are therefore assumed to come from low-income classes. Mission hospitals on the other hand, are supported by religious-based oriented organizations which require them to charge minimal fees for medical care. Most people who utilize such facilities come from the middle-income class. Finally, privately-owned hospitals are managed by individuals or groups of individuals with a profit motive. They charge high fees for the services rendered. In total, seven hospitals were selected for data collection; five from rural areas and two from urban areas. Of these, three were government-owned, whereas the other two each were run by NGOs and private individuals.

The list of variables that were included in the questionnaire was determined by the availability of information. Since this was not a prospective survey, the information recorded was not very detailed. The variables included in the questionnaire were; place of residence, age of mother, occupation of mother, marital status, educational level of mother, frequency of use of modern contraceptives, whether mother visited antenatal clinic, person consulted for antenatal care, previous obstetric history (i.e. number of births, abortions, complications, etc.), current obstetric and gynecological situation -i.e. blood pressure, birth weight, nature of delivery and reproductive health problems experienced during delivery.

Table 1 : Percentage distribution of study cases by background characteristics

The data collection exercise took three months, between March and June, 1995. A total of 1,756 questionnaires were completed. More cases were obtained from urban hospitals than rural. This may suggest that less rural people utilize hospitals for delivery care compared with urban counterparts. There is therefore a need for a separate study to establish factors that lead to low level of utilization of health facilities for birth deliveries in rural Kenya. Table 1 below shows the percentage distribution of all the respondents by background characteristics.

From Table 1, it is evident that most people utilize government hospitals probably because they offer services free of charge. As regards occupation, most adolescent mothers are not in formal employment, they are either housewives (41 per cent) or students (11.2 per cent). This shows that most young mothers lack both the social and economic autonomy to be self-reliant. It is only 21.3 per cent of the respondents who were in formal employment. Over 60 per cent of the respondents were married which clearly shows that early marriages are still prevalent in Kenya. About 38.8 per cent are single. More than half of the respondents had only primary level education; this reflected that they drop out of school early. Ever use of contraception is very low as evidenced in Table 1 above. Reasons for non use were not indicated but this could be due to demand for children amongst married adolescents and to the government policy that prohibits single adolescents from being given contraceptives. Earlier studies have however shown that low contraceptive use amongst Kenyan adolescents is due to negative perceptions that associate contraceptive information with promiscuity, lack of information, lack of access to services and prohibitive policies that outlaw accessibility to adolescents (Ajayi et al., 1991; Njau, 1993 and AMREF, 1994).

Utilization of Antenatal Care

The health of a pregnant mother has been found to significantly compare with utilization of antenatal care. This is because antenatal care can help to identify those women who are at risk of complications during pregnancy and delivery, and thus ensuring that they obtain special attention in suitably equipped facilities. It also provides an invaluable opportunity to increase the awareness of women, their families and communities of the risk of pregnancy and how this can be overcome. The extent of utilization of modern antenatal clinics and the increase in proportion of mothers who visit trained personnel for antenatal check up, therefore, indicates the success being made in improving maternal health. Data obtained from the records indicated the extent to which mothers had sought ante-natal care during pregnancy and the person consulted. Tables 2 and 3 show the percentage distribution of all respondents who utilized antenatal services and the distribution as per the type of personnel contacted respectively.

From the tables, it will be observed that over 80 per cent of women who delivered in the hospitals received antenatal care. The majority of them, however, visited health centres where the personnel consulted most were trained nurses (65.4 per cent) followed by clinical officers (13.4 per cent). Table 4 on the other hand, shows the distribution of respondents utilizing or not utilizing antenatal clinics by selected background characteristics.

Table 2: Percentage distribution of the adolescents who visited antenatal clinic by type of facility

Table 3: Percentage distribution of all cases by type of medical personnel consulted for antenatal care

Table 4 : Percentage distribution of adolescents utilizing antenatal clinics by selected background characteristics

There are variations between urban and rural residents with more rural residents consulting antenatal services compared with their urban counterparts. Young adolescents have a low rate of utilization (i.e. 66.7 per cent) compared with older adolescents who have 82 per cent rate of use. This is probably due to fear of revelation of pregnancy, lack of information and other psychological problems. As for the influence of occupation, it is observed that housemaids and barmaids have the lowest rate of utilization whereas the highest rate of use is amongst women in formal employment. There is also a marked difference in utilization according to maternal level of education. Those with lower education have lower utilization rates (i.e. 56.2 per cent for those with none and 77.5 per cent for those with primary education level) compared with those with secondary education (i.e. 90.4 per cent). This shows that education plays an important role in improving utilization of antenatal services.

