“Children are a blessing from God” – a qualitative study exploring the socio-cultural factors influencing contraceptive use in two Muslim communities in Kenya

Abstract

Background:
Family planning (FP) is one of the high impact public health interventions with huge potential to enhance the health and wellbeing of women and children. Yet, despite the steady progress made towards expanding access to family planning, major disparities across different regions exist in Kenya. This study explored the socio cultural factors influencing FP use among two Muslim communities in Kenya.

Methods:
A qualitative study involving Focus Group Discussions (FGDs) and In-depth Interviews (IDIs) was conducted (from July to October 2018) in two predominant Muslim communities of Lamu and Wajir counties. Open ended questions explore key thematic areas around knowledge, attitudes and understanding of contraception, perceived FP barriers, and decision making for contraceptives, views on Islam and contraception, and fertility preference. All interviews were conducted in the local language, recorded, transcribed verbatim and translated into English. Data was analyzed using thematic content analyses.

Results:
Although Islam is the predominant religion the two communities, perceptions and belief around FP use were varied. There were differing interpretations of Islamic teaching and counter arguments on whether or not Islam allows FP use. This, in addition to desire for a large family, polygamy, high child mortality and a cultural preference for boys had a negative impact on FP use. Similarly, inability of women to make decisions on their reproductive health was a factor influencing uptake of FP.

Conclusion:
Misinterpretation of Islamic teaching on contraception likely influences uptake of family planning. Cultural beliefs and lack of women's decision power on fertility preferences were a key inhibitor to FP use. Countering the negative notions of FP use requires active engagement of religious leaders and Muslim scholars who are in position of power and influence at community level.

Full text

R E S E A R C H Open Access
“Children are a blessing from God”–a
qualitative study exploring the socio-
cultural factors influencing contraceptive
use in two Muslim communities in Kenya
Batula Abdi
1,2*
, Jerry Okal
3
, Gamal Serour
4
and Marleen Temmerman
5,6
Abstract
Background: Family planning (FP) is one of the high impact public health interventions with huge potential to
enhance the health and wellbeing of women and children. Yet, despite the steady progress made towards
expanding access to family planning, major disparities across different regions exist in Kenya. This study explored
the socio cultural factors influencing FP use among two Muslim communities in Kenya.
Methods: A qualitative study involving Focus Group Discussions (FGDs) and In-depth Interviews (IDIs) was
conducted (from July to October 2018) in two predominant Muslim communities of Lamu and Wajir counties.
Open ended questions explore key thematic areas around knowledge, attitudes and understanding of
contraception, perceived FP barriers, and decision making for contraceptives, views on Islam and contraception, and
fertility preference. All interviews were conducted in the local language, recorded, transcribed verbatim and
translated into English. Data was analyzed using thematic content analyses.
Results: Although Islam is the predominant religion the two communities, perceptions and belief around FP use
were varied. There were differing interpretations of Islamic teaching and counter arguments on whether or not
Islam allows FP use. This, in addition to desire for a large family, polygamy, high child mortality and a cultural
preference for boys had a negative impact on FP use. Similarly, inability of women to make decisions on their
reproductive health was a factor influencing uptake of FP.
Conclusion: Misinterpretation of Islamic teaching on contraception likely influences uptake of family planning.
Cultural beliefs and lack of women’s decision power on fertility preferences were a key inhibitor to FP use.
Countering the negative notions of FP use requires active engagement of religious leaders and Muslim scholars
who are in position of power and influence at community level.
Keywords: Family planning, Islam and contraception, Culture and religion
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* Correspondence: abdi@unfpa.org
1
United Nations Population Fund Tanzania country Office, Zanzibar, Tanzania
2
Ghent University, Ghent, Belgium
Full list of author information is available at the end of the article
Abdi et al. Reproductive Health (2020) 17:44
https://doi.org/10.1186/s12978-020-0898-z
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Plain English summary
The ability of families and individuals to decide freely,
for themselves, whether, when, and how many children
they want to have is a basic human right. However many
women in developing countries are not able to exercise
this basic right for various reasons. This study sought to
understand social cultural factors that influence the
utilization of FP in two Muslim communities in Kenya.
The findings show that misinterpretation of the Islamic
teaching on family planning is one of the reasons why
women are not using family planning. Further the study
shows that social cultural values and norms on; desired
family size; men marrying many wives; families losing
many children due to childhood illness and preference
for boy child were seen as hindrance to family planning
use. Similarly women’s inability to make their own deci-
sion on matters of FP was another deterrent. Engaging
religious leaders and Muslim scholars to educate the
community and dispel myths on family planning and
Islam is very important.
Introduction
Family planning is one of the high impact public health
interventions. Studies have shown that access to family
planning services in countries with high fertility rates
has the potential to significantly reduce poverty and
hunger, as well as avert maternal and childhood deaths
[1,2]. However, many women who would like to delay
their next birth or stop childbearing altogether cannot
access this important services. Worldwide, 214 million
women of reproductive age have unmet needs for family
planning (defined as wanting to stop or delay childbear-
ing but are not using any method of contraception) [3–
5]. Further, women with an unmet need for modern
contraception account for 84% of all unintended preg-
nancies in developing regions [5].
