Glorias Natukunda paced about the compound of Shuuku Health Centre IV in Sheema district trying to shush her one-year-old baby Asaf Kabagambe.
It is hot; her son is agitated by the heat, Natukunda is angry.
“What has happened to the hospital? I have been here since 11am and it is locked. Where are all the doctors?” she asks one of the cleaners. It is now 2pm.
Natukunda, 27, has come to get a family planning method – Implanon – because she wants to stop having children. She feels her seven children are enough. And anyone in her situation would be tired; her oldest child is nine years old, and the youngest is one-year-old Kabagambe. A cleaner tells Natukunda that all doctors have gone to court to give evidence in a case about a missing solar panel.
Shuuku health centre is new and fairly well-equipped, but does not have patients because it does not have health workers. One of the few staff here says the health centre had even more medicine and equipment but they were taken to other health centres because there was no one to administer them and they would often expire.
On hearing this, Natukunda says she will get Depo Provera, an injectable contraceptive, at a private clinic until she can find a long-term method she can hide from her husband. More women prefer the secret method because their husbands do not want them to use family planning as they prefer larger families.
Therein lies one of the contributing factors to the unmet need for family planning in Uganda; up to 45 per cent of women who want to use contraceptives do not get them because they are not affordable, accessible, or there are no skilled attendants to provide them.
Across the country, in the eastern Uganda village of Isikilo, Iganga district, 39-year-old Nuru Biliwali says she has been waiting for tubal ligations for years – in vain.
“Every time the doctors said they would come, they would not come,” says Biliwali, who now has 13 children.
Of the 52 health units in Iganga, there are only two health centre IVs and one hospital, where she can get a tubal ligation. Yet these are miles away. The women in this Busoga sub-region have an average of seven children; the national fertility rate stands at 6.2 children per woman.
The 20ll Uganda Demographic and Health Survey preliminary report says that usage of modern contraceptives has improved from eight per cent in 1995 to nearly one in three women today. Contraception use among women currently in union increases steadily with age and peaks at 38 per cent among women aged 35-44.
No mandate for lower HCs for long-term methods
Natukunda and Biliwali join thousands of women in Uganda who cannot access their choice of family planning method when they need it. This is because it is not available and oftentimes they don’t know that HC IIs or IIIs do not provide long-term methods – methods like Implanon, IUDs, vasectomy and tubal ligation which require skills of a medical doctor or clinical officer.
Dr Moses Muwonge, the Reproductive Health Commodity Security Consultant, says because of this, when sending family planning kits, National Medical Stores does not send long-term methods to lower health centres. So, women like Biliwali will have to wait for midwives to be trained to provide them since the policy shift is now advocating for midwives to give these long-term methods.
Ruth Namusaabi, a medical officer at Iganga district Health office, says the district has no money to give comprehensive training yet the available few trained workers leave for better-paying jobs. As the ministry tries to combat this problem, another one lingers in the background: ignorance of the right information on family planning and its importance.
It is no doubt that Ugandans know about family planning; DHS reports show that 90% of women know that family planning exists – but not much more.
Knowledge gaps and myths
Twenty-four-year-old Fatuma Namukose, from Iwawu village in Iganga district, fits the above statistic. She started having children at 15. Her husband wanted children. After her sixth child, she started seeking information.
“I have never used family planning because they told us it has bad side effects on women. I heard that a woman’s fallopian tubes were affected by the pills,” Namukose says.
Sawura Namayanja, a resident of Nankoma in Bugiri district, knows about family planning but chose to have 13 children. Namayanja was married off at 15 years and immediately started giving birth.
“My husband is an only child and he wanted me to give birth to many children to expand his clan. When you have children here, you are respected. When you die, you have many children to mourn your death and bury you because every child brings something,” Namayanja says.
Rural Uganda is awash with cases like Namayanja’s; girls drop out of school and are married off at a tender age, sometimes as young as 13. Baker Kasadha, the district education officer for Iganga, says the biggest cause of this is poverty. Most families do not even have what to eat and girls become a source of income.
“I have heard of stories of mothers who send their daughters to look for ‘sugar’. When they go out, they become pregnant and that marks the end of school,” Kasadha says.
The boys drop out and go into petty trade, bricklaying, mining sand and roasting chicken in the trading centres. They then marry their age mates and start a family. Some Muslim families also marry off their girls at an early age. Kasadha says his office has rescued a 13-year-old girl, who was married off to a rich man as his fourth wife.
“Ideally, when girls stay in school and complete, they delay giving birth, they get gainful employment and have wonderful families. We cannot have equal rights where women decide for their bodies when people don’t have skills,” Kasadha says.
The DHS preliminary report states that more urban women (39%) use contraceptives than rural areas (23%), with Kampala having the highest at 48 percent and Karamoja is lowest at 8%. The use of contraception increases with rising levels of education; 44% of currently married women with secondary or more education are using a contraceptive method compared to 18% of those with no education.
In general, women do not begin to use contraception until they have had at least one child. Only about one-third of married women with three or more children are currently using a method of contraception. Namusaabi says many women, especially upcountry, do not appreciate the full impact of having many children.
“Many men, especially Muslims and Catholics, do not believe in family planning. They do not want their women to use family planning and tell them ‘if you don’t want to have children, leave my house’. When you talk to them, they say ‘it’s a women’s issue’,” Namusaabi says.
In Mutanoga village, Kigarama sub-county, Sheema district, Ben Mugisha, who is a member of the village health team, says that while these problems persist, VHTs have helped to improve attitude.
“A home is made up of two people. For a woman to become pregnant, a man must participate. When I talk to men, they become interested because they know me. When we come in as the men, the woman can tell you ‘convince my husband to allow me to use family planning’,” Mugisha says.
The Lancet family planning series, in a paper authored by Melinda Gates and others, states that the health benefits of family planning would include nearly 600,000 fewer newborn deaths and 79,000 fewer maternal deaths every year. The paper, titled ‘Giving women the power to plan their families’ states that unintended pregnancies would drop by two-thirds, resulting in 21 million fewer unplanned births and 26 million fewer induced abortions.
Beyond health, at the household level, families are able to invest more of their scarce resources in the health and education of their children. Girls from smaller families are more likely to complete their education and women with fewer children are more able to seek employment, increasing household income and assets.
Falling birth rates also bring the potential for a “demographic dividend”, by increasing the ratio of working adults to dependants.