Limited knowledge of sexual and reproductive health information leads to unplanned pregnancies.

Participants in all seven focus groups identified and expressed the need for information and education on sexual and reproductive health and rights in their communities as a means of preventing unplanned pregnancy, especially for socially disadvantaged young women: “(Unplanned pregnancy) is something that happens almost daily because, one, people are not educated. So, because they are not educated, and again parents do not just talk to their children, it’s normal for children in the ghetto to get pregnant.” (Participant from FGD 3). Other consequences of a lack of sexual and reproductive health and rights education included early marriage, with one participant linking her lack of information to loss of future opportunities: “You find someone like me got married very early because I had no information. Maybe I could be very far today.” (Participant from FGD 2). When prompted by facilitators to list what kinds of information they thought would be most valuable and useful to them and women in their community, highly cited topics were information on contraception, gender-based violence, prevention of sexually transmitted infections and HIV, and sexuality.

Limited access to and use of contraception leads to unplanned pregnancies and stigma.

Participants cited contraceptive failure as one reason why women in their community have unplanned pregnancies. Although participants were aware of methods to prevent pregnancy and their availability at public health facilities free of charge, fear of stigma and discrimination from health providers, poor quality of services, and lack of availability or access to wider family planning options were described as primary drivers of women’s limited access to and use of contraception. For example, health facilities frequently experience contraceptive stock-outs, causing gaps in their ability to provide methods and services: “Some of them [methods] are free in city council health facilities. But if you go there late, like in the middle of the day, and they tell you come tomorrow, that was the day the injection was due.” (Participant from FGD 2).

As a result of these barriers, unplanned pregnancy was a relatively frequent occurrence in this community: “Many times we girls get pregnant without a plan, you just find yourself pregnant.” (Participant from FGD 2). Unplanned pregnancy-associated stigma was commonly described, particularly among young unmarried women, who were socially isolated from their friends and family and gossiped about: “They put you in an isolation…if the victim [woman with the unplanned pregnancy] is your friend, your mother tells you not to walk around with her.” (Participant from FGD 3). Some women experience denial and refusal from their partners: “Your boyfriend makes fun of you, in fact, he denies it saying, ‘It’s not mine.’” (Participant from FGD 1). Participants also described emotional stress and fear as consequences of unplanned pregnancy: “You get stressed out and left with no other option, you commit suicide telling yourself you’re letting go.” (Participant from FGD 4). Participants described a myriad of negative consequences of unplanned pregnancies that women in their communities face, such as early marriage and loss of employment and educational opportunities: “Others, if they are at school when they get to this point, their education comes to a standstill and they do not continue.” (Participant from FGD 6). Another participant summarized the diminished life goals women with unplanned pregnancies face: “Their dreams are shattered.” (Participant from FGD 3).

Unplanned pregnancies lead to abortion and further stigma.

Participants linked the negative consequences of unplanned pregnancy to why many women seek abortions. However, abortion was viewed very negatively by communities, and, as such, participants reported that women are highly judged and stigmatized if they are known or suspected to have procured abortions. Stigma manifested most commonly as gossip, verbal and physical abuse, being socially ridiculed or “laughed at,” and accusations of engaging in sex work or prostitution. Stigma also led to perceptions that abortions were the results of infidelity or of being unfaithful to their partners, and in conflict with the gendered social expectations of motherhood. One participant described this: “You will be breaking your own marriage because there is no man who doesn’t want a child; you were married to give birth.” (FGD 5). Other forms of stigma included social isolation, accusations of murder, and lack of respect. “Some are stigmatized and not allowed to say anything in the society, they are considered social misfits since they aborted.” (Participant from FGD 7). Abortion stigma brought disgrace and shame to these women, their families and communities.

Secret-keeping and non-disclosure was a result of women attempting to avoid abortion stigma: “Some [gossip] are caused by our friends. You tell them you are pregnant and they spread the news.” (Participant from FGD 3). Many participants echoed this sentiment: “Let me tell you, if I got pregnant and had an abortion, it would be my secret.” (FGD 1). Participants described how people in the community believed that women who have abortions could be identified by clues, such as physical or behavior changes. However, perceptions were not always correct and clues could be misleading, as described by one participant: “I have a personal experience when I was in Form Three, my breasts appeared quite early and people used to say this girl has big breasts she has procured an abortion, and I was still a virgin and I had not had sex.” (FGD 2).

Stigma leads women to use unsafe methods to end pregnancies.

