With 10 mouths to feed, no source of income and nowhere proper to sleep, Fatuma Hamed has many difficulties to contend with.
We find her and four of her children sitting by the doorstep of her house - a grass-thatched shelter with holes everywhere.
She looks lost in thought. She wonders what to buy with the Sh50 she got from selling vegetables: Whether to buy food for the daytime meal or spare the money for dinner.
On a good day, when she makes a sale, she can buy flour for her children's porridge, which is the most affordable meal for her. As long as the children are full, the nutritional value of whatever they eat is the least of her worries.
Most times she goes hungry, so that her children can eat. Other times there is not enough to go around, and the younger children eat as the older ones and their mother watch.
Worse still is that some of her children have to sleep in the mosque as their small structure cannot house them all.
Fatuma's life has been this way for as long as she can remember. A life of constant worry about whether her children will eat or have a decent place to sleep. She is the second wife in a family of four wives.
Give birth forever
Back-to-back pregnancies have also left her vulnerable, depleting her nutritional stores. This means she is never healthy enough to breastfeed her children whenever she gives birth.
With the family's resources spread thin, her children are unlikely to go to school, increasing their chances of being trapped in a cycle of poverty.
However, the hard life does not stop her from wanting to continue giving birth. "Children are a blessing from God and child spacing is a sin, going against the religion and Islamic culture," she tells HealthyNation at her home in Balich village, Garissa County. "I just want to continue giving birth even if it means having 20 children whether I can feed them or not. It is God who gives children. Allah provides for each child."
What Fatuma does not understand is that frequent pregnancies without spacing of the births take a substantial toll on a woman's health and the risks are more pronounced in counties like Garissa, where quality healthcare is inaccessible.
All her 10 children were born at home. She does not remember a day when she was not either carrying a baby in her womb or her arms as she gives birth after every two years.
Her younger ones, including her three-year-old lastborn, are occasionally put down by illnesses related to malnutrition.
Her husband believes the more the children you have, the more respected you are in the society. "Muslims who are using family planning methods are sinning," he says.
Ismael Omar is among religious leaders who preach against family planning. "The Koran allows us to marry as many women as we want, so that they can give birth to many children who will continue with our lineage," the father of 12 tells HealthyNation.
But, a wave of change is sweeping across Garissa and unlike Fatuma, women are choosing a different path. They want a better life for their families.
Quoting the Koran
Mubarak Hussein, the assistant chief of Dololo Midi village, says: "Somali women fail to use contraceptives because they think this is against their religion. I am happy that things are changing. Mothers and children of most families who space their children have good health."
Anneb Ibrahim, a 29-year-old from Ithin location, wants better. In the past 14 years of marriage, Anneb has given birth to only five children, a small number compared to what has been the norm for women from the region. She is grateful to a religious leader, who convinced her to consider spacing her children. Anneb does not want more children and is on injection contraception.
"When I informed my husband about the family planning methods, he did not object to them. He only wanted an assurance that I was safe," she says.
When she had her first injection, people were against it. They told her that modern contraceptives caused cancer. But, she went for the injection anyway. "I know it takes our men time to accept such things, but it is upon the woman to take a stand. Before the injection, I used to hide my pills and take them without his knowledge," she says. "Alikuwa ananikasirikia lakini mimi naficha na nakunywa (he used to get mad, but I would still take them)."
She said the Koran was not against child spacing. "In fact, I am in the (child spacing) programme with the Sheikh's wife," says Anneb, whose firstborn is in Class Seven.
Anneb is not alone. Twenty-five-year-old Fatuma Ibrahim has been on her three-year implant for one-and-a-half years.
This is not the first time the mother of three is using a contraceptive method. Soon after she gave birth to her first child, who is six years old now, she went for an injection. However, she developed complications and changed to the current method. "Men do not want us to use the drugs, but it is the woman and the child who suffer when a mother fails to space her children. All the births have been through Caesarean section. Child spacing has given me time to heal and take care of myself and my children as well," says Ibrahim.