Kenya has made steady progress in improving access
to family planning services. In the past decade, the pro-
portion of married women using a contraceptive method
–defined as Contraceptive Prevalence rate (CPR) –in-
creased from 32% in 2003 to 39% in 2009 and to 58% in
2014 [6]. Similarly, unmet need for contraception has
slowly but steadily declined, from 28% in 1998 to 26% in
2009 and 18% in 2014.
[6]. Despite the impressive growth in CPR over time,
huge disparities exist between counties, with CPR ran-
ging from 2% in Wajir to 76% in Kirinyaga County.
Similar disparity exists in fertility levels, ranging from 8
to 2 children per woman in Wajir and Kirinyaga Coun-
ties, respectively [6,7].
Existing evidence shows that several social and cultural
barriers impede access to contraceptive services. These
include women’s fear of contraceptive side effects, disap-
proval by partners, lack of knowledge about the
contraceptive methods, religion, minimal or lack of
spousal communication, and misconceptions [3,8,9].
Furthermore, contraceptive uptake is influenced by
women’s autonomy and levels of education [10]. Simi-
larly, maternal education has proven to enhance uptake
of contraceptives. Research shows that education has a
knock-on effect on age at first marriage and entry to the
paid labor market, which correlates with reducing fertil-
ity [11–13].
Critically, religion has historically raised debate on
whether contraceptives should be used. However, from
the Islamic perspective, evidence from different authori-
tative sources suggest that Islam does not forbid the use
of contraceptives. For example, the first source of Is-
lamic sharia
1
(law), the Quran, specifically recommends
that mothers breastfeed for two complete years “and
mothers should suckle their children for two whole
years...”(Qur’an 2:233) [14].Scholars describe the 2 years
of breast feeding mentioned in the Quran as a means of
child spacing to give the mother adequate time to re-
cover from childbirth and care for the child [15–17].
The 2 years of breastfeeding mentioned in the Quran
also concurs with the World Health Organization
(WHO) recommendation on birth spacing [18].Simi-
larly, the Sunnah, a documentation of the prophet Peace
Be Upon Him (PBUH) tradition indicates that coitus
interruptus or withdrawal (al Azl) method was practiced
during the time of the prophet (PBUH). Many Muslim
scholars have used analogical reasoning (qiyas), the third
source of Islamic sharia, to legitimize reversible contra-
ceptive methods because both coitus interruptus and
modern methods prevent conception. All the four
Schools of Islamic Jurisprudence
2
agree that permanent
methods are not permissible without medical justifica-
tion [16,19,20]. Despite enormous evidence and Fatwa
3
showing the permissibility of reversible contraceptive
methods in Islam within the confines of marriage, some
Muslim leaders oppose FP in totality. Their objection to
FP is based on the following premise: the recommenda-
tion in Islam to have many children; beliefs that children
are adornment of life and a gift from God; producing
1
Sources of Islamic law (Shariah) -The primary sources of Shariah are
the Quran (Islam’s holy book) and the Sunnah, the sayings and deeds
of the Prophet Mohammad and his Companions. Also based on the
Quran and Sunnah but subordinate to them are two other sources for
Shariah: the consensus of Islamic jurists (ijmae) and analogy (qiyas).
2
Schools of Islamic Jurisprudence-The schools of Islamic
jurisprudence are called madhahib, which means “paths”or “ways.”. All
schools of jurisprudence consider the Quran and the Prophet’s
tradition (Sunnah) as their primary sources. They differ only in
relation to some interpretations, the validity of other sources of
jurisprudence, and the methods of formulating a ruling. The four
schools of thought are; Hanafi, Maliki, Shafei and Hanbali
3
Fatwa- authoritative legal opinion or learned interpretation by a
qualified jurist regarding issues pertaining to Islamic Shariah.
Abdi et al. Reproductive Health (2020) 17:44 Page 2 of 11
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children is the purpose of marriage and family planning
contradicts the will of Allah and his ability to provide
[16,19]. Those who oppose use of contraceptives cite
the following verses from the Quran (Quran 17:31;18:
46) [14]. “And kill not your children for fear of want.
We shall provide sustenance for them as well as for you.
Verily the killing of them is a great sin.”(Qur’an 17:31)
“Wealth and children are the adornment of the life of
this world.”(Qur’an 18:46) However, neither of these
two verses talks about contraception, but rather about
value of children and the obligation to protect their
lives.
Although some believe that Islam opposes contracep-
tion, no valid explanations exists as to why contexts
sharing similar religious values have different CPRs. For
example, Wajir and Lamu counties are predominantly
Muslim regions; however, these two sites have a stark
CPR of 2 and 42% respectively. Apart from Kenya
Demographic and Health Survey (KDHS) there has been
limited evidence on factors affecting uptake of FP among
the muslim comunities in kenya. It is against this back-
ground that our study examines how socio-cultural fac-
tors influence uptake of family planning.
Methods
Study design
This was a qualitative study involving Focus Group Dis-
cussions (FGDs) and In-depth Interviews (IDIs) among
the Muslim communities in Lamu and Wajir counties.
The design was considered suitable for gaining in-depth
explanations of the prevailing perceptions and practices
regarding contraceptive use and the socio- cultural fac-
tors that influence contraceptive use.
