A woman takes contraceptives.
Public health specialists are pushing for the adoption of autonomy in contraceptive use among women, which involves usage without interference from the husband or family.
Uganda, a country with deep-seated patriarchal views, has a track-record of men foiling contraceptive usage, with the Health ministry’s National Family Planning (FP) Advocacy Strategy and Costed Implementation Plan for 2020-2025 painting a grim picture.
“Although men are, to a large extent, involved in decisions on the use of FP (62 percent of married women made the decision to use contraception jointly with their husbands), the high unmet need for FP implies that men are similarly involved in deciding that their partners should not use, or should opt out of FP,” the ministry states.
“Moreover, 44 percent of married women, who were non-users of contraception, made the decision against using FP jointly with their husbands. The fact that 45 percent of all cases of contraceptive use were discontinued within the 12 months prior to the Uganda Demographic and Household Survey (UDHS) of 2016 equally points to the role of men in decisions to discontinue FP use,” it adds.
Health officials are now pushing for the country to go against the grain, saying this will address maternal deaths and the country’s stubbornly high fertility rate.
“They (women) don't need to depend on anybody—not on the husband, not on community members, but their self-determination because the use of family planning is a right,” Prof Peter Waiswa, a senior lecturer and researcher at the Makerere University’s School of Public Health, told Monitor in an interview.
Ms Fiona Bwogi, a midwife at Rakai Hospital, attends to babies at the Neonatal baby care unit in February, 2020. PHOTO / FILE
Prof Waiswa also pointed to the empowering effect of the push, with the net effect being women being able to “take charge of their lives, the number of children they want or even their sexual life.” It is something that Dr Dinah Amongin, a researcher and lecturer at the School, reinforces.
"She (a woman) can use it (contraceptive) without her partner knowing if she feels he's unsupportive. So that's the privacy, but the woman is in charge," she said in a separate interview.
Both Prof Waiswa and Dr Amongin contend that contraceptive autonomy would be essential in reducing high maternal deaths and addressing the economic effects of high fertility rates. This autonomy, the researchers further note, pulls this off through the reduction of rampant unplanned pregnancies, currently at 43 percent, and also taming reproduction coercion in communities.
It, however, remains to be seen what inroads can be made, with observers noting that since men tend to be the final decision-makers in households, few women tend to have control over their bodies in every sense of the description. For instance, some studies have shown that some men strongly believe that contraception encourages “infidelity and weakens their dominance over their wives.”
Mayuge, Oyam studies
That notwithstanding, Dr Amongin notes that self-care interventions such as the use of self-injectable contraceptives will allow for attaining this autonomy. She also reveals they have been doing studies to determine whether or not injectable contraceptive methods can, for one, put the “power in women's hands.”
“We found that even adolescents would love to use that method because it offers them privacy where they can use it without someone else knowing that they are using it. Even older women love the privacy it offers," she disclosed.
Studies have been conducted in the eastern district of Mayuge, as well as up north in Oyam to see how autonomy in contraception use works.
"We spent four years there, trying to understand which women benefit from injecting themselves,” Prof Waiswa revealed, adding: “We found that all women benefit from it, including young people. Young children in Uganda, whether we hide our heads in the sand or not, especially those 14 years and above are having sex and some of them are using contraceptives. And the contraceptive of choice they want is when they have the autonomy, when they can inject themselves.”
Maternal death link
According to the United Nations Population Fund (UNFPA), one reason for the persistently high maternal and newborn mortality rates is the lack of access to family planning.
“Family planning, through eliminating unintended pregnancies, reduces maternal and newborn mortality rates and improves the health and wellbeing of women and their existing children,” the UN agency states.
UNFPA also notes that women’s ability to make decisions on reproductive health, contraceptive use and sexual relations is pivotal to “gender equality and universal access to sexual and reproductive health and rights.”
Dr Amongin, on the other hand, says: “We know, as a country, that many women continue to die following unsafe abortions—abortions for pregnancies that they did not want.”
She added: “These abortions are highest among adolescents and also other women categories. So we would want to ensure we enhance access to contraceptives by making it easier for them to have it and putting the power in the hands of a woman to as much extent as we can.”
According to information from the Health ministry, around 18 percent of maternal deaths in the country happen among teenage mothers. Most of the pregnancies are unplanned. Some mothers that doctors have advised to delay or avoid conception because of underlying medical conditions are also failing to adhere and this increases death risks.
According to the 2022 Uganda Demographic and Health Survey (UDHS) report, the country has a maternal mortality rate of 189 per 100,000 live births. This is very high when compared to countries like the United Kingdom (UK) where only 10 women die out of 100,000 live births. The 2022 UDHS also reported a 38 percent prevalence of modern contraceptive use among married women aged 15 to 49, with a high total fertility rate of 5.2 children per woman. In the UK, the prevalence of contraceptive use is at around 76 percent, according to a 2021 report by UK researcher Abimbola Ayorinde.
A collection of different contraceptives available in Uganda. Some are more popular than others because they are easy to use with few reported side effects. PHOTOs by Racheal Mabala.
Reproduction coercion
This recommendation about autonomy, especially among (adult) women, is in line with current campaigns by UNFPA and other activists to address reproductive coercion (RC) and address barriers to access to contraceptives. RC is where a partner uses pregnancy or sabotage contraception to control a person.
The drive for autonomy comes at a time when there is an increasing push for rights-based initiatives favouring women's empowerment and challenging male dominance in family decision-making.
According to information from UNFPA and researchers, women who are coerced by their husbands to reproduce, or those who fail to agree with their husbands on reproduction goals, often resort to covert contraceptive use (CCU). CCU involves using methods without the knowledge of one’s partner.
A study conducted in Rakai by Craig Heck and Neema Nakyanjo indicates that CCU can result from "discordant fertility desires and/or intentions" between partners. CCU allows women to control, time, and prevent their pregnancies, at their discretion.
“Men may prefer larger families as they see it as recuperation of the paid bride price. Additionally, son preference (especially for a family/man that has not yet produced a male child or wants more male children) acts as a catalyst for pregnancy due to the cultural and patrilineal importance of males,” the researchers note.
The researchers also indicate that partner disapproval of contraception is a contributing factor to the practice of CCU. Some men, according to the researchers, have expressed that contraception “encouraged infidelity, weakened their dominance over their wife/partner, led to infertility, and thwarted their own fertility desires.”
Dangers of CCU
Dr Simon Kibira, another lecturer from the Department of Community Health and Behavioural Sciences at the Makerere University School of Public Health, and his colleagues, in another study, note that CCU can have negative impacts such as relationship/marriage breakup.
“Repercussions include increased suspicion, threats, or violence, though some women reported improved couple communication with disclosure,” the report reads.
CCU, the same study shows, can also result in the dissolution of a relationship or marriage after sparking violence. The researchers also note that the negative impact of CCU is often experienced when a woman starts getting the side effects of the medicines or when the husband discovers the secret use.
“While some women initiated using contraception covertly due to tensions within relationships or to keep peace within the home due to known partner opposition, others did not consider family planning to be a male responsibility,” the report reads.
“Although covert use was commonly discussed, it was also socially sanctioned, and portrayed as an act of female disobedience that questioned the social order of patriarchy,” the researchers further reveal.
Still in their findings, challenges of using contraceptives covertly included “lack of financial and social support, and suspicions surrounding delayed fertility and contraceptive-related side effects.”
