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Globally, COVID-19 has had a negative impact on health systems and health outcomes, with evidence of differential gender impacts emerging. The COVID-19 timeline of events spanning from closures and restrictions to phased reopenings is well-documented in Kenya. This unique COVID-19 situation offered us the opportunity to study a natural experiment on pregnancy trends and outcomes in a cohort of Kenyan adolescent girls and young women (AGYW), enrolled in the KENya Single-dose HPV-vaccine Efficacy (KEN SHE) Study. The KEN SHE Study enrolled sexually active AGYW aged 15–20 years from central and western Kenya. Pregnancy testing was performed at enrollment and every 3 months. We determined pregnancy incidence trends pre- and post-COVID-19 lockdown, pregnancy outcomes (delivery, spontaneous, or induced abortion), and postabortion and postpartum contraceptive uptake. Kaplan–Meier survival estimates of incidence rates were used to estimate the cumulative probability of pregnancy during the study period. Cox regression was used to investigate factors associated with pregnancy incidence. Of the 2,223 AGYW included in the analysis, median age was 18.6 IQR (17.6–20.3), >90% had at least secondary school education, 95% were single at the time of enrollment, and 82% had a steady/primary sexual partner. Pregnancy incidence peaked at 2.27 (95% CI [1.84, 2.81])/100 women-years of observation at the end of the first quarter of 2020, a period coinciding with the government-imposed lockdown. AGYW had 60% increased risk of being pregnant during the lockdown when compared to prelockdown period (HR = 1.60, 95% CI [1.25, 2.05]). Among the 514 pregnancies reported, 127 (25%) ended in abortion, of which 66 (52%) were induced abortions. Our findings demonstrate the adverse sexual and reproductive health (SRH) consequences of the COVID-19 pandemic and the lockdown measures among AGYW. As services continue to be disrupted by the pandemic, there is an urgent need to strengthen and prioritize AGYW-centered SRH services, including contraception and safe abortion.

ObjectivesDespite significant public health emphasis on unintended pregnancy prevention among adolescent girls and young women in Sub-Saharan Africa, there is a gap in understanding how adolescents’ own reproductive priorities and the social influences on their decision-making align and compete. We examined the social context of contraceptive decision-making among Kenyan female adolescents.MethodsUsing community-based sampling, we conducted 40 in-depth interviews and 6 focus group discussions among sexually-active or partnered adolescent girls and young women aged 15–19 in the Nyanza region of Kenya. We analyzed the data in Dedoose using an inductive, grounded theory approach, and developed a conceptual model from the data illustrating social influences on adolescent contraceptive decision-making.ResultsParticipants viewed adolescent pregnancy as unacceptable, and described severe social, financial, and health consequences of unintended pregnancy, including abortion under unsafe conditions. Yet, their contraceptive behaviors often did not reflect their desire to delay pregnancy. Contraceptive decision-making was influenced by multiple social factors, centering on the intersecting stigmas of adolescent female sexuality, pregnancy, and contraceptive use, as well as unequal power in sexual relationships. To prioritize pregnancy prevention, adolescents must navigate conflicting social norms and power dynamics, and put their perceived future fertility at risk.ConclusionsContraceptive decision-making among Kenyan female adolescents is strongly influenced by opposing social norms within families, communities, and sexual relationships, which compel them to risk stigma whether they use a contraceptive method or become pregnant as adolescents. These findings put into perspective adolescents’ seemingly incongruent pregnancy preferences and contraceptive behaviors. Interventions to address adolescent unintended pregnancy should focus on supporting adolescent decision-making agency, addressing fertility-related contraceptive concerns, and promoting innovative contraceptive access points rather than increasing contraceptive prevalence.

Objectives. To assess the effect of 2-way short message service (SMS) with a nurse on postpartum contraceptive use among individual women and couples. Methods. From 2016 to 2017, we conducted a randomized controlled trial at 2 public hospitals in western Kenya. We assigned eligible pregnant women to receive 2-way SMS with a nurse or no SMS, with the option to include male partners. We delivered automated family planning–focused SMS messages weekly until 6 months postpartum. Women and men receiving SMS could interact with nurses via SMS. In intention-to-treat analysis, we compared highly effective contraceptive (HEC) use at 6 months postpartum between groups using the χ2 test. We used Poisson regression in adjusted analysis. Results. We randomized 260 women to 2-way SMS or control, and we enrolled 103 male partners. At 6 months postpartum, 69.9% women receiving SMS reported HEC use, compared with 57.4% in control (relative risk = 1.22; 95% confidence interval [CI] = 1.01, 1.47; P = .04). In analysis adjusted for baseline demographic differences, the adjusted relative risk for HEC use in the SMS group was 1.26 (95% CI = 1.04, 1.52; P = .02). Conclusions. Two-way SMS with a nurse, including optional male participation, increased postpartum contraceptive use. Trial Registration. ClinicalTrials.gov; identifier: NCT02781714.