Study setting
Wajir County is part of the former North Eastern prov-
ince. The county boarders Mandera County to the
North, Garissa to the South, Isiolo and Marsabit Coun-
ties to the West. The neighboring countries include
Somalia to the East and Ethiopia to the North West
[21]. The county has a population of 661,941 of which,
298,175 are females and 363,766 are males [22]. It has
the lowest CPR in the country at 2% and highest Total
Fertility Rate (TFR) of 8 children per woman [6]. The
county is ranked as one of the poorest in the country
with 76% of the population having no formal education
and only 4% having completed secondary level of educa-
tion or higher [23].
Lamu County is part of the former coast province, lo-
cated on the Northern coast of Kenya. The county bor-
ders Garissa County to the North, Tana River County to
the South West, Somalia to North East, and Indian
Ocean to the South [24]. It has a population 101, 539
people, 48,494 females and 53,045 males [22]. The
county has a CPR of 42% and TFR of 4 children per
woman. Nearly a third of the county residents live below
poverty line, with only 13% of the resident having com-
pleted secondary education [23].
Wajir and Lamu Counties were selected to provide di-
versity of context for contraceptive uptake, as they both
have high Muslim populations, but different levels of
contraceptive prevalence.
Study participants and sampling
Prior to the study, community engagement was done in
both counties by working with the local chiefs and com-
munity elders. The participants were purposefully se-
lected from three sub-counties, namely Wajir east and
Wajir North in Wajir County, and Lamu west in Lamu
County. The FGD participants were selected based on
sex, age and residence while IDI participants were se-
lected based on their knowledge on socio-cultural prac-
tices, religious teaching and their role within the
community. Muslim men aged 18–54 and Muslim
women aged 15–49 living in study area and willing to
participate were targeted for interview. The participants
for FGDs and IDI were identified with the help of com-
munity leaders, health officers and members of the sub-
county health management teams.
A total of 11 FGDs (Wajir n= 6 and Lamu n= 5) were
conducted. FGDs were composed taking age, sex, and
position in the community (e.g., religious leader) into ac-
count, such that in each county there was an FGD for
young women (under age 24 years), older women (above
age 30 years), younger and older men (under 24 years,
over 30 years), and religious leaders.
A total of 93 participants were recruited to participate
in 11 FGDs (7 with men and 4 with women). A descrip-
tion of FGD and IDI participants characteristics is in-
cluded in Table 1. There were 13 IDIs (Wajir, n= 7 and
Lamu, n= 5) IDI respondents included Islamic scholars,
community leaders including women leaders and health
workers. In general more men than women were re-
cruited because some of the roles this community are
enacted by men (for example most religious leaders and
scholars were men with no woman occupying/holding
such position. This study was conducted as part of a lar-
ger quantitative survey with women in Wajir and Lamu
Counties.
Data collection
Data was collected between July and October 2018.
Open-ended semi-structured question guides were used
to explore participants’knowledge of contraception, per-
ceived barriers, attitudes, decision making regarding
contraceptive use, views about Islam and contraception
and fertility. Discussions and interviews were conducted
in Somali and Swahili languages for Wajir and Lamu
Abdi et al. Reproductive Health (2020) 17:44 Page 3 of 11
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Counties, respectively, and later translated to English.
The average duration of the FGDs and IDI was 45 min
to 1 h. Interviews were conducted by a team of experi-
enced qualitative researchers supervised by the first au-
thor. Data was collected until saturation was reached
and no new information emerged during daily study
team debriefing meetings. FGDs were conducted in a
central place agreed upon with the participants. The
FGDs for men and women were conducted separately
given the sensitivity of the research topic. The IDIs were
conducted in private places of the respondents’choice.
The lead author of the study, fluent in both languages,
supervised the data collection process.
Ethical consideration
Ethical approval for the study was obtained from the Re-
search Ethics Committee of the Aga Khan University,
Nairobi (2016/REC-56 (v3)). We also obtained a research
permit from the National Commission for Science,
Technology and Innovation (NACOTI/P/18/14340/
20946) to conduct research activities in the community.
All participants provided verbal consent after being in-
formed about the objective of the study. Considering the
cultural sensitivities, literacy levels and precedent set by
other researchers it was deemed appropriate to obtain
verbal consent followed by signature from the research
team verifying that consent was indeed taken.
Regarding minors below the age of 18 years, only those
who were considered emancipated minors (in this case
married adolescents were considered as mature/emanci-
pated minors who could provide their own consent) par-
ticipated in the interviews. Minors were included in the
interviews because early marriage is widely practiced in
the two counties. It was therefore necessary to under-
stand the perceptions of married adolescents regarding
the challenges in accessing family planning services.
Data analysis
Data from the FGDs and IDIs were recorded and tran-
scribed verbatim and translated into English. The tran-
scripts were validated for accuracy, through a set review
process involving validation by two separate transcribers.
