Cost of contraception: The burden of preventing unwanted pregnancies

An assortment of contraceptives.

An assortment of contraceptives. 

Photo credit: Pool

What you need to know:

  • Despite the progress the country has made in reducing maternal deaths, Kenya still records an unacceptably high number of maternal deaths.
  • An estimated 6,000 women die each year during pregnancy and childbirth.

For Everline Nyambura, finding her preferred birth control method without paying cash has been a struggle despite Kenya launching a programme that offers free maternity care to women.

From buying her preferred pills at a nearby chemist and coughing thousands of shillings to have her long-term family planning method in place, Everline’s predicaments continued until she was able to settle on one at a fee.

Being a newly married couple, Everline and her husband had an agreement to use a method to allow them to have the baby when they were ready.

After talking to her gynaecologist, she settled on pills. However, she had to buy them since they were out of stock in her nearby public health facility. 

But she could not bear the side effects of the pills, they made her feel worse, she was bleeding throughout with a terrible headache and stomach pains.

She stopped using the pills and settled for a non-hormonal method, copper intrauterine (coil), which she said she would remove immediately after when she was ready to have a baby. This she had to buy since it was also not available and her insurance was not covering the insertion of the method.

Before the insertion, she was charged about Sh2, 000 for an ultrasound, which her doctor used to guide the insertion of the device. This was covered by the insurance but with the insertion of the coil, she parted with another Sh25,000.

She was told that the method was not covered by her insurance health plan and that family planning was not a necessity.

“Why is family planning not a priority to private insurance in the country? It is now women against their bodies, if you can’t access the free pills which are normally out of stock in public hospitals, then one will have to wait, purchase or go without the methods,” Everline wonders.

Everline was lucky to have the money to pay for her preferred method unlike thousands of women in the country who would really wish to have a contraceptive but because it is not available for free and they cannot afford to pay for it, they would rather continue with the ones that are reacting to their bodies and deal with the side effects or deal with the long-term effect of not having a method and thus, an unwanted pregnancy.

The ping-ponging from method to method left Winnie Keziah exhausted and furious since she was not able to afford her preferred contraceptive. She has so far used three types of birth control methods - pills, injections and implants.

“The only one that worked for me was the three months injection and on many occasions, it was always out of stock. I had to be on pills, this is despite the headaches and bleeding because in private hospitals, they are sold at a fee,” she tells Healthy Nation.

In one of the facilities, the method was available but she was required to pay Sh1, 500 for the injection. She could not afford this. She had to do with what was available, which was not her preference.

The 34-year-old mother of two depends on her National Health Insurance Fund (NHIF) cover for all her treatments whenever she is unwell. This, however, does not cover all the contraception methods apart from the surgical ones.

“I have never tried any long-term method but when I went to inquire in one of the private facilities, I was told that I needed between Sh5,000 to 25,000 depending on the method and facility,” she says.

“I wish more could be done just to include the family planning services in our NHIF cover. Can you imagine bleeding every time because of using a specific contraceptive?”

This is how the government and medical insurance firms have made it difficult for women to access certain contraceptives. Family planning service is not classified by the public insurance programme as a medical need. It’s considered a lifestyle decision. Therefore, consumers bear the entire cost.

A majority of women with medical insurance are beneficiaries of their employment. Many have no idea what the details of the policy document look like and what services are being offered.

The policy is known to the procurement and the human resource department, which negotiates with the insurance on behalf of the employee. This will be dictated by the annual payable premiums remitted by the company.

However, many of employers do not understand the needs of their employees,  with a company with more female employees not negotiating for family planning to be included in the medical insurance. Why a huge maternity package with no future plans?

Dr John Ong’ech, a gynaecologist, tells Healthy Nation that contraceptives can be expensive if not covered under medical insurance and this has long-term consequences of an unwanted pregnancy which later results in abortion and even death. “Family planning is part of reproductive health, just like covering maternity. Sometimes I don’t understand employers who decline to pay for family planning in their cover,” Dr Ong’ech says.

The charges of family planning in private facilities differ. First, one has to pay for a consultation fee to see a doctor, which ranges between Sh5,000 to Sh10,000 depending on the hospital that one visits.

The consultation can be paid for using a private cover or NHIF card. “I do not take NHIF so one has to either pay cash or use a private insurance card,” Dr Ong’ech notes. 

For hormonal contraceptives, the doctor just makes a prescription. For the ones to be inserted, the cost ranges between Sh10,000 to even Sh30,000. 

Dr Isaac Bashir, director family wellness and nutrition division at the Ministry of Health, indicates that private insurance has been a hard nut to crack.

“We have had a number of conversations with the insurance firms but it is like they are not walking the talk. We can only persuade them to see the sense but a conversation has to change if we want to give our women the best.” 

To ensure that this becomes a priority, the government has included family planning in the Universal Health Care package, which is spearheaded by  NHIF, so that women are able to get contraceptives for free in any health facility once UHC is rolled out countrywide. 

Currently, NHIF only covers surgical and permanent family planning including vasectomy and Bilateral Tubal Ligation, blocking the fallopian tubes to prevent the ovum (egg) from being fertilised.

But not every woman or man would wish to go the permanent way as others prefer the surgical methods. The uptake is still very low compared to the rise in the number of women who are in need and using modern contraceptives.

Ms Evelyne Opondo, regional director for Africa, International Centre for Research on Women, says reproductive rights are not a yes-or-no question. They are not a black-or-white question. It is a constitutional right.

“Why should we judge when, how or why women need to receive the comprehensive healthcare options they need? Why do we make decisions for them? Is it, not their right?”

She says the struggle for control over one’s body has become more urgent for women and girls more so on issues affecting their access to care services and information relevant to their full sexual and reproductive health and rights.