Objective We examined the men's attitudes and perceptions toward the concept of female nonsurgical permanent contraception (NSPC) or novel approaches to permanent contraception (PC) that do not require incisions or surgical equipment/hysteroscope. Study design Cross-sectional survey of married/partnered men in Portland, OR, and rural eastern Maharashtra, India. Descriptive analysis was performed. Results In India ( N =150), most men (80%) anticipated that their partners would undergo PC in the future, compared to 30% in Portland ( N =170). About a third (39.6% in India, 82% in Portland) reported being uncomfortable with PC for partners due to the need for surgery. Most men (85% in India, 82% in Portland) expressed a preference for a hypothetical new method of female NSPC over surgery, if safe and effective. Conclusion Most men sampled in two diverse settings expressed interest in NSPC for women. Implications Men's perceptions of new female contraceptive methods are important to the contraceptive development process. Men may find a safe and effective nonsurgical method of permanent female contraception more acceptable than surgical PC.

Background: New permanent contraceptive methods are in development, including nonsurgical permanent contraception (NSPC). Objective: In the present study, perceptions of NSPC in India among married women, married men, mothers-in-law, providers, and health advocates in Eastern Maharashtra (Wardha district) and New Delhi were examined. Methods: We conducted semi-structured interviews with 40 married women and 20 mothers-in-law; surveys with 150 married men; and focus group discussions with obstetrics/gynecology providers and advocates. Transcripts were coded and analyzed using a grounded theory approach, where emerging themes are analyzed during the data collection period. Results: The majority of female respondents expressed support of permanent contraception and interest in NSPC, stating the importance of avoiding surgery and minimizing recovery time. They expressed concerns about safety and efficacy; many felt that a confirmation test would be necessary regardless of the failure rate. Most male respondents were supportive of female permanent contraception (PC) and preferred NSPC to a surgical method, as long as it was safe and effective. Providers were interested in NSPC yet had specific concerns about safety, efficacy, cost, uptake, and government pressure. They also had concerns that a nonsurgical approach could undermine the inherent seriousness of choosing PC. Advocates were interested in NSPC but had concerns about safety and potential misuse in the Indian context. Conclusion: Although perceptions of NSPC were varied, all study populations indicated interest in NSPC. Concerns about safety, efficacy, appropriate patient counseling, and ethics emerged from the present study and should be considered as NSPC methods continue to be developed.

In sub-Saharan Africa, high burdens of HIV and unmet need for contraception often coexist. Research emphasises the need to engage men and couples in reproductive health, yet couples’ negotiations around fertility and family planning in the context of HIV have been sparsely studied. This study examined the gendered power dynamics that frame women’s and couples’ negotiations of contraceptive use in western Kenya. We conducted 76 in-depth interviews with 38 couples, of whom 22 couples were concordant HIV-positive. Qualitative data were analysed using a grounded theory approach. Direct communication around contraception with men was often challenging due to perceived or expressed male resistance. A substantial minority of women avoided male reproductive decision-making authority through covert contraceptive use, with concern for severe consequences when contraceptive use was discovered. Many men assumed that family planning use signified female promiscuity and that infidelity motivated covert use. Men were more willing to use condoms to avoid HIV re-infection or at the recommendation of HIV care providers, which allowed some women leverage to insist on condom use. Our findings highlight the tension between male-dominated reproductive decision-making and women’s agency and point to the need for gender transformative approaches seeking to challenge masculinities that negatively impact health.

Research in sub-Saharan Africa has shown significant diversity in how HIV influences infected couples’ fertility intentions. Supporting HIV-infected, sero-concordant couples in sub-Saharan Africa to make informed choices about their fertility options has not received sufficient attention. In-depth interviews were conducted among 23 HIV-positive, sero-concordant married couples in Kenya, to better understand how HIV impacted fertility intentions. HIV compelled many to reconsider fertility plans, sometimes promoting childbearing intentions in some individuals but often reducing fertility plans among most, largely due to fears of early death, health concerns, stigma, perinatal HIV transmission and financial difficulties (particularly in men). Preferences for sons and large families influenced some couples’ intentions to continue childbearing, although none had discussed their intentions with health care providers. Additional support and services for HIV-infected, sero-concordant couples are needed. Family planning counselling should be tailored to the unique concerns of HIV-infected couples, addressing perinatal transmission but also individual, couple-level, and socio-cultural fertility expectations. Community-level programmes are needed to reduce stigma and make HIV-infected couples more comfortable in discussing fertility intentions with health care providers.

Despite increasing efforts to address the reproductive health needs of people living with HIV, a high unmet need for contraception exists among HIV+ women in sub-Saharan Africa. This study explores the fertility intentions and family planning (FP) preferences of Kenyan women accessing HIV treatment. We conducted 30 semistructured interviews and qualitatively analyzed the data with a grounded theory approach. Fears of premature death, financial hardship, and perinatal HIV transmission emerged as reasons for participants’ desire to delay/cease childbearing. Participants strongly identified FP needs, yet two-thirds were using male condoms alone or no modern method of contraception. Women preferred the HIV clinic as the site of FP access for reasons of convenience, provider expertise, and a sense of belonging, though some had privacy concerns. Our findings support the acceptability of integrated FP and HIV services. Efforts to empower women living with HIV to prevent unintended pregnancies must expand access to contraceptive methods, provide confidential services, and take into account women's varied reproductive intentions.