We analyzed the data using thematic content analyses,
in which a set of codes were developed based on the
interview tools, and the emerging themes from the dis-
cussions. A code sheet was developed and used for cod-
ing the transcripts in ATLAS.ti (Version 7). Data coding
was done by two coders, who consulted with the lead
author closely, to ensure consistency the codes created
were discussed and agreed upon by the team. After the
coding process, further analysis was done by grouping
texts in analytic categories such as demographics, site,
interview type (IDI or FGD) and also by grouping the-
matically related codes into a code family, in order to
gain a broader and deeper understanding of the issues
discussed within that theme. The themes were compared
across the transcripts and specifically the different ana-
lytic categories, to establish the range and similarities of
the participants’perceptions, experiences and views. Re-
view and validation was done by comparing the emer-
ging themes, discrepancies were discussed and
consensus was reached. Verbatim quotes used to illus-
trate the text and effectively communicate its meaning.
Results
We present findings from FGD involving 93 discussants,
and 13 IDI of which 65% were men and 35% were
women. Over a third (38%) of the respondents had no
education, 31% had completed primary and only 31%
completed secondary education and above.
Table 1shows details characteristics of the
respondents.
The findings from this study identified three main
themes as the key socio- cultural factors influencing FP
Table 1 Characteristics of study population
Characteristics Focus Group Discussion In-depth interviews
Number Wajir Lamu Number Wajir Lamu
Male 54 32 22 7 4 3
Female 39 18 21 6 3 3
Age
16–19 years 7 3 4
20–24 years 9 4 5
25–29 16 8 8
29–35 24 14 10 3 2 1
36–40 18 9 9 4 2 2
41–49 19 11 8 6 3 3
Education
No education 36 21 15
Primary 30 18 12
Secondary above 27 12 15 13 7 6
Occupation/Role
Unemployed 22 12 10
Casual job 20 10 10
Farmer/pastoralist 8 8 –
Business 11 6 5
Fishermen 8 –8
Civil servant 2 1 1
Health worker 5 2 3
Religious leader 24
Islamic scholar 2 1 1
Community leader 4 2 2
Total FGD participants 93 Total IDI participants 13
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uptake: divergent interpretations of Islamic teaching on
FP, fertility preferences, gender dynamics and decision-
making around contraception.
Islam and family planning: the divergent opinions
Narratives from Lamu and Wajir both showed divergent
views among Islamic scholars, religious leaders, and
women and men from the community. Most of the reli-
gious leaders and scholars in both the locations asserted
that FP (especially child spacing) is supported by Islam.
They argued that nowhere in the Quran and the Sunnah
prohibited FP. Furthermore, they referred to specific evi-
dence in the Sunnah which showed that contraception
was allowed, particularly, the use of the withdrawal
method (Al azl). The following quotes illustrate views
that Islam supports FP/ child spacing:
The Sunnah does not directly talk about child spa-
cing as such but it talks about the prophet (PBUH)
noticing that his companions doing practicing co-
itus interruptus (Al azl) and when he heard about it
he did not forbid this practice therefore his fol-
lowers concluded that if it was anything that is not
allowed in Islam he could have stopped it immedi-
ately. The intention of Al azl was to prevent preg-
nancy just like the modern temporary methods". -
(IDI, Islamic Scholar,-Wajir)
Our religion says that God is the one who gives us
children, but on another perspective, we are not
allowed to burden ourselves. To do family planning
is okay, what is wrong is abortion. Its better you
have a child that you can take care of". (IDI woman
leader- Lamu)
However, most respondents from Wajir believed that
FP was strictly limited to child spacing for 2 years only.
They implied that women should give birth after every 2
years between pregnancies until menopause. Often the
responses referred to the Quranic recommendation that
mothers breastfeed their children for 2 years to restore
their physical and psychological wellbeing before an-
other pregnancy. Respondents from Wajir also alluded
that women will not get pregnant during the 2 years of
breastfeeding since they have lactational amenorrhea
(absence of menstruation during breastfeeding).
In our religion in the Quran we were told for the
woman who gives birth she should breast feed her
child for 2 years so that both the mother and the
baby’s health will not be affected but if what you are
talking about is child spacing more than those two
years unless it is for medical reason then the reli-
gion does not allow, even ALLAH says in his book
give birth and do not think about poverty because
he is the provider". (FGD Religious leader- Wajir)
“Most people believe that when women are breast-
feeding they will not get pregnant”(women leader,
wajir)
Additionally, some respondents believed that FP was
only acceptable under certain circumstances. For ex-
ample, they alluded that FP was permissible if the health
of the woman has deteriorated or the woman has had
several caesarian sections such that another pregnancy
would be detrimental to her health.
Islam allows family planning only if it’s child spa-
cing and not stopping the women from giving birth
completely and also the other reason is that if a
doctor recommends family planning for a woman
for a reason related to her health and the baby, the
religion has no objection. (FGD, Religious leader-
Wajir,)
On the contrary some respondents opined that Islam
does not support FP, pointing out the contradiction be-
tween FP and the principles of God as the sustainer and
provider. Such respondents frequently quoted the Quran
to back their claims that children are a blessing from
God and that each child comes with their own provi-
sions (rizq).
“Family planning is haram because you are prevent-
ing a living creature from coming to the world.”
(Male FGD-Lamu)
“Because they have the belief that God is the one
who provides and sustains so family planning is a
sin to them even when we are giving them health
talk some say we the health workers are irrational,
they ask why do you want us to kill the unborn
child, they tell us taking the pill is to kill the child.”