Birth Order and Previous Birth History

Information on parity, birth spacing and previous obstetric history is important in determining the risk factors associated with childbearing. Research has shown that close birth spacing leads to high risk of maternal and infant mortality (WHO, 1993). Research has also shown that primigravidae who are normally under 20 years of age have higher incidence of difficult labour and thus a higher number of assisted deliveries and caesarian sections (Dhutla, 1981).

Unfortunately the medical records examined in this study did not have detailed data on past obstetric history of the respondents. They, however, had some information on parity that is presented in Table 5.

Table 5 : Percentage distribution of all cases by number of previous births

The table shows that most births (i.e. 78.1per cent) were primigravidae and hence had higher chances of being risky due to low maternal age.

Reproductive Health Problems

From the cases reviewed, the major reproductive health problems reported are, hypertensive disease of pregnancy, haemorrhage, obstructed labour, operational deliveries and low birth weights. Also, cases of anaemia, neonatal deaths and sexually transmitted diseases were reported. Table 6 shows the distribution of major reproductive health problems recorded among the respondents.

 Table 6 : Percentage distribution of major reproductive health problems identified among the study cases

Hypertensive Disease of Pregnancy

The major disorders in most cases are high blood pressure, protein in the urine and swelling of tissues. Past research shows that if this condition is left untreated it becomes severe and the patient may die within two days (Maine et al., 1991). For the purpose of this study, data on blood pressure is relied on to measure the severity of hypertensive disorders among adolescent mothers. The results from Table 6 show that 35 per cent of adolescent mothers suffer from high blood pressure before delivery. The causes of hypertensive disorders have not been properly documented. However, research done elsewhere shows that one’s way of life greatly plays a role in determining blood pressure (WHO, 1994). The percentage distribution of all cases by their blood pressure according to selected background characteristics is shown in Table 7.

From the table the proportion of women with high blood pressure is high (36.2 per cent) for rural residents compared with urban residents (29.0 per cent), it is also high for those aged 10-15 years (46.7 per cent) compared with those aged 16-20 years (31 per cent). When one considers maternal occupation, the proportion of the respondents with high blood pressure is highest for farmers followed by students, housewives and business women in that order. This probably indicates the level of stress due to nature of work and other psychological problems. On the side of marital status, single mothers have higher chances of having high blood pressure compared with married or ever married mothers: ever married here combines both divorced and widowed. Mothers with high level of education have less incidence of high blood pressure as against those with no education.

Haemorrhage

Bleeding related to late pregnancy and delivery can be divided into two categories namely, antepartum haemorrhage in which vaginal bleeding occurs before birth and postpartum haemorrhage where excessive bleeding occurs shortly after birth of the baby. In this study, postpartum haemorrhage was the major reproductive health problem reported and 29.2 per cent of the respondents reviewed experienced it. The major causes of postpartum haemorrhage that have been identified in the past are retained placenta, prolonged labour, operative vaginal delivery, the action of anaesthetic agents and uterine tumour such as fibroid (Royston and Armstong, 1989). The risk of dying from postpartum haemorrhage depends on the amount and rate of blood loss, and on the state of health of the patient. It is, however, estimated that a woman with haemorrhage cannot live for two hours unless she receives treatment (Royston and Armstong, 1989). Table 8 shows percentage distribution of all the examined cases, whether they experienced postpartum haemorrhage by selected background characteristics.

Table 7 : Percentage distribution of all cases by their blood pressure according to selected background characteristics

From Table 8, it is observed that there is a marked difference between rural residents (38.3 per cent) compared with their urban counterparts who experienced slightly low rates of postpartum haemorrhage (25.9 per cent). This is also evident when one considers age whereby a higher percentage (45.2 per cent) of mothers aged 10-15 years experienced postpartum haemorrhage compared to only 29.4 per cent of mothers aged 16-20 years. The same trend appears when one considers marital status where a great proportion of single mothers experienced postpartum haemorrhage compared to ever married. Level of education also seems to play a role in determining haemorrhage as it is a small proportion of women with secondary level of schooling and above who experience postpartum haemorrhage compared with those with no education and primary level schooling.

Table 8 : Percentage distribution of all cases with post-partum haemorrhage by selected background charactersitics

Obstructed Labour

In most cases, obstructed labour in adolescence arises because the space in the bony birth canal of the mother is either too small or too distorted by disease to permit easy passage of the head of the baby during labour. Several reasons have been advanced to determine the stature of a person and how it affects labour. Some of them are genetic, physiological, environmental and nutritional factors (Royston and Armstong, 1989). In this study, data on the frequency of operative deliveries is used to indicate occurrence of obstructed labour. The most frequent operative deliveries that were reported were vacuum extraction which accounted for 10.4 per cent of total deliveries, and caesarian section which was commonest accounting for about 18.2 per cent of total deliveries. The remaining 71.4 per cent were normal deliveries. Operative deliveries are associated with risks to the mother and the infant which arises partly from the nature of operation and the complications which necessitated the operation in the first place. There are other complications such as infections and severe bleeding that may follow a delivery. Table 9 shows the percentage distribution of all women by nature of delivery across background characteristics.

