Access to reproductive health services by female survivors of sexual gender-based violence: a descriptive cross-sectional study of Nairobi City County, Kenya

INTRODUCTION

Sexual gender based violence has affected many countries worldwide with more than one third of women reporting having been affected1.¹ Literature review from previous studies suggest that more than sixty percent of women worldwide have experienced reproductive health problems resulting from exposure to sexual gender based violence (UNFPA, 2013). Globally, the impact of sexual gender-based violence is immense resulting in physical, psychological and social negative impacts to the survivors.²

Intimate partner violence is highest in African with low income countries prawn high incidences and prevalence of about 37 percent women recounting their ordeals SGBV experience.³ The negative outcomes of sexual gender based violence for women reproductive health, adolescent, and long term mental health impacts have been reported and shows correlation with maternal morbidity, and mortality, and reduced level of use of reproductive health (RH) services.^4,5 Additionally, due to SGBV there is an increased prevalence of STIs beyond child birth and pregnancy due to coercive (and unprotected) sex. There is an increased risk level to sero-conversation resulting from forced sex compared to consensual sex.⁶ According to Campbell et al, young women with previous history of sexual violence are most of the time willing to use contraceptives to protect themselves and therefore are at a greater risk to experience genital tract infection symptoms resulting from sexual gender-based violence.⁷

In Kenya, statistics show that sexual gender-based violence forms the top most risk factors for the burden of disease and high mortality rates among women. National statistics accounts for 14% of women and 6% of men who are between the ages of 15-49 having gone through sexual violence at one point in their life.⁸ According to report by Gender Recovery Centre Annual report, about 45% which is higher than the national statistics of women ages who are between ages 15-49 in Kenya have been abused either physical or sexual violence of which women and girls have higher proportion of cases at 90% of the gender-based violence (GBV) cases reported.

METHODS

The study adopted descriptive cross-sectional research with qualitative and quantitative components aimed at collecting information from female survivors of sexual gender base violence. The study used a mixed method where both qualitative and quantitative techniques was used to collect data on availability of reproductive health services to female survivors of sexual gender-based violence, knowledge and attitude of female survivors of sexual gender-based violence on reproductive health and types of reproductive health services for female survivors of sexual gender-based violence in Nairobi City County, Kenya. Female survivors reporting for the first time or coming for revisit and were willing to participate were selected. The study was carried out at Mama Lucy hospital which is a government health facility and the Nairobi women’s hospital gender recovery center. The study involved 269 female survivors who are either ongoing with services or were reporting sexual gender-based violence cases for the first time and survivors who report to the facility for counseling services. The study was carried out between 1^st of February and 30 April 2023. Data was collected using questionnaires which were assessed and then categorized before coding. Data was analyzed using version 20 of SPSS for statistical analysis. Analyzed data was presented as figures and tables in the results section. Pearson chi-square was used to test the significance level at a p value of ≤0.05, while odds ratios were used to test the strength association between variables.

RESULTS

A total of 269 respondents who were receiving services in the two facilities of Mama Lucy Kibaki hospital or Nairobi women’s hospital and were willing to participate were recruited into the study. A total of 167 (62.1%) respondents were drawn from Mama Lucy Kibaki hospital while 102 (37.9%) respondents were drawn from Nairobi women’s hospital. The response rate was one hundred percent.

The sociodemographic characteristics are shown in Table 1. Table 1 sets out details of sample demography. In terms of age, most respondents n=58 (21.6%) were aged 33-37 while respondents aged 18-22 were the least n=49 (18.2%). Majority of the respondents had secondary level of education n=170 (63.2%). In terms of marital status most respondents were in a relationship n=98 (36.4%), while n=95 (35.3%) were married, n=36 (13.4%) were separated, n=26 (9.7%) divorced and n=14 (5.2%) were widowed. In terms of occupation majority of the survivors were in self-employment n=98 (36.4%), n=86 (32%) were unemployed, n=53 (19.7%) of the survivors were students while n=32 (11.9%) were civil servants. Most respondents were Christians n=231 (85.9%).

Access to reproductive health services by survivors of sexual gender-based violence

According to the findings of this study, access was granted when a survivor received at least three services of the five reproductive health services, those who received either one or two services were considered to have no access to reproductive health services. Figure 1 illustrates that access to reproductive health services by survivors was only at n=71 (26%). About n=198 (74%) of survivors did not access reproductive health services.