(IDI health worker- Wajir)
Interestingly, although there are those who believed
that Islam is in contradiction of the use of FP, they justi-
fied using contraceptives because of the economic situ-
ation which they said prevents them from sustaining the
desired large family, a common situation in Lamu.
“Islam doesn’t allow family planning, it is haram,
(forbidden) we are just practicing because of the dif-
ficult economic times, even the Prophet said fill the
world with children so that I have a big ummah (so-
ciety) in the day of judgement”.- (FGD women,
Lamu)
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Fertility preferences and contraceptive uptake
Understanding fertility preference of a community is
fundamental for family planning programmes. With
regards to fertility preference many sub-themes
emerged: desired family size and contraceptive use,
influence of child mortality on contraception, role of
polygamy, son preference and contraceptive use. The
desireformorechildrenamongmeninWajirstems
from the cultural value of children in a predomin-
antly nomadic society where children are a form of
wealth and provide labor force. The desire for more
children as expressed by men in Wajir has a direct
impact on contraceptive use.
Desired family size and contraceptive use
Women in both Lamu and Wajir counties desired a
“modest”family size of between 4 and 6 children. Men
in Lamu also desired a similar family size of between 4
to 5 children; however, most of their counterparts in
Wajir desired as many as 15 children.
“In our community we want our wives to give birth
until the menopause stage that is what I want per-
sonally. If you ask a number, I can tell you person-
ally I need many children, around 15, because
nobody wants few number when it comes to chil-
dren”-(Male FGD- Wajir).
“In our community we want our wives to give birth
until the menopause stage that is what I want person-
ally …My reason is am following the practice of the
prophet and the prophet said I want my followers to
reproduce and fill the earth”-(Male FGD_ Wajir)
On the other hand, respondents in Lamu justified their
desire for a smaller family size because of the economic
burden of sustaining larger families.
“I would say four is enough. Many women in this
current time, they are employed women and the
economy doesn’t favor one having many children.
Some say they want four, others even seven children,
but most prefer four because it is manageable.”
–(IDI woman leader- Lamu)
Child mortality and contraceptive use
Both counties had similar views on child mortality and
contraception. Having many children was a mitigating fac-
tor in the high prevalence of child mortality. Respondents
view a large family size as a coping mechanism for child
mortality. The results show that child mortality affects up-
take of contraceptive use in two ways; when a child dies,
the mother will stop using contraceptives to have another
child and families tend to have more children considering
that some could die in their childhood, thus affecting
contraceptive use.
“We prefer many children so that when some die at
least you will still have some. For example, when
you have only one or two and God takes them what
will you do? So it’s wise you bear as many children
as you can.”(FGD women –Lamu)
“many people have that perception that I rather
have many children so that when some die, still you
have other children.”(IDI Women leader- Wajir)
The role of polygamy in contraceptive use
Across the sites most respondents supported the
view that polygamy (a practice in which a man has
more than one wife), is accepted in Islam. With
greater importance attached to procreation, polyg-
amy seems to accelerate child births and fuel compe-
tition among co-wives to have more children.
Competition among co-wives likely leads to more
pregnancies among women in polygamous relation-
ship thus leading to low contraceptive use. This
phenomenon was more frequently reported by re-
spondents in Wajir as opposed to Lamu.
“On my personal judgement, polygamy is one of the
drivers of not using contraceptives as the women
may compete having many children.”(IDI health
worker- Wajir).
“In polygamous marriage when a woman is married
to a rich man many children will help her to inherit
more wealth.”(IDI woman leader- Wajir )
Preference for sons and contraceptive use
Generally, most respondents mentioned a preference for
male children. This finding was more pronounced in
Wajir than Lamu County. Consequently, respondents in
Wajir, affirmed that having a boy is an honor. Thus,
many women with only daughters will avoid FP at all
costs in the hopes of having a boy.
“…the other one is cultural bias towards the male…
you will see a mother has 4 girls she sees this is a good
number but her wanting to get a boy child, she will
keep trying to get pregnant until she is able to get a boy
or until menopause.”-(IDIHealth worker- Wajir)
“The society values boys more than girls, so if you
don’t have a boy you keep giving birth until you are
able to get [one].”(women FGD-Wajir).
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Gender relations and decision-making regarding
contraceptive use
In patriarchal societies, men are the sole decision
makers, and they also dominate sexual and reproductive
issues including FP use. In the two communities, the
perception of the man as the head of the family led most
women to believe that men had authority on the deci-
sions about contraceptives use. Nevertheless, a few of
the respondents disagreed, stating that this decision
should be jointly made by couples after a healthy discus-
sion. The ability of women to make their own decisions
on how many children to have and how often directly
correlated with high/low contraceptive use. The quotes
below illustrate how respondents viewed FP decision-
making. Furthermore, the discrepancy between desired
family size between men and women in Wajir shows
that often men achieve their fertility desires regardless of
their partner’s choices.
