Discussion
covert contraceptive, generalised, Covert contraceptive
NAIROBI
In the first evaluation of a clinic-based model to address RC and IPV within contraceptive counselling in an LMIC, this trial found evidence that ARCHES was implemented with relatively high fidelity by providers and increased contraceptive uptake at the appointment, covert contraceptive use, awareness of IPV services and decreased attitudes justifying RC over time as compared to standard contraceptive counselling among female patients seeking contraceptive services from private clinics in Nairobi, Kenya. We did not find an effect, however, of the intervention as compared to controls, in the change of contraceptive use overtime, contraceptive self-efficacy in the face of opposition, or attitudes justifying IPV overtime.Women receiving ARCHES were more likely to have received a contraceptive method at their service visit than those in the control group. Prior studies have shown that improved quality of family planning services can increase contraceptive useWe also found evidence that ARCHES marginally increased covert use of contraceptives at three-month follow-up, but this was not maintained at six-month follow-up. Unlike in the United States, we found no significant effect on self-efficacy to use a contraceptive method in the face of RC, including using covertly. Covert contraceptive use is an act of female resistance in the face of restrictive, patriarchal gender norms that prioritise male-decision-making on family planningLike findings from the evaluation in the United States,We also found that ARCHES reduced attitudes justifying RC over time as compared to those receiving standard of care, and that both the intervention and control group saw a significant decrease in attitudes justifying IPV. This similar decrease in attitudes justifying IPV, as well as comparable increases in self-efficacy to use contraceptives in the face of RC, may be explained by the survey acting as an intervention. Other studies have shown that simply asking the survey questions may cause a testing effect.This study has several limitations which highlight opportunities for further study. The evaluation was conducted among women visiting six private clinics in metropolitan Nairobi. Our sample is not representative of women seeking contraceptive care across Kenya or in public facilities in Nairobi, thus, results cannot be generalised. Future studies should consider testing the approach among a more representative population. Additionally, lack of randomisation and the small number of clusters created imbalanced groups at baseline. While this was adjusted for using IPTW and DiD, it is possible that unmeasured confounders remained. For example, it is possible that the effect on contraceptive uptake was the result of unmeasured confounding by the type of family planning service sought. Larger randomised controlled trials with additional possible confounder measurement are needed to clarify and confirm effects found in this study. Self-report data, particularly on violence and coercion, is subject to social desirability and testing biases which may have differed across groups based on the intervention. Furthermore, the intervention itself is limited to reaching only those women who have the privilege and access to seek contraceptive care. It is unknown if the main strategies of the intervention would have an impact outside of this setting, and, while this does not diminish the need for interventions to address the common experiences of violence and coercion in clinical settings, it does highlight the need for further adaptation of these intervention approaches in the community context to reach those most at need. Finally, the evaluated approach was resource-intensive, requiring a three-day provider training, which may not be sustainable at scale. Future work is needed to refine the approach into a scalable model and to re-test intervention effectiveness within a less resource-intensive approach. Additionally, cost-effectiveness studies are needed to clarify for policy makers the practical cost-benefit of the intervention. Despite these limitations, this study offers valuable learnings on proximal outcomes for interventions striving to improve women’s reproductive autonomy and address IPV within routine contraceptive care in Kenya and similar contexts and underscores pathways for future research.