“It is therefore imperative that we honour our commitments to our women and girls and fully implement our Constitution.”

Dr Josephine Kibaru Mbae, former director-general at the  National Council for Population and Development, says a common source of distress for many Kenyan women is reproductive health, including lack of access to family planning services, maternal deaths and unmet need for family planning.

According to the Economic Survey 2023, the number of women undergoing sterilisation Bilateral Tubal Ligation (BTL) rose by 13.6 per cent to 4,107 in 2022.

Injectable contraceptives (2.6 million) and implants (1.1 million users) are the most commonly used contraception methods among women of reproductive age in Kenya as shown in the recently released data from the 2022 Kenya Demographic and Health Survey.

Despite the progress the country has made in reducing maternal deaths, Kenya still records an unacceptably high number of maternal deaths. An estimated 6,000 women die each year during pregnancy and childbirth.

“A major contributing factor to maternal deaths is unplanned pregnancy. Many Kenyan women are at risk of unplanned pregnancy,” Dr Mbae says. One in every five women (18 per cent) in a marriage or union in Kenya who want to postpone their next birth for two years or more, or not have any more children, are not using any method of contraception.

Unfortunately, the NHIF does not entirely cover members seeking family planning services, with access to contraceptives not included as part of the cover.

“Inclusion of all aspects of family planning in the NHIF cover will have high returns on investment. Access to family planning services, including access to contraceptives, can go a long way in reducing these maternal injuries and deaths,” she says.

Studies have established that family planning investments have a tremendous return on investment in health and other development outcomes.

Family planning investments have also been shown to lead to savings in the cost of healthcare services by reducing pregnancy-related injuries and deaths while easing the burden on public amenities such as health, water and sanitation as well as education.

“It is therefore important that we include the entire family planning services spectrum, including contraceptives, in the NHIF cover. Doing so will boost Kenya’s efforts towards Universal Health Coverage,” she says.

Dr Bashir adds that it is high time Kenya changes its conversation on family planning if we are to achieve our 66 per cent modern contraceptive prevalence rate by 2030 since the inclusion of the service is much more cost-effective.  The costs associated with access to family planning are more likely to be the cause of the number of unintended pregnancies in the country.

One of the commitments Kenya made in 2020 was to strengthen partnerships with the private sector through a total market approach to enable an increase in private sector family planning delivery contributions. 

“When you get an unintended pregnancy, looking at the delivery bill and the upkeep of the baby compared to paying Sh100 or Sh1,000 for the long-term methods in a cover for three years. Insurances should not control costs on the backs of women. If they are covering other ailments including post-natal, why are they not covering the vital commodity for women,” he asks 

He adds: “I know insurances sell services; this is a service like any other and needed by many. We need to fix it.”

Kenya is characterised by a high unmet need for family planning and a high number of unplanned pregnancies. In the country, 52 per cent of women of reproductive age are eligible for family planning methods yet not everyone can afford the methods. 

Wide disparities, however, exist, with counties such as Marsabit, Tana-River and West Pokot recording a higher unmet need for family planning at 38 per cent, 37 per cent and 29 per cent respectively. 

This is mostly because of the high cost of getting long-term family planning occasioned by stock out of commodities including implants, injectables, pills and male condoms. 

Despite Kenya making notable strides to improve the uptake of modern contraceptives and surpassing the target of 58 per cent to 61 per cent while revising it to 66 per cent by 2030 and 70 per cent by 2050, more women are not able to get their preferred methods.

 Also revising the unmet needs target from the current 14 per cent to 10 per cent by 2030, there is a lot that needs to be done to increase accessibility of the preferred methods in our facilities.

When asked about covering birth control or treating it as preventive medicine, James Kiumbe, head of Technical Underwriting and Reinsurance at Jubilee Health Insurance said insurance sells services as per the specific needs of companies and their workforce. “Jubilee Health Insurance offers customisable health insurance plans designed to meet the specific needs of companies and their workforce and family planning can be tailored in the plans as requested by the employer.”

AAR covers family planning on a case by case basis when demanded by a client employer. Healthy Nation contacted a number of private insurances but a majority did not get back.

It is a common practice among many insurance companies in the country — family planning is not covered. They consider birth control as an elective choice, arguing that covering contraception is not part of the collective health project.

• In as much as the Kenyan government is struggling to have family planning covered by private insurance, other countries have managed and women are able to access a full range of contraceptives using the health insurance plan.

• In the United States, federal law requires health insurance coverage for all “female-controlled” contraceptive methods, including counselling and related services, without out-of-pocket costs.

•As part of the Affordable Care Act, health plans are required to cover preventive care at no cost, a provision that has been interpreted to include women’s birth control approved by the Food and Drug Administration (FDA).

•This mandate applies to 18 specific methods delineated by the United States  Food and FDA, which includes female sterilisation and methods available over the counter (when obtained with a prescription).•In Germany, everyone has health coverage, and most women get family planning through a government-funded system.

•In Germany, everyone has health coverage, and most women get family planning through a government-funded system.

•In Ghana, family planning is included in Ghana’s National Health Insurance Scheme’s benefit package! This means free access for all insured women and girls, so millions will now be able to get the family planning services they need without paying out-of-pocket.

•Rwanda has achieved high coverage of health insurance, has included family planning in its insurance benefits, and has experienced an increase in family planning uptake. In 2019, The Ministry of Health in Rwanda in partnership with UNFPA, developed the Business Case for Family Planning in order to provide an evidence base on the returns on investment in family planning. The Business Case demonstrates the returns Rwanda will get from investing in family planning; on average, between 2015 and 2050, every US$1 invested in family planning could yield US$112 in returns or savings across many sectors.