“In many cases, the decision of how many children
the family needs lies with the husband. In some in-
stance[s], the decision is made by the couple. In few
instances, advice from the doctor due to the health
of the mother.”(FGD men- Lamu)
“Mostly, you will find it is the man who makes the
decision and sometimes they don’t care. I think
there are very few families who sit down and say,
“Ok, how many children do we want to have?”But
if there is one of them who were to make decision it
is usually the man.”(Islamic Scholar- Wajir)
In some instances mothers-in-law have a big influence a
couple’s decision to use contraception. These narratives
show the influence mothers-in-law have on contracep-
tive use.
“Mother-in-law also suggests, and most of the time they
can’t be ignored because they have so much influence in
their son’s lives.’” (FGD women- Lamu)
“When other people like mothers-in-law are in-
volved, this issue about family planning she will not
accept; she will even curse you….”(FGD women-
Wajir)
Spousal communication and contraceptive use
Couple communication is a very important factor in
contraceptive decision-making and utilization. However,
respondents had varied opinions on couple communica-
tion on contraceptive use. In Lamu respondents reported
that to some degree, there are conversations on contra-
ceptive use, and while in Wajir similar discussions were
rare or non-existent but often associated with the
education level of the couples. As depicted in the quotes
below spousal communication appears to happen more
frequently in Lamu than Wajir.
“We talk to our husbands, some support the idea
while others don’t support the idea.”(FGD women-
Lamu)
“At the family level discussing family planning is an
issue [for only the few] who are educated because
there is mass which are over 80 percent of unedu-
cated people the issue of a family planning it is not
a topic of discussion…” (IDI health manger- wajir
)
However, some respondents reported covert use of
contraceptives, likely due to of lack of communication.
Those who reported covert use of contraceptive mostly
attributed partner and other family member opposition
to contraceptive use.
“There are some who say they hide the pills because
if their husbands find out they end up getting di-
vorced but there are those who are clever enough
they come for injection that way the husband will
not know.”(IDI women leader-Wajir)
“In cases where men don’t support, this forces the
woman to practice family planning in secrecy. This
can also lead to relationship wrangles and [di-
vorce].”(FGD- Lamu women)
Discussion
This study explored the sociocultural factors that influ-
ence use of family planning among Muslim communities
in Lamu and Wajir counties, Kenya. The counties vary
substantially in terms of rates of poverty, level of educa-
tion, and utilization of modern contraceptives. Interest-
ingly, the findings highlight that the residents of the two
counties also hold divergent interpretations of Islamic
teaching on family planning, role of fertility preferences
in contraceptive uptake and gender dynamics and
decision-making on FP uptake.
The position of Islam on contraception has been a key
subject of debate, centered on the permissibility of fam-
ily planning in Islam, with important consequences for
contraceptive uptake in Muslim communities. As one of
the few empirical studies in sub-Saharan Africa explor-
ing sociocultural factors influencing uptake of family
planning among Muslim populations, this study provides
important insight into how varies interpretations of
Islam intertwine with other cultural values to produce
support for, or opposition to, modern contraceptive use.
Specifically, findings highlight how cultural values have
Abdi et al. Reproductive Health (2020) 17:44 Page 7 of 11
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been labeled as religious teachings, with implications for
contraceptive uptake.
Notably, our study shows that many Muslim scholars
and leaders in both counties agree that FP is accepted in
Islam. They accept it within the context of marriage and,
more specifically, to aid with the spacing and timing
of pregnancies. However scholars interviewed noted
that permanent and non-reversible contraceptive
methods without medical justification are not permis-
sible. These findings correlate with the broader
consensus on the acceptability of FP within Islam and
are consistent with the documentations in the Islamic
doctrine [17,19,25–27].
In the debate around Islam and contraception, the ad-
vocates of FP have used many citations from the Quran
and Sunnah, the first and second sources of Islamic sha-
ria, respectively. The Quran mentions that Allah desires
ease for us (Quran 2:185) and “Allah tasks not a soul be-
yond its capacity (or limits).”(Quran 2:286) [14].Fur-
thermore, proponents of FP have used evidence from
Hadith and Sunnah show that FP is permitted in Islam,
and that Al Azl (withdrawal method) was used during
the time of the prophet (PBUH); based on analogical de-
duction (i.e the third source of Islamic Sharia (Qiyas))
modern FP methods are allowed [19]. The citations rep-
resent Islam as a religion of mercy and moderation [16,
19].
However, our findings show an apparent disconnect
between the understanding of FP from the above citation
of Islamic teaching and knowledge and practices of FP
in the community. This disconnect is influenced by con-
flicting opinions regarding FP, with most men and
women interviewed considering the use of FP as ‘haram’
(forbidden). This belief might be a key driver of the low
uptake of FP, especially in Wajir. Moreover, many re-
spondents believe that FP is only allowed in special cir-
cumstances such as, when a woman is ill or has had a
caesarian section, meaning that by the community stan-
dards many women will not “qualify”to use FP. Another
misinterpretation which could influence the attitude and
use of FP is that Islam recommends only 2 years of
breast feeding for child spacing. Many of the respon-
dents interviewed highlighted this philosophy by stating
that mothers have lactational amenorrhea (absence of
menstruation during breastfeeding) and therefore will
not conceive during this period. This perception was
more common in Wajir as opposed to Lamu, which may
explain the difference in uptake of FP and high TFR. In
a similar study, Mir and Shaikh argue that misconcep-
tion in Islamic teachings contributes to the low
utilization of contraception [25,28–30]. To see change,
Muslim scholars and religious leaders must demystify re-
ligious and cultural myths and misconceptions. Further-
more, given their influence, different studies [25,28,31]
have highlighted the importance of working with
Muslim scholars and religious leaders to yield positive
results in FP uptake.
