POLICY AND MANAGEMENT CHALLENGES TO WOMEN’S REALISATION OF THE RIGHT TO SEXUAL &REPRODUCTIVE HEALTH  IN  POLYGYAMOUS MARRIAGES IN UGANDA

Ashah Mastullah
Posted October 20, 2020 from Uganda

POLICY AND MANAGEMENT CHALLENGES TO WOMEN’S REALISATION OF THE RIGHT TO SEXUAL &REPRODUCTIVE HEALTH  IN  POLYGYAMOUS MARRIAGES IN UGANDA

Mwanga Mastullah  Ashah

 

ABSTRACT

Polygamy remains one of the key topics in various societies. It is through cultural practices, beliefs and also on the individuals’ choices that people decide to be committed to polygamy lifestyles. Polygyny remains widespread across the world.  The study was conducted in Arua, Buikwe, Gomba, Jinja, Mayuge, Namayingo and Iganga districts of Uganda. The study investigated the policy challenges to the realization of the right to sexual and reproductive health of women in polygamous marriages in Uganda. The study employed a case study design where qualitative approaches were adopted. Data was collected using surveys, interviews and focus group discussion. Data was analysed using content thematic analysis. The findings revealed that  polygamous marriages are in violation of women’s rights suggesting a recommendation that polygamous marriages should not be considered a human right as long as it puts women’s universal human rights at risk. The analysis of the realization of   sexual reproductive rights in Uganda was based on family planning, HIV/Aids concerns, quality of maternal health care, battering, mental health, emotional stress. After an analysis of the findings, the researcher made quite a number of recommendations among which; decision and policy makers should consider prefacing laws prohibiting polygamy with the international legal obligations, as well as policy arguments, requiring states to modify such practices.

Key words:

Polygamy, Sexual reproductive health rights, realization, instruments

 

Introduction

Good sexual and reproductive health is a state of complete physical, mental and social well-being in all matters relating to the reproductive system. Reproductive rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health (Tamale, 2014). Sexual and reproductive health and rights is the concept of human rights applied to sexuality and reproduction (Amira, 2005). Reproductive rights, according to the ICPD, rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health (ICPD, 2015)." CEDAW (Article 16) guarantees women equal rights in deciding “freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights.” CEDAW (Article 10) also specifies that women’s right to education includes “access to specific educational information to help to ensure the health and well-being of families, including information and advice on family planning. The Platform for Action from the 1995 Beijing Conference on Women established that human rights include the right of women freely and without coercion, violence or discrimination, to have control over and make decisions concerning their own sexuality, including their own sexual and reproductive health.

The provision of reproductive, prenatal and postnatal health care services is a critical part of the right to health, comparable with the core obligations that are subject to immediate effect, rather than progressive realization under Article 12 of the ICESCR (Section 1.1). Reproductive health, therefore, implies that people are able to have a responsible, satisfying and safer sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so (Ekirikubinza, 2001).

Muhanguzi(1996) notes that the human right of women to control their fertility and sexuality free of coercion is guaranteed implicitly by the Women’s Convention. Women have the right to be fully informed of their options in health care, including likely benefits and potential adverse effects of proposed methods of treatment and available alternatives, including the option of refusing treatment (Ekirikubinza, 1999). Cultural and religious attitudes may value women according to their ability to produce children. Their health may consequently be jeopardized by repeated pregnancies spaced too closely together, often as the result of efforts to produce male children (Trowel, 2014). Women who have not borne children may be cast out of marriages on the assumption that they, rather than their male partners, are infertile. Women may be denied access to health care that is unrelated to their reproductive functions, and their health needs may be considered secondary to those of their children or, in the case of pregnant women to the health of their fetuses (Tamale, 2014). Women have been subjected to forced sterilization, forced virginity examinations, and forced abortion, female genital mutilation (FGM) and early marriage. Women are also often blamed for infertility, suffering ostracism and being subjected various human rights violations as a result women and girls are often unable to refuse sex or negotiate safe sex; they therefore face risks of contracting sexually transmitted diseases, including HIV/AIDS. Stereotypes of women’s sexuality underlie codes of chastity that circumscribe women’s freedom of movement and their participation in public life. Certain practices harmful to women’s health are related to discriminatory attitudes about women’s sexuality that deny them the right to a satisfying sex life (Tamale, 2014). These entail unnecessary interventions, such as female genital mutilation, forced virginity examinations and hymen repair (Nakayi, 2015). Women’s sexuality is frequently subordinated to the satisfaction of male needs, exposing them to risks of sexual abuse and violence (Fereni, 2011)  

Polygamy in Uganda’s