Table 9 : Percentage distribution of all cases by nature of delivery according to selected background characteristics

From data in Table 9, it is observed that operative deliveries due to obstructed labour are higher for rural residents; mothers aged between 10-15 years; single mothers and mothers who have low level of education. This supports earlier findings that most extreme forms of pelvic contraction are found in societies where there is mass poverty and where childbearing begins early before girls are fully developed (WHO, 1993).

Birth Weight

The World Health Organization defines low birth weight as a birth weight less than 2500 grammes, because below this value, risks of infant mortality are extremely high. Babies weighing less than 2500 grammes are much more susceptible to illness and infection than heavier babies. In other words, if they are far below that weight, they are likely to die (WHO, 1993).

Out of all the cases reviewed in this survey, 30 per cent of births were low birth weight. Though the cause of low birth weight remains unexplained, there

are some risk factors that have been identified. These include; gender, ethnic origin, socio-economic status, maternal height, parity, STDs, malaria, smoking, alcohol consumption, etc. (Walsh et al., 1993).

Table 10 : Percentage distribution of all study cases by birth weight according to selected background characteristics

Table 10 presents data on birth weights from all the study cases according to selected background characteristics. The data shows that a higher proportion of rural mothers deliver low birth weights than urban residents. This trend is also true for young adolescents aged 10-15 years, single mothers, and those with low level of education. Thus, it confirms the assumption that low level of socio-economic status and age are key risk factors to low birth weights.

Anaemia

Anaemia describes the condition in which there is a reduction of the concentration of haemoglobin in the blood stream (of a pregnant woman). It is mainly caused by nutritional deficiency of iron and folic acid. Other causes include sickness from malaria, sickle cell, bacterial infection, blood loss and intestinal parasites. Only 4.7 per cent of all the respondents were recorded to have had anaemia.

Sexually Transmitted Diseases (STDs)

Sexually transmitted diseases (STDs) form another major potential consequence of unprotected sexual activity during adolescence. In most cases, STDs tend to have adverse effects on future fertility. Screening of all pregnant women has long been advocated both because of specific risks of consequences of infection in pregnancy to the woman and fetus and as an opportunistic screening of sexually active population in an attempt to control the spread of diseases. Even though the particulars of the diseases were not included, the data collected showed that 4.1 per cent of the respondents had been infected with STDs.

Perinatal Health Problem

Perinatal health reflects the health of women and the quality of care during pregnancy, delivery and the neonatal period. Perinatal deaths include stillbirths (also called fetal deaths) and deaths in the first week of life. Other than low birth weights discussed earlier, perinatal health can be measured by the number of reported stillbirths and neonatal deaths. Data on stillbirths and neonatal deaths was sketchy but then it indicates that 7.4 per cent of recorded births ended up dying immediately whereas 6.8 per cent of births were stillbirths.

Even though the data was not detailed enough for us to ascertain the causes of the neonatal death and stillbirths that were reported, other studies have identified some of the causes of these problems. These include; infection of amniotic fluid, congenital syphilis, compression of the umbilical cord, birth trauma, obstructed labour, premature rupture of the membranes and congenital malformations (Walsh et al., 1993).

CONCLUSIONS AND POLICY IMPLICATIONS

This paper has outlined the major reproductive health problems facing adolescents in Kenya. Most important among them are high blood pressure, haemorrhage, obstructed labour, low birth weight, sexually transmitted diseases, anaemia, maternal and perinatal mortality.

The severity of these problems has been found to vary with the socio-economic and demographic characteristics of the mother. The reproductive health problems have been found to be higher for mothers who have low levels of education, do not utilize antenatal services, are aged below 15 years old, are residents of rural areas, and are single, and not in formal employment. The same study reveals that most adolescents have never used any modern contraceptive method, while a good number of them are single, not gainfully employed and have only attained primary level of education. Any policy measure should therefore address the above issues.

The current policy of the government of Kenya on safe motherhood involves two activities, i.e. establishing a full range of maternal child health as well as family planning services, and training of traditional birth attendants to assist mothers deliver safely and hygienically. These, however, are contradicted by the government’s declaration that contraceptives should not be made available to unmarried youths and other forms of family life education programmes must not be imparted in Kenya’s schools (Njau, 1993). The scenario that arises is that efforts to deal with unwanted pregnancies amongst the youth are paralysed.