Those who viewed FP as unacceptable in Islamic cul-
ture justified their beliefs through several factors: the
view that contraceptives kill the unborn child, that every
child comes with their own blessing and provision (rizq)
and that the prophet (PBUH) urged his followers to pro-
duce and fill the earth. Non- use of FP is therefore based
on the view that it will infringe on the principles of
Islam of directing one’s trust towards Allah (tawakkul),
the provider and sustainer. However, Omran argues that
the idea that FP contravenes the principles of tawakkul
requires further analysis. Omran posits that FP does not
breach the ‘tawakkul’concept, but instead suggests that
we need to see FP as doing what is humanely possible
within the context of what is willed by Allah [19]. An-
other possible reason for this misunderstanding of
Quran and Hadith is the language barrier. The Holy
Quran and Hadith are written in Arabic. Even with ac-
curate translation, people may misunderstand the verses
and need clarification by religious authorities fluent in
Arabic. This has been the experience of the Al Azhar
mission to several counties in Kenya, including Lamu in
2015 [32].
The second theme to emerge in this study is fertility
preference. Having insights into people’s fertility inten-
tions helps to understand child bearing norms, as well as
improving the design for behavioral change interventions
of FP programmes. Research from Kodzi and others has
shown a significant relationship between past intentions
of having additional children and future fertility [33].
The findings show that the desire for more children was
informed by many factors, including: sociocultural values
attached to large family size, child mortality, and polyg-
amy and son preference.
In relation to ideal family size, our study shows a strik-
ing difference between the two counties with regards to
desire for larger families, influenced by cultural and reli-
gious belief. The demand for larger family size, as
expressed by men in Wajir, could be one of the key
drivers of non-use of contraception in Wajir County
compared to Lamu. The preference for large families has
mainly been expressed by men in the study, particularly
men in Wajir County. They base their preference on the
belief that more children constitute more wealth, pres-
tige and from a religious perspective that every child is a
gift from God, with their own provisions and blessings.
These findings are consistent with what has been docu-
mented previously [33–35]. Furthermore, a study in
Kenya, looking at male fertility preference found that
men in North Eastern region (wajir is in this region) de-
sire more children three times higher as compared to
men in Nairobi [36]. This is also evident from the
Abdi et al. Reproductive Health (2020) 17:44 Page 8 of 11
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finding of KDHS, which shows the TFR for Wajir is
double (7.8) that of the national average 3.9 [6].
The women in both counties are predominantly con-
trolled by a strong patriarchal system, which encourages
polygamous marriages. There is cultural importance
given to female fertility and women in the communities
are expected to bear as many children as possible. Con-
sequently, women in polygamous marriages compete
with co-wives regarding the number of children they
conceive to acquire more of the husband’s wealth. Fur-
ther, the findings show remarkable difference between
the counties with regards to polygamy which could be
another factor influencing the low uptake of contracep-
tive in Wajir compared to Lamu. While the men ratio-
nalized polygamy both from a religious and cultural
perspective, it is also an honor, prestige, and a sign of
wealth to have many wives and children. Other studies
have shown that men use polygamy to attain their fertil-
ity goals independent of their individual wives [37].
The findings of this study show a relationship between
child mortality and contraceptive uptake. Given the high
child mortality in the two counties, bearing more chil-
dren is used as a coping mechanism to compensate for
the death of a child. In these situations, women will dis-
continue a contraceptive method when a child dies or
have more children as a forward-looking strategy. This
link between child mortality and fertility concurs with
other research [38,39]. In addition, our findings indicate
that son preference drives high fertility, especially in
Wajir, where women will continue giving birth until they
get a son thus, and affecting contraceptive use. The pref-
erence for sons is informed by the patriarchal norms
that sons are agents for family continuity and lineage as
evidenced by studies elsewhere [36,40].
The degree to which women exercise their decision-
making powers about their health and lives is shaped by
the social intuitions around them. The patriarchal sys-
tem of most African households means that women con-
tinue to be relegated to low status within their
communities [41,42]. The findings confirm the inability
of women to make decisions about family planning;
some resort to using FP in secret for fear of their hus-
bands or mother-in-laws. Our finding on women’s in-
ability to decide the number, timing and spacing of their
children which directly impact contraceptive use, agrees
with others studies [10,41,42].
Lack of communication on matters of contraception
was also a key issue highlighted in the study. Research
has shown that couple communication is positively
linked to uptake of family planning [43]. Furthermore,
our findings show limited couple communication on
matters of contraception. Lack of spousal communica-
tion was more prevalent in Wajir County, which could
further explain the low uptake of FP in the county.