Secret in the messaging
Through the efforts of the sheikhs, imams and administration officers, who hold barazas to highlight the importance of child spacing, there has been a difference.
Mohammed Khalif, a sheikh in the county, says Islam does not prohibit child spacing and it does not interfere with the women's health and fertility.
However, he says, the effective way to deliver the family planning messages is through religion and culture. Religious leaders are deeply trusted. "In the past, Muslims used Al-Azl, also known as withdrawal, as a family planning method. Others are breastfeeding for two years as a method," says the sheikh.
Initially, threats would be issued to the community on the health dangers of failure to plan families, which failed to work. "The health of the mother is paramount and family planning is only meant to space children and not terminate an individual's fertility. The mother is a factory. She will keep on giving you children, but if her health is in danger, the whole family is affected," he says.
He tells HealthyNation the change in messaging was why most women had accepted the Fountain of Hope Foundation.
Fountain of Hope, a six-month programme that seeks to discuss more post-partum family planning, said it has so far reached 423 people with its messages.
Abdirizak Adan, the project manager Fountain of Hope, says the plan was to address the unmet need of postpartum family planning or contraception use among Muslim women. "In Garissa, religion is pervasive on all matters of life, even managing family life. The challenge has been the myths and misconceptions. There is also the challenge of what is permitted; that is child spacing in Islam vis-a-vis the conventional family planning," Adan tells HealthyNation.
The county's maternal, newborn and reproductive health coordinator, Fatuma Maalim, said the county was winning the war.
As we celebrates World Contraceptive Day on Saturday, most countries, including Kenya, will be reflecting on some of the necessary measures to adopt to turn the bulging population into a socio-economic success.
For some women, challenges
Lathan Hawes does not have the luxury to choose the family planning method she wants.
She started using the Depo injection three years ago, but changed to a three-year implant. However, the unavailability and inaccessibility of the methods made her go back to the natural method of breastfeeding for two years to avoid pregnancy.
The only option the mother of nine has is to walk for hours to the nearest health facility for her preferred method, five hours to Garissa Referral hospital or stay without it.
"I learnt my lessons the hard way. I was giving birth every year, I did not have good health, my children were not as healthy as I would have wished them to be. My husband would not let me be. But, I made a choice. I want to take care of my body," she tells HealthyNation at her home in Doholo Sub-County, Garissa County.
Through the mobile clinic initiative, the mothers in the rural area get their preferred methods. However, these services are offered once in three months. "Before Covid-19, we would get the services on a monthly basis," she says.
She is hopeful that one day the county government will construct a health facility near her. "I have always given birth at home because of the distance. I am afraid that I might give birth on the road while going to the hospital," she says.
As Covid-19 takes up most of the health resources, people with other needs are struggling to get care and among the forgotten medical needs are reproductive health services.
Due to lockdowns in some countries, there has been a disruption in the importation of contraceptives into the country. As a result, in various health facilities, most of the methods are unavailable, especially the long-term ones.
Covid-19 impact on condoms
Population Reference Bureau Country Director Kenya and Regional Technical Advisor East and Southern Africa Angeline Siparo said if counties prioritised family planning, they could avert the loss of an additional 2,138 lives by 2020.
Kenya is already experiencing a shortage of many commodities since Covid-19 has impacted on the production of condoms and other contraceptives in the main manufacturing countries, including India, Indonesia, Malaysia and Thailand.
A mother told HealthyNation that most long-acting methods were not available at Garissa County Referral Hospital and many health facilities in the county.
Like Hawes, one in seven married women aged between 15 and 49, who need contraceptives to space or delay their next birth lack them, resulting in many unintended pregnancies, according to data from the Performance Monitoring and Accountability 2020, which monitors family planning indicators in 11 counties in Kenya.
The reason given for non-use of birth control among all women ranged from health-related concerns, opposition to use and lack of access.