Accessibility of reproductive health services among women living in the informal settlements of Mathare slums, Nairobi City County, Kenya

INTRODUCTION

Reproductive health is a concept that refers to a condition of total physical, mental, and social well-being rather than just the absence of disease.¹ Inequalities in access to reproductive health care have led to increased perinatal morbidities, despite various developments in the administration of these services across the globe.² Globally, over five hundred thousand women living in slums die each year in the process of reproduction, according to the world health organization, and if women gain access to sexual and reproductive care, the majority of these deaths can be avoided. ³

Informal settlements are characterized as underserved populations with limited access to health care services around the world. These areas are characterized by poorly constructed houses, bad environmental features such as a lack of safe drinking water and sanitation, inadequate drainage with abundant open sewers, uncollected trash, extreme congestion, flies, and low lighting.⁴ They also contribute significantly to high cases of malnutrition, maternal and child-related complications, delivery complications, and postpartum morbidity.⁵

Rapid urbanization is changing the dynamics of health in Africa, and those living in densely populated areas and slums are directly affected.⁶ Access to quality health care in such areas is limited due to various issues, such as poorly maintained road networks and relatively high transportation costs. This is especially true for reproductive health and family planning. Moving to the city used to mean becoming wealthier and having better access to institutional services. According to recent surveys, 70% of urban residents live in poverty; often in low-income informal settlements with no recognized public services.⁷

Kenya's healthcare infrastructure has improved in recent years, but many women still live far from healthcare facilities and cannot afford reproductive and maternal health services. As a result, many women encounter obstacles in obtaining high-quality reproductive healthcare.⁸ When comparing the health indices of urban and rural populations, significant differences arise. Women in Nairobi's slums are more prone to unwanted pregnancies and fertility than those living in non-slum areas. In slum regions, the contraceptive prevalence rate (CPR) is believed to be around 45 percent, while non-slum areas have a CPR of 50 percent.⁹ In Kenya, private hospitals, pharmacies, and dispensaries provide contraception to more than 40% of the contraceptive users.¹⁰

Mathare slum in Nairobi is characterized by high incidences of poverty, insecurity, illiteracy, drug abuse, gender-based violence, inaccessibility, poor accommodation, and improper waste disposal systems, which make reproductive health a matter of least concern to the dwellers. Due to poverty, the slum is also characterized by high school dropouts due to lack of food, school fees, drug abuse, and peer pressure. These affect girls as well, leading to early exposure to illicit sex, prostitution, and early marriages. Dropping out of school hinders young girls from getting adequate knowledge about their reproductive health through the education system, reduces their ability to read and understand reproductive health, and reduces their ability to engage in meaningful economic activities that would guarantee access to RHS.

Despite the many reproductive health challenges the residents of Mathare slum face, little research has been published in Nairobi County among women living in informal settlements. As a result, this study was conducted to determine health facility-related and social factors influencing the accessibility of RHS among women living in the informal settlements of Mathare slums, Nairobi City County, Kenya.

METHODS

This cross-sectional study focused on Nairobi County, Kenya, and specifically targeted Mathare slums, known for poor reproductive health (PRH) indicators among women. Four villages (Mathare 3B, Mathare 4A, Kosovo, and Mathare village 2) within Mathare were purposively selected due to their larger populations. Employing a multi-stage cluster sampling technique, the research recruited 300 women using simple random sampling for women in selected households.

The tool used for data collection was a semi-structured questionnaire. This tool was pretested and necessary corrections were made. The study included women aged 15-49 residing in the Mathare slums of Nairobi County, Kenya, who were willing to participate. The researcher excluded women outside this age range, those residing outside the Mathare slums, and those unwilling to participate. Data was collected from April 1, 2023, to May 31, 2023, on weekdays from 8 a.m. to 5 p.m.

Background characteristics (age, marital status, employment, and education level) and health facility and social factors were the independent variables. The accessibility to RHS amongst women living in the informal settlement of Mathare slums, Nairobi City County, Kenya, was the dependent variable. All necessary ethical approvals were obtained from relevant bodies, and measures were taken to ensure respondents' anonymity, voluntary participation, and information safeguarding.

Data analysis involved descriptive statistics, such as frequencies and percentages, for both the independent and dependent variables. Then, inferential statistics, such as chi-square or Fisher’s exact test (which is an alternative to chi-square when chi-square assumptions are violated), were used to assess the association between the dependent variable 'accessibility of RHS' and various independent factors (including background, health facility-related, and social factors). The findings are presented in tables, figures, charts, and in prose.

RESULTS

Background characteristics of the respondents

A total of 300 women were surveyed, representing a response rate of 78.1%. The socio-demographic profile of the participants is shown in Table 1. The majority of respondents were aged between 18 and 29 years (48.7%, n=146), had a primary level of education (61.7%, n=185), were married (58.7%, n=176), and were unemployed (69.3%, n=208). However, as shown in Table 2, statistically significant associations were only observed between accessibility and the woman's age (χ²=83.013, df=1, p<0.001), education level (p<0.001), marital status (p<0.001), and employment status (p<0.001).