Although the study has revealed some interesting find-
ings on the social cultural factors influencing uptake of
FP, it is worth noting that the study had its own limita-
tions. The findings documented may not be generalized
among the Muslim communities given the diverse social
cultural backgrounds. While there are fundamental dif-
ferences with other faith denominations, we believe our
approach and lessons learned can contribute broadly
and inform expanded research on faith based perspec-
tives and family planning. Due to the limited scope this
study we did not explore how observed differences in
CPR across the two counties is attributed to differential
interpretations of Islam in the context of differences in
levels of poverty, education, pastoralism, child mortality
between the two counties –all of which are known to
affect contraceptive utilization. Furthermore this study
was not powered to compare whether respondents’an-
swers varied by age, education and parity which have
been shown to be correlated with family planning uptake
and fertility desires.
This an understudied area and to our knowledge this
study is among the first few to explore the role of reli-
gion particularly Islam on family planning uptake in
sub-Saharan Africa. Therefore, there is need to explore
the role of Islamic teaching as an important factor to
consider along with the other sociocultural elements
when designing and implementing family planning pro-
grammes in similar settings. In the last decade the FP
programmes have focused on system strengthening and
addressing structural barriers around the supply and de-
mand. However to achieve the global and national FP
targets it is imperative that we understand and address
the complexity around FP and sociocultural barriers par-
ticularly religion and design culturally appropriate FP
programmes. Given the role of men at family level as
key decision makers it is critical to understand better
men’s fertility preference. Therefore, there is need for
further research on men fertility desires and its implica-
tion for contraceptive use especially in Wajir County.
Conclusion
This study analyzed information from community mem-
bers in the two counties with diverse background as de-
scribed in the result section. Our findings shows that
three key factors influencing the uptake of FP. The mis-
interpretation of Islamic teaching on contraception has
negatively influenced uptake of family planning. Simi-
larly, fertility preference, influenced by social cultural
values that encourage many children, has also hindered
use of FP. Further, gender dynamic and decision making
on contraception play a pivotal role in determining use
of contraceptives, with women’s inability to make deci-
sions about family planning being the major deterring
factor.
Abdi et al. Reproductive Health (2020) 17:44 Page 9 of 11
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In order to address the low uptake of FP especially in
Wajir, it is critical to engage religious leaders and
Muslim scholars to demystify myths and misconceptions
around FP and Islam. It is worthwhile to learn from pro-
gressive Muslim countries that have made strides in
family planning and dialogue at the county level with
key stakeholders on family planning. Given the role of
education in decision-making on contraceptive use, it is
imperative for the national and county government to
invest in education, particularly for women and girls to
enhance their ability to make informed decisions. Finally
the findings of this study can be used to develop cultur-
ally appropriate social behavior change materials on
family planning with active engagement of religious
leaders.
Abbreviations
CPR: Contraceptive prevalence rate; DHS: Demographic and health survey;
FP: family planning; FGD: Focus Group Discussions; IDI: In-depth Interviews;
KDHS: Kenya demographic and health survey; TRF: Total fertility Rate;
PBUH: Peace Be Upon Him.
Acknowledgments
The authors are grateful to the county health teams of wajir and Lamu, focus
group and in-depth interview participants, research field staff for their will-
ingness to participate in and support this study. The authors would like to
thank Francis Obare who reviewed the initial draft of the manuscript and
provided feedback.
Authors’contributions
BA conceptualized and designed the study. As principal investigator, BA was
responsible for all aspects of data collection, coding, analysis, and writing of
the initial manuscript draft.MT GS and JO provided overall guidance in
interpretation of the findings, reviewed the manuscript and edited drafts and
added substantive intellectual content with a particular attention on how it
adds to body of knowledge. All authors read and approved the final
manuscript.
Authors’information
BA is a PhD student at Ghent University in Belgium and also Reproductive
and Maternal Health Specialist at UNFPA Tanzania Country office. JO is
Senior Research Associate at Population Council- Kenya, GS is Prof of OB/
GYN and Director International Islamic Center for Population Studies and
Research, Al Azhar University, Cairo Egypt.MT is a Professor and MD, at the
Ghent University, Faculty of Medicine and Health Sciences and also Director
Centre of Excellence Women and Child Health, Aga Khan University, Kenya.
Funding
This research was partially funded by UNFPA Kenya country office specifically
the data collection for Wajir County.
Availability of data and materials
The datasets used and/or analyzed in the study are available from the
corresponding author on reasonable request.
Ethics approval and consent to participate
Ethical approval for the study was obtained from the Research Ethics
Committee of the Aga Khan University, Nairobi (2016/REC-56 (v3)). We also
obtained a research permit from the National Commission for Science,
Technology and Innovation (NACOTI/P/18/14340/20946) to facilitate the
conduct of research activities in the community. All participants provided
verbal consent after being informed about the objective of the study.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
United Nations Population Fund Tanzania country Office, Zanzibar, Tanzania.
2
Ghent University, Ghent, Belgium.
3
Population Council, Nairobi, Kenya.
4
International Islamic Center for Population Studies and Research, Al Azhar
University, Cairo, Egypt.
5
International Centre for Reproductive Health,
Department of Public Health, Ghent University, Ghent, Belgium.
6
Centre of
Excellence Women and Child Health, Aga Khan University, Nairobi, Kenya.
Received: 5 March 2019 Accepted: 18 March 2020
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