From the results, it is evident that most of the survivors of sexual gender-based violence had clue of reproductive health problems associated with sexual gender-based violence at about n=175 (65%) against n=94 (35%) who were a little informed about the reproductive health outcomes of SGBV. Furthermore, n=236 (88%) of the survivors alluded to the fact that failure to seek medical attention after experiencing SGBV had an impact on their reproductive health. Only n=33 (12%) said they were not sure. However, when the knowledge levels were tested through asking questions there was disparity from the earlier findings. On effects of failure to seek immediate medical attention in order to test for cues of action and need for access. The findings reveal that n=31 (11.5%) of the respondents said that it will result into complications during delivery, about n=43 (16%) said that it will lead to contraction of STDs and STIs, n=30 (11.2%) said it may lead to giving birth to children with complications and majority of the respondents n=165 (61.3%) were not sure of the effects of failure to seek immediate medical attention after experiencing sexual gender-based violence. Majority of the respondents n=222 (83%) were not sure of the correct time to start a prophylaxis in the event of SGBV against n=47 (17%) who were aware. On potential reproductive health effects, majority n=133 (49%) were not aware of any problem, about 81 (30%) said it may result to contraction of HIV, STDs and STIs, n=34 (13%) said it may lead to death and about n=21 (8%) said it may result into unwanted pregnancy (Table 2).

Bivariate analysis

Knowledge on period to access prophylaxis for reproductive health problems had after SGBV was a key issue for women survivors to access reproductive health services at 76.2% indicating that it influenced access to reproductive health. But this finding was not significant with χ²=2.056 df=1 and p value =0.15, reveal that there was an association between survivor’s knowledge on prophylaxis and access to reproductive health services for SGBV. Awareness on reproductive health problems associated with SGBV was also rated as important towards access to reproductive health services by female survivors however it was not significant χ²=2.865 df=1 and p value =0.09. Effect of failure to seek immediate medical attention had χ²=7.202 df=1 and p value =0.01, this indicate that there was an association between survivor’s awareness on effect of failure to seek immediate medical attention and access to reproductive health services and the association was significant.

Knowledge on undesired reproductive health outcomes was important factor in access to reproductive health services by female survivors of sexual gender based violence with 76.2% of the respondents saying it affects access to reproductive health services by female survivors of sexual gender based violence had χ²=6.583 df=3 and p value =0.09, indicate that there is association between perceived danger of SGBV on reproductive health with access to reproductive health services for SGBV survivors however this association was not significant. Survivors’ knowledge on health effects of failure to seek immediate treatment on reproductive health had an association with access to reproductive health services with χ²=5.274, df=2 and p value =0.15, however, this association was not significant (Tables 3 and 4).

Multivariate analysis

In this study a survivor who was aware of the period they should receive prophylaxis was 4.66 times more likely to receive sexual reproductive health services (OR= 4.66, 95% CI (1.43-13.71); p=0.02) compared to a survivor not aware of the period they should start prophylaxis after sexual violence

A survivor who was aware of reproductive health problems associated with sexual gender-based violence was 5.79 times more likely to access sexual reproductive health services compared to survivor who did know reproductive health problems associated sexual gender-based violence [OR= 5.79, 95% CI (3.16-11.52); p=0.02]

A survivor who was aware that failure to seek immediate medical attention after sexual violence affect reproductive health was 0.16 times more likely to access sexual reproductive health services [OR=0.16, 95% CI (0.04-0.57); p=0.00], compared to a survivor who was not aware that failure to seek immediate medical attention after sexual violence affect reproductive health

A survivor who was aware of the health effects of failure to seek immediate medical attention after sexual violence was 3.56 times more likely to access sexual reproductive health services compared to survivor who did know health effects of failure to seek immediate medical attention after sexual violence [OR=3.56, 95% CI (1.20-10.54); p=0.02] (Table 5).

DISCUSSION

Access to reproductive health services by survivors of sexual gender-based violence

The found a relatively low level of access to reproductive health services by survivors of gender-based violence at only 26%. Access was majorly hindered by availability of services in the facilities. Availability of services within the facilities was n=119 (44%) said services were available while n=150 (56%) said services were not available. It is evident that most of the sexual reproductive health services were more available at Nairobi women’s hospital n=76 (64%) than Mama Lucy Kibaki hospital n= 43 (36%).

The findings of this study are supported by a study conducted by Chepuka et al that alluded to the fact that availability and accessibility of quality post-sexual violence care is a challenge in all settings, but especially in low- and middle-income countries.⁹ In many such settings, management of sexual violence is focused on physical injuries, STIs, and pregnancy. Longer-term follow-up with psychosocial counselling and legal support are suboptimal, and the strengthened integration of these services is needed to improve overall health and life outcomes.

Knowledge factors influencing access to reproductive health services in this study included, knowledge about the need for screening, need for access to prophylaxis on time, awareness on reproductive health problems associated with sexual gender-based violence, effects of failure by survivors to seek medical attention, and knowledge on undesired outcomes of sexual gender-based violence on reproductive health.

A survivor who was aware that failure to seek immediate medical attention after sexual violence affect reproductive health was 3.56 times more likely to access sexual reproductive health services compared to a survivor who was not aware that failure to seek immediate medical attention after sexual violence affect reproductive health, survivor who was aware of the period they should receive prophylaxis was 4.66 times more likely to receive sexual reproductive health services compared to a survivor not aware of the period they should start prophylaxis after sexual violence. A survivor who was aware of reproductive health problems associated with sexual gender-based violence compared to survivor who did know reproductive health problems associated sexual gender-based violence was 6 times more likely to access sexual reproductive health services. These findings on knowledge factors as contributor to access to reproductive health services are consistent with the findings of studies in Sub Saharan Africa that indicated that among many other factors knowledge on early screening for any form of sexual violence was key in helping survivor detection and entry to complete sexual gender base service.¹⁰

Association between sociodemographic factors and access to reproductive health services

According to this study, age was found to have influence on access to reproductive health services, age affects access to reproductive health services by survivors of sexual gender-based violence. Survivors with advanced age were the one who mostly sort for sexual reproductive health services compared to survivors with less age. This finding agrees with the findings of Kenya Demographic Health Survey (2014), which revealed that 38% of women and girls aged 15-49 have experienced abuse and 14% underwent sexual assault. This showed that SGBV has age factor and thus some age brackets are more susceptible to experience SGBV and reproductive health challenges associated with age.

The variable education is a key pillar for knowledge and was found to affect access to reproductive health services by survivors of sexual gender based, the higher the education levels the higher the need to seek sexual and reproductive health services among women survivors. This finding is consistent with a study carried out by Mc Cleary-Sills et al, which revealed that most cultural and knowledge gaps greatly determine attitude on seeking sexual gender-based violence services and at the same time greatly contributes to underutilization of sexual gender-based violence services in healthcare facilities.

On other variables such as marital status, occupation and religion, were found to have no influence on access to reproductive health services by survivors of sexual gender-based violence. These results are consistent with the findings of study carried out in Mumbai, India, which indicates that 35% of women have experienced spouse-beating and says that it is justifiable if they disrespected their in-laws or argued with their husband, or failed to offer excellent meals, housework and childcare, or went out without permission.¹¹

Duration of the study was limited due to financial constraints to pay research assistant to be involved and bringing up different stakeholders to participate in the study.

Fear of repercussions of opening up by survivors compromised the outcome of the study.

CONCLUSION

In conclusion, our study revealed that, availability of comprehensive sexual reproductive health services at the facility is key towards access to sexual reproductive health services for women survivors. Survivors access was significantly influenced by either availability or unavailability of the comprehensive package for response to survivors of sexual reproductive health as indicated on the Kenya National guidelines on management of sexual gender-based violence 3^rd edition 2014.

Knowledge about reproductive health problems associated with sexual gender-based violence was positively associated with access to reproductive health services by survivors of sexual gender-based violence. And therefore, knowledge enhancement will enhance access to reproductive health services. Finally that study concluded that type of sexual gender based violence provided to survivors at the facility and provision of comprehensive sexual and gender based violence services as advocated for in the National Guidance on management of sexual gender-based violence is key to increasing access to sexual and number of the services received by survivors influenced access to sexual reproductive health services by survivors.

ACKNOWLEDGEMENTS

We thank our supervisors Dr. Harun Kimani and Dr. Judy Mugo. We also appreciate the Kenyatta University research ethics review committee for approving my thesis. Our appreciation also goes to all community volunteers for data collection and distribution of the questionnaires. We also thank Madam Harriet, the counselling psychologist at Nairobi women’s hospital and Mr. Andrew the counselling psychologist at Mama Lucy Kibaki hospital. Our sincere appreciation to all respondents who gave their time and participated in this study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Approval to carry the study was obtained from Kenyatta University Graduate School (Ref: Q57/CTY/PT/38840/2016); ethical approval was obtained from Kenyatta University Ethical and Review Committee (Approval number PKU/2488/11615). A research permit to conduct the study was obtained from the National Commission for Science, Technology and Innovation (License No: NACOSTI/P/22/18316, Ref No: 144747). Research authorization was also obtained from the Nairobi City County Government (Ref: NCCG/DHS/REC/270)

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