Secret-keeping, non-disclosure, and lack of awareness of safe methods were described as primary reasons why women choose to forgo abortion in the health services sector and rather undergo riskier procedures or self induce. Participants generally described women as knowing the significant dangers that unsafe abortion carries, including risk of method failure and ongoing pregnancy, delays in the treatment of complications, and often death. One participant described this risk: “So, if I find the Jik [liquid bleach] and Omo [laundry detergent], I use it alone because I don’t want my mother to find out. Someone comes [to help] at the very last minute when you realize you are dying. Some [women] say something at the last minute, some even die before they tell anyone.” (FGD 1). Another described why, even despite the risks, that women are forced to resort to unsafe methods: “Why? Because we’ve been saying here how we use hangers and crotchets. We wouldn’t be using them if there were safe methods.” (Participant from FGD 3). Indeed, risks were considered calculated as women are desperate to end their pregnancy: “In that situation you have decided either to die or not.” (Participant from FGD 3).

Participants cited a variety of methods that women in their communities used to terminate pregnancies, all of which fall under the World Health Organization definition of unsafe abortion[23] (Table 1). The two most commonly cited methods were the ingestion of concentrated tea leaves, undiluted juices, or large amounts of soda. One participant said, “I know of a friend who took some Quencher [fruit flavored drink] that was not diluted and then she bled excessively; by the time she was getting to the hospital, she was dead.” (FGD 2). Others cited solvents and cleaning solutions such as bleach and laundry detergent and traditional herbal medicines as commonly used ingestible methods. Collectively, these different methods were discussed in all focus groups. Participants reported that these methods were relatively inexpensive (less than $0.50 USD), widely available, and easy to obtain in small quantities. However, these ingestion methods were regarded as unsafe: “If someone uses Jik [liquid bleach] it can kill. It almost works like the way it bleaches clothes—it can also bleach your uterus—it can even cause tears on clothes, it means it is dangerous.” (Participant from FGD 2).

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Table 1. Methods reported by participants to self-induce abortions.

https://doi.org/10.1371/journal.pone.0191412.t001

Some participants described insertion methods such as crochet needles, straws, coat hangers or other metal objects: “Crotchets, they use them to hook the fetus.” (Participant from FGD 3). Other insertion methods were mentioned: “You can also insert a pipe/straw at the uterus and prick it, it will come out as long as air get inside the uterus.” (Participant from FGD 6). While many of these methods were possible to procure and use alone, participants also reported that women went to chemists (local pharmacists) or traditional birth attendants/midwives to procure such methods, as one participant said, “For example, there is a woman who helps women with childbirth in the village and does unsafe abortions, she uses straws, bottles.” (Participant from FGD 3). Insertion methods were identified as particularly unsafe due to trauma to the uterus: “Some are treated badly by local traditional birth attendants, they insert crude things and the womb comes out. It can damage your uterus and you won’t be pregnant for the rest of the your life.” (Participant from FGD 2).

Only one participant in all seven focus groups spontaneously mentioned Medabon (mifepristone and misoprostol) as a method of abortion. When prompted by FGD facilitators, medication was discussed in only three groups. Participants in those groups referred generally to pills that one could obtain from a pharmacist, chemist or traditional birth attendant, though some reported an uncertainty of what type of medication women were given: “You just go and buy tablets for abortion and sometimes you don’t know which ones to use and how to use them.” (Participant from FGD 2). Participants in two focus groups mentioned a distrust of these sources and methods, with the common perception that ineffective or counterfeit medications are one reason for abortion failure: “One tells you that if you take these four family planning pills, you’ll get rid of the pregnancy. You try, it fails.” (Participant from FGD 1). Participants also reported off-brand use of known medications such as Panadol (acetaminophen) and deworming medication to induce abortion: “It aborts because it is usually written, ‘do not use if pregnant.’” (Participant from FGD 3).

Overall, participants viewed all of the aforementioned methods, including abortion medications, as unsafe, unreliable, and carrying severe adverse consequences for women in their community. In every focus group, women unanimously agreed that abortion is unsafe and can lead to death. In all focus groups, women had examples of friends, neighbors, or other women in their community who died from abortion: “Up to now three of them have already left us after carrying out abortion. We already buried them at Langata [a cemetery].” (Participant from FGD 1). Other acute and chronic complications after inducing abortion that were specifically described by participants included bleeding, infertility, and repeat miscarriages.

Women lack information about safe abortion methods.

