Reproductive Health Decision Making among Nomadic Pastoralists in North Eastern Kenya: A Qualitative Social Network Analysis

"Norms related to child spacing and FP [family planning] are often upheld by important individuals in a woman's reference group, which can in turn influence her use."

Gender norms are social norms that define what is expected and acceptable for a woman or man in a given society. Unequal gender norms tend to disadvantage women, who are often not in charge of their own reproductive and sexual health (RSH) decisions, including their use of modern family planning (FP) methods. Amongst pastoralist communities in Kenya, women make decisions related to pregnancy and childbirth with others, influenced by perceived normative approval or disapproval. These marginalised communities have little or no access to RSH services due to a range of cultural, political, economic, and structural factors. This paper has four aims: to explore pastoralist women's views on modern FP; to describe the social support networks in which pastoralist women are embedded; to identify key people within these networks who influence RSH decision making; and to explore perceived versus tangible support of modern FP.

To explore the social networks in which nomadic (Mandera county) and semi-nomadic (Wajir county) women were embedded, and how these shaped social norms related to RSH, the researchers carried out qualitative egocentric social network analysis (SNA). The egocentric approach to data collection is designed "to illuminate the arenas of social interaction that shape or enforce social norms, as well as the composition of network partners, patterns of influence, and the enforcement of social norms that uphold or challenge prevailing practices".

Specifically, in each of the study sites, community leaders helped to purposively identify women of reproductive age (19-49 years) who were willing to be interviewed. Four women were chosen by the community leaders to be seed informants, two each from a nomadic and a semi-nomadic community. In the initial interviews, these women served as "ego", or the interviewee providing names of and information about people within their social circles; these social contacts who were named are referred to as "alters". Each ego listed individuals of importance to them. The five most influential alters were identified, and they, in turn, became secondary respondents (egos) in the following interviews. A total of 23 men and women were interviewed. The combined networks of primary and secondary respondents were used to create visual displays of the networks and were compared across study sites.

When asked about personal modern FP use, all four egos had heard of some modern methods. They said women in their communities either did not use modern FP or kept their modern FP use hidden. (Data show that just 2% of married women in Wajir and Mandera counties use modern FP methods, compared to 61% of married women in Kenya overall.) Modern FP was described as going against religious beliefs and God, who was ultimately in charge of spacing children.

While there was variation between the women's social networks, there was overlap in the role of the mother and husband across the networks. It is likely that mothers were decision makers in issues relating to pregnancy and childbirth before the women left home, but not necessarily in relation to modern FP. One ego said of her husband, "[H]e is the only one who I agree with. It is just him, because nobody else has the right over my body." While men and husbands were involved in RSH decisions such as whether to have another child, they may be less involved in day-to-day decisions (such as whether to visit a health facility).

With regard to perceived and tangible support of modern FP, none of the four women knew who within their social networks would support their use of modern FP. These perceptions were often incorrect, and influencers reported differently than their egos. Few patterns emerged by age or nomadic type; however, husbands in all three of the ego networks in which they appeared were unsupportive of its use. The researchers found evidence for a norm against modern FP that was both descriptive (that no one in the community uses modern medical FP) and injunctive (that women hide their use of modern FP, possibly to avoid negative social sanctions).

Female relatives and neighbours formed a large part of the network and provided support in areas related to reproductive health and FP (for example, advising on breastfeeding periods). Positive attitudes towards breastfeeding point to an opportunity for information and counselling around exclusive breastfeeding/lactational amenorrhoea method (LAM). The researchers advise that interventions (e.g., through small-group engagement) to increase awareness of modern FP should engage with women's wider networks.

The study also highlights the value of reaching out to individuals who are influential in RSH decision making, particularly husbands, who are are key in the decision-making process for women. In fact, studying men's networks could help target interventions. It may be advisable to attend to transitions in RSH influencers over the life course, with mothers influential before a woman marries and female peers and relatives more influential afterwards.

The researchers point to the fact that the extremely sensitive nature of discussing FP in these communities limited the questions they could ask. "Despite these [and other] limitations, the in-depth studies of these four pastoralist women allowed [researchers] to unpack their complex social networks and how these relate to modern FP. This study provides a useful guide for future research to explore how perceived support impacts uptake of modern FP, how social networks of pastoralists change with migration, and to further explore using social network methods amongst these populations, or similar groups."