Health facility-related and social factors influencing the accessibility to RHS

Table 3 summarizes key health facilities and social factors influencing access to RHS. Among the health facility factors, the primary barriers were service-needs mismatch at facility at 70.3% (n=211), transportation cost challenge at 65.3% (n=196), and affordability barrier at 62.7% (n=188).

On the social front, the key challenges are "age affects RHS accessibility" at 78.0% (n=234), "age increases RH awareness" at 65.7% (n=197), and "spouse influences RHS" at 73.7% (n=221).

On cross-tabulation (Table 4) health facility factors such as challenges in the reaching reproductive health centers (p<0.001), long distances to health facilities (p<0.001), transportation cost (p<0.001), and difficult terrain (p<0.001), were identified were significantly associated with RHS accessibility. Additionally, the cost of the services (p<0.001), whether the health facilities provided services needed (p<0.001), and availability of required medications (p<0.001) emerged as critical factors.

Discouragement by friends or family (p<0.001), the perceived influence of age on RHS accessibility (p<0.001), the perceived influence of education level on RHS choices (p=0.014), and the perceived role of a spouse in influencing RHS (p=0.002) were all significant social factors associated with accessibility to the reproductive health services.

DISCUSSION

The majority of respondents belonged to the 18-29 years’ age group, had primary education, were married, and were unemployed. Notably, significant associations were observed between accessibility and factors such as age, education level, marital status, and employment status. Specifically, higher accessibility was more prevalent among women aged above 29 years compared to those aged between 18 and 29 years. This finding corroborates previous literature that underscores the challenges faced by young women.

Annually, approximately 16 million females aged 15 to 19 give birth, often experiencing unplanned pregnancies.¹¹ Teenage women frequently possess less comprehensive knowledge about reproductive health, placing them at elevated risk of unsafe abortions, STIs, teenage pregnancies, and HIV/AIDS. Marital status and women's income levels significantly influence their reproductive health. In Africa, the majority of married women are often economically dependent on their spouses, limiting their ability to assert their reproductive health rights. This implies that women's reproductive health is also contingent on their partner's acceptance and understanding of its importance.¹² Additionally, uneducated women are more likely to seek traditional reproductive health treatments.¹³

This study identified various challenges in reaching RH centers, including long distances to health facilities, transportation cost constraints, and difficult terrain. The alignment of health facilities with needed services and the availability of required medications were also crucial factors. Affordability of services played a significant role in accessibility. Social factors associated with accessibility to reproductive health services included discouragement by friends or family, perceptions of age affecting RHS accessibility, perceptions of education influencing RHS choice, and the perceived role of a spouse in influencing RHS. High accessibility was noted in women whose spouses were involved in RH matters, women who believed that education was a key determinant of RHS service seeking, and women who reported discussing RHS issues with their spouses. These findings align with previous studies. Cost may deter women from accessing RH services because they are unable to pay them and are hesitant to ask friends or family for financial assistance.¹⁴ Furthermore, RH service providers may be located far from where women live, work, or go to school, and women may have restricted access to transportation.¹⁵ According to Usonwu et al it is unfortunate that the healthcare system that should be a source of hope for women has instead become a source of disillusionment for them, partly due to healthcare workers' critical attitudes and the unfriendly quality of the services themselves.¹⁶ While studies have highlighted healthcare institutions as a feasible location for adolescent women to seek sexual health information and services, they claim that many adolescent women avoid using healthcare institutions for this purpose.¹⁶ According to Rosenberg et al, the infrastructure in health systems may not be tuned to the interests of women, with providers who are hesitant or unequipped to attend to women and facilities with inadequate resources to ensure discreet services.¹⁶

Limitations

Being a cross-sectional survey, this study can only infer association, but not causal-effect relationships. Findings in the study can only be interpreted in the context of the Mathare slums and may not be generalizable to non-slum dwellers or the rest of the country. Administering the questionnaires proved challenging, as convincing women to participate required significant persuasion. Additionally, there were difficulties navigating the unfamiliar terrain in the slum. To address these limitations, local enumerators familiar with the landscape were employed to establish rapport, facilitate easier entry, and persuade women to participate.

CONCLUSION

The determinants of accessibility included various characteristics, with age emerging as a significant factor even after adjusting for control variables. Older women aged above 29 were significantly more likely to have high accessibility compared to their younger counterparts.

Health facilities and social factors presented multifaceted challenges, including geographical barriers, transportation costs, and medication availability. Social factors, such as the influence of friends and family, age perceptions, and education-related choices, were found to impact accessibility. Notably, women whose spouses were involved in RH matters, those who believed in education as a determinant of RHS service seeking, and those who discussed RHS issues with their spouses demonstrated high accessibility.

Recommendations

Further, and given the observation that demographic characteristics, health facilities, and social factors are linked to the accessibility of RHS, the study recommends the ministry of health (national and county governments of Nairobi) implement tailored reproductive health education programs for Mathare slum residents to improve knowledge on RHS among women in the target population, build more RHS centers in the slum areas, and make RHS affordable to the slum dwellers.

ACKNOWLEDGEMENTS

The researchers are very grateful to the Mathare slum women who consented to participate in this study. The Principal investigator is also thankful to the health managers and county and sub-county administrations for allowing this study to be carried out in their respective areas.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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