When prompted by facilitators to list what kinds of information they thought would be most valuable and useful to them and women in their community, information on access to safe abortion was one of the most highly cited topics. In addition, participants discussed the importance of knowing more about their rights when accessing health care, including abortion services: “They [women] need to know that they should not be abused by doctors when they go to hospital.” (Participant from FGD 3). Regarding perceived appropriate sources of sexual and reproductive health information, participants mentioned the roles of community organizations, doctors and other healthcare providers, and schools in providing formal and informal education. In particular, participants expressed a desire for additional educational sessions from the grassroots organization: “We need more of this kind of education that you are giving us like today, keep doing this.” (Participant from FGD 7).

When asked by facilitators whether women would feel comfortable talking to a counselor over the phone about access to safe abortion and other sexual and reproductive health concerns, participants reported that if women were aware of a hotline, they would call it: “In [this neighborhood] many girls are in trouble, and now when they know there is this hotline they will call, because there are some who are used badly by their husbands.” (Participant from FGD 2). Participants also reported being comfortable with asking someone they don’t know directly for advice because of the stigmatization of abortion and unplanned pregnancy in their community: “I’d rather [talk to] one you don’t know because a friend might go and spread the news out there or they don’t even believe all your words.” (Participant from FGD 5). However, lack of money was a major concern cited by participants, even for potentially low-cost interventions such as a sexual and reproductive health phone hotline: “But then they will find out it is not free and they won’t call again.” (Participant from FGD 5).

Participants also described peers and family as informal sources for abortion information, but were aware that some information received from such sources can be inaccurate or unsafe: “You will talk to a friend, and they advise you to use a crotchet because you don’t have information.” (Participant from FGD 3). Overall, participants expressed women’s eagerness for education and training on sexual and reproductive health topics for themselves and so they can disseminate accurate information to their friends and community members. Indeed, participants discussed the support that women can and should provide for one another. Participants in FGD 1 described this role of social networks, “You know in the ghetto there are problems and wherever I find help I would obviously want my friend to find the same." (Participant 1). “Like in my case, my friends are gone, I’m only left with [name of friend withheld], there’s no way I’d hear of good information and fail to let her know.” (Participant 2).

Women perceive abortion to be illegal.

The legal status of abortion was not known or understood among women in participants’ communities; the perceived illegality was a primary reason why women chose not to attend health facilities for abortion services. As one participant described, “Maybe what you are going to do there might bring you problems, sometimes you go and sit with the doctor thinking that he is going to assist you, you tell him everything and at the end of the day you are arrested.” (Participant from FGD 5). Participants further described the perception that anyone who helped women obtain abortions would be imprisoned.

Women have limited access to abortion services.

Many participants described women’s financial barriers to abortion services in the healthcare sector. Some believed that hospitals offer clandestine services that are available to a woman only if she is able to bribe a doctor: “In fact I know of one very big one and he is a doctor at [Hospital A], [he’s] so corrupt, he helps people abort when you bribe him, you see.” (Participant from FGD 3). The extremely high cost for abortions at hospitals was mentioned repeatedly as a barrier to seeking care from facilities: “So, right now I can go to [Hospital A] and abort, yes. As long as you have money. They tell you to pay twenty thousand shillings [~$200 USD] and you pay it.” (Participant from FGD 5). Participants cited cost as a reason for why women engage in unsafe methods: “The costs at [Hospital A] and [Hospital B] is high, that is why we take Omo [laundry detergent].” (Participant from FGD 6). Notably, the costs of abortion from health facilities was significantly higher than the cited costs of obtaining an abortion from midwives or chemists, which ranged from 1,500 to 3,000 Kenyan shillings ($15 to $30 USD). However, there was some disagreement over whether chemists and midwives were qualified abortion providers. Some participants reported that chemists are licensed doctors, while other women acknowledged, “They are just quacks here.” (Participant from FGD 1).

Participants also generally believed that abortions were only available at hospitals for women with life-threatening conditions: “I remember when I was about to deliver, we were taught that some pregnancies can be fatal, you see you can be tested, some can be risky to your health, in that case an abortion can be carried out in a hospital, you see. There are some that are allowed and some that are not.” (Participant from FGD 5).

Additionally, geographic proximity to care was considered a barrier to accessing formal abortion services. One participant described the challenges of not having local services available: “Us from [this informal settlement] have no hospital to take our problems to unless you have money to go to a private hospital.” (Participant from FGD 3). Rather than travel long distances, manage logistical scheduling, and financial issues related to travel, participants summarized how, “The majority of us use what is closest to us.” (Participant from FGD 2).