Sheba had an abortion after she became pregnant outside of marriage at 24. Following the procedure, the staff at a Marie Stopes clinic in Uganda advised her to use contraception. She chose not to, although she doesn't want children yet. She has heard myths about contraception, and is afraid of the side effects. Instead, she and her boyfriend use something she calls "safe days", where they calculate the days in her menstrual cycle when she is least likely to become pregnant.
Gynecologist and obstetrician Dr Charles Kiggundu says that in Uganda Sheba's scepticism of contraception is not uncommon. "If anyone delivered an abnormal baby, the first question they would ask is 'have you been on contraception?' – trying to link abnormal babies to contraception. Or if someone for some reason failed to conceive, the first question is 'have you been on contraception?'"
In fact, according to centre manager at one of Marie Stopes's clinics in Kampala, Dorcus Tuhirirwe, belief that contraception may lead to infertility is so strong that most of the women who come to the clinics seeking family planning methods are married and have already made the decision not to have any more children.
According to the Uganda Demographic and Health Survey 2011, although knowledge of at least one contraceptive method is almost universal, the contraceptive prevalence rate is only 30 per cent. Modern methods account for 26 per cent and traditional methods, such as Sheba’s “safe days”, account for 4 per cent.
The survey also states that approximately one in three women have an unmet need for family planning – as they do not want more children either for the foreseeable future or on a long-term basis – but do not have access to any contraceptive methods. This equates to about 1.6 million women with an unmet need for contraception in Uganda.
Maries Stopes says the average number of children per woman is around six, but in rural areas the number of children can be significantly higher, although this figure has been decreasing in both urban and rural areas in recent years. Yet according to Tuhirirwe, this figure is two more children than women typically want.
In contrast, men generally want more children than their partners do. Tuhirirwe says that that mentality could stem from the fact that in Ugandan culture men “value children as wealth”, to the point where some men attempt to stop their partners from using contraception.
“You find that when women come for contraception they are looking for that contraceptive method that the husband won’t find out,” she says. “And we have had just a few incidences where men come and blame us for having given their wives contraception without their authorisation.”
Many women's desires to limit or space the number of children they have are also hampered by negative social connotations around contraception. According to Angela Akol, country director of the nonprofit human development organisationFHI360, which has a branch dedicated to contraception services, husbands believe a woman on contraception may be harder to control. "The biggest reason is they fear infidelity."
Despite this, public opinion is slowly turning. According to the head of Marie Stopes's contraceptive social marketing team, Henry Mulunda, "there's been great change. In the early 1990s when someone was seen with a condom they would be considered people who were really immoral". Now, he says, condoms are the most popular form of contraception. That change is also reflected in the Uganda Demographic and Health Survey, which reports the use of modern methods of family planning almost doubled from 2000 to 2011.
Yet, accessibility and affordability remain major issues, and the survey notes that contraceptive prevalence varies significantly depending on location and wealth bracket. As the urban capital, Kampala has the lowest unmet need at an estimated 16 per cent, compared to about 43 per cent in northern rural areas. 23 per cent of the wealthiest women have an unmet need for family planning, compared to 42 per cent of the poorest women.
However, Akol points out that statistics reflecting a high unmet need can also be interpreted positively, as they reflect a knowledge of contraception in the first place, and a subsequent desire for family planning.
Currently, the government sector is the major provider of contraceptive methods in Uganda, supplying almost half. Its target in the Health Sector Strategic and Investment Plan is to reduce the unmet need for family planning in Uganda to 20 per cent by the end of 2015.
Marie Stopes says its family planning counselling services contribute about 27 per cent of Uganda's contraceptive prevalence rate, and it aims to increase that figure to 35 per cent by the end of 2015. Regarding its work on family planning and contraception prevalence, Mulunda says the government is "strongly behind" Marie Stopes. Last year the president of Uganda, Yoweri Museveni, named Marie Stopes "Best Reproductive Health and Family Planning Organisation".
Similarly, within the last decade FHI360 has worked closely with the Ministry of Health to increase access to contraceptives across the country. Yet, Akol recalls that previously there was “a lot of resistance” from the leadership.
Kiggundu expresses a similar sentiment. “At one time in our history contraception was banned,” he says. He recalls that years ago it was possible to qualify from medical school without hearing about contraception. He says it has taken “a long struggle” to convince politicians and government that family planning will improve maternal health.
However, he says now there is “commitment and talk from the leaders” and that he and many others want to see contraceptive prevalence increase to 50 per cent by 2020. Noting the changes in recent years he acknowledges this target as simultaneously realistic and ambitious, calling the movement “a rebirth”, as both “a medical process, and as a social process”.
Second in a series of three. Monday: Menstruation in Uganda: From stigma to sanitary pads
* This article was supported by a grant from the Simon Cumbers Media Fund