The present study’s findings, therefore, lead to the following policy recommendations:

1. the government should consider introducing family life education early, preferably, in primary schools, with a view to making the adolescents understand more about their bodies; this would encourage use of contraceptives;

The problem of adolescent reproductive health, therefore requires an integrated approach whereby socio-economic reforms complement the health sector with policies directed towards the poor and disadvantaged mothers, who are also malnourished and at high risk of contracting diseases many of which are fatal.

REFERENCES

• Aggarwal, V.P. and J.K.G. Mati. 1992. ‘’Epidemiology of Induced Abortion in Nairobi, Kenya.’’ Journal of Obstetrics and Gynaecology of Eastern and Central Africa. 54(3).
• Ajayi, A.O. et al. 1991. ‘’Adolescent Sexuality and Fertility in Kenya ; A Survey of Knowledge Perceptions and Practices.‘’ Studies in Family Planning 22 (4) 203-216.
• AMREF, 1994. Female Adolescent Health and Sexuality in Kenya Secondary Schools ; A Survey Report.
• Barker, G.K. and S. Rich. 1992. ‘’Influences of Adolescent Sexuality in Nigeria and Kenya ; Findings of Recent Focus Group Discussions’’, Studies in Family Planning Vol.23 No.3.
• Barreto, T. et al. 1992. ‘’Investigating Induced Abortion in Developing Countries ; Methods and Problems’’, Studies in Family Planning Vol.23 No.3.
• Dhutia, H.P. (1981). ‘’Primigravida on Labour at the Coast’’. Medicom Vol.3.1.
• Feyisetan, B. and A.R. Pebley. 1989. ‘’Premarital Sexuality in Urban Nigeria,’’ Studies in Family Planning, 20(6) 343-354.
• Geronimus, A.T. 1987. ‘’Teenage Childbearing and Neonatal Mortality in United States.’’ Population and Development Review Vol.2.
• Ilinigumugabo, A. Njau, P.W. and Rogo K. (1994). The Social-Cultural and Medical Outcomes of Adolescent Pregnancies. A Survey Report of Four Rural Districts. Centre for African Family Studies, Nairobi, Kenya.
• Kenya, Republic of . 1993. Kenya Demographic and Health Survey, NCPD; Nairobi.
• Kiragu, K. 1991. ‘’The Correlates of Sexual and Contraceptive Behaviour in School Adolescents in Kenya’’, A Ph.D Thesis The Johns Hopkins University.
• Kulin, H.E. 1980. ‘’Adolescent Pregnancy in Africa : A Programmatic Focus,’’ Social Science and Medicine 26, (7) 727-735.
• Lema, V.M. et al. 1987. ‘’Review of Medical Aspects of Adolescent Fertility in Kenya’’ Journal of Obstetrics and Gynaecology for East and Central Africa.
• Liku, J. 1987. ‘’The Socio-Economic Factors Associated with Teenage Pregnancy in Makueni’’ Dunson M.A. Thesis, University of Nairobi.
• Maggwa, A.B.N. 1987. ‘’Knowledge, Attitude and Practice, a Survey of Contraceptive Use and Teenage Pregnancy Living in a Rural Set-up of Kenya’’. M.Med Thesis University of Nairobi.
• Maine, D. 1991. Safe Motherhood Programs and Options. Division of Family Health, Columbia University.
• Makinson, C. 1985. ‘’The Health Consequences of Teenage’’, Family Planning Perspectives Vol.17, No.3.
• Mati, J.K.G. 1989. ‘’Review on Adolescent Health’’, Journal of Obstetrics and Gynaecology of East and Central Africa Vol.8, No.1.
• Njau, P.W. (1993). ‘’Factors Associated with Pre-Marital Teenage Pregnancies and Childbearing in Kiambu and Narok Districts’’. Ph.D. Thesis, University of Nairobi.
• Royston, E. and S. Armstong, 1989. Preventing Maternal Deaths. World Health Organization.
• Shangvi, H.C. et al. 1983 ‘’Nairobi Birth Survey : Outcome of Pregnancy in Teenage Mothers in Nairobi, Kenya.’’ Journal of Obstetrics and Gynaecology for Eastern and Central Africa 69(3).
• Senderowitz, J. and J.M. Paxman. 1985. ‘’Adolescent Fertility : Worldwide Concerns.’’ Population Bulletin Vol.40, No.2. : Evidence from Developing Countries. Vol.II, New York ; Population Studies, No.109.
• Walsh, J. et al. 1993. ‘’Maternal and Perinatal Health ‘’ in Disease Control Priorities in Developing Nations edited by Jamison D.T. et al World Bank.
• World Health Organization. 1993. Health for Young People : A Challenge and Promise.
• WHO. 1994. Mother, Baby Package ; Implementing Safe Motherhood in Countries.

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