Implants in untold places; Gulu’s family planning dilemma

Confined in a home, cut with a razar blade
Akumu would give a peek into her marital home. “My husband rides me on the bicycle to the health centre to deliver after which he takes me back home,” she narrates, misery patted on her face. “The moment I reach home, it is like I have entered a prison. He never allows me leave home, not for anything. He goes personally to the market to buy food, fetches water, brings children for immunisation and does everything so I do not leave home. He releases me only on Sundays.” Yes, release! And why?
“Because he knows Sunday is the only day there are no family planning services at the health centre. He is suspicious if I ever leave home on any other day, say, for shopping or children immunization, I will be given contraceptives.”

It is a poignant real life story. Yet perhaps worse is Susan Ayite’s*. She is a resident of Kalawinya village, Angagura sub County, Pader District. Kalawinya is in Pader, but close to the border of the two districts, Ayite and many others cross over to receive health services at Cwero Health Centre III in Gulu District.
Ayite bears a scar on her left arm. Having had two miscarriages and later succeeding to have six babies, Ayite sought to stop at that or at least have a temporary break until she was sure she needed another baby. “I opted for an implant,” Ayite recalls.

“It was put under my arm but because my husband was not happy with me taking birth controls, when he saw my hand, he used a razor blade to cut through my skin and removed it.”
The wound on Ayite’s arm has since healed but one cannot imagine the pain she underwent at the hands of her husband. And the physical pain he inflicted on her was not all. “He threatened to cut off my arm should he ever find anything like that (implant).”

10 children and still counting
Betty Atim* has come for immunisation of her 3-months old twins at Awoo Health Centre II. The twins are her fourth and fifth children in her second marital home. She divorced her first husband with whom she had five children. Atim is not sure 10 children will be all but it. “I do not know,” she says on whether March, the last time she was in labour would indeed be the last. “As long as I am still fertile,” she says, “I will conceive again; he wants children.”

According to Jacline Aceng, the midwife and maternity in-charge at Awoo Health Centre II, who assisted Atim deliver her latest – it is not possible to state for certainty the twins will be Atim’s last born babies. These are just a few of the many mothers facing tremendous obstacles in uptake of family planning services in Gulu.

Worrying fertility rate
In an interview with this newspaper late last year, Dr. Paul Onek, the Gulu District Health Officer observed that despite the relatively low income levels of the people in Gulu, fertility rate is worryingly high, at 7.4. The national statistics indicate that an average Ugandan woman produces seven children.
The curves showing the number of deliveries are steadily on the rise. At Cwero Health Centre III, there were 39 deliveries in October 2014, 44 in November, 35 in December and 40 in January 2015. Awoo Health Centre II had 17 in January 2015, 20 in February, 16 in March and 23 in April. “Mothers are giving birth uncontrollably,” remarks Aceng.

Aloo attributes high fertility rate mainly to resistance from men towards family planning services. “When I tell husbands to come with their wives for antennal where they can get family planning services and information, they do not come, yet the pregnancies belong to them,” she laments.

Encouraging men participation
The United Nations Population agency, UNFPA is funding programmes in the region to encourage male participation in reproductive health. Men are encouraged to come with their spouses for antennal services where they can receive family planning information and services, escort their wives to labour and be involved in their wives reproductive health thereafter. Grace Anena, the Senior Nursing Officer in charge of midwifes in Gulu District Health Office said men’s perception to reproductive health is changing particularly as regards to men accompanying their wives for antennal services and delivery but not as much concerning uptake of family planning services.

Tough choices
Meanwhile, midwives have devised means of helping mothers in the face of hard realities. Aceng explains, “We talk with a mother and ask her, ‘on which side of the bed does your husband normally sleep?’ If she says on the wall side, say, on the left, meaning the woman must lie on her right hand side facing her husband, then we put the implant on the side she lies on most while facing her husband. That way the husband may not notice since she will be laying on the implant. But then some husbands explore the bodies more, so what we do is put the implant between the buttocks because this is a part he is not likely to touch,” she says.

But won’t giving contraceptives, I inquire, without knowledge of husband be recipe for conflict in the home when by any chance he gets to know? “What do you do when faced with hard choices?” Aceng wonders.
“Sometimes a woman first discusses family planning options with her husband but then the husband refuses yet when it comes to maternal death; it is women who suffer, not men. The irony is when she dies, he gets another wife, if that one dies too, he gets another. That is why when a woman comes to me and she wants contraceptives, I first counsel her so she makes an informed choice, administer her preferred option and tell her she can always come to me for any help.”

Dr. Anthony Mbonye, the Commissioner Community Health at the Ministry of Health, under whose docket is reproductive health and health promotion, agrees. “If a man is resistant to family planning but when there is another option, the woman can go for it,” he says.
Mbonye also says there is neither a clinical nor ethical problem with midwives inserting implants inside the mothers’ buttocks. “Absolutely not,” he states. Mbonye stresses the importance of upholding women’s rights to sexual and reproductive health. “Women must have control over their bodies,” he stresses.
“They have got powers to determine the number of babies they can give birth to, over which they do not have to consult anybody.”

Must it be implants?
In the community where uptake of family planning services faces big obstacles especially with resistance from men, Anena says options like vasectomy, a surgical procedure for permanent men contraception, are at almost zero consumption level. And men opposed to birth control will definitely never opt for condoms, male or female condoms, the other readily available option.
And because of limited expertise and equipment at health centre IIs where majority of the people would easily access family planning services – Anena says 30 per cent of deliveries and family planning services in Gulu District are at Health Centre IIs, the rest (70 per cent) shared by Health Centre IIIs, IVs and hospitals – options like IUDs are not very much in use.

Implants, Anena says, are preferred by mothers because they are least associated with side effects such as dizziness and disruptions in menstrual cycle which mothers complained over injectables.
She adds implants help reduce the risk of cancer of the uterus or cervix cancer and are less inconveniencing in the sense that unlike pills for example which a mother is supposed to take each single day, something she can easily forget, use of implant is not a daily activity.
Maybe at 38 with 14 children it is too late for Akumu to have a pre-planned family but what about those who are younger with fewer or yet to have children? It is clear something is being done but much more should be done if communities such as these are to realise the dividends of planned parenthood.

*names changed to protect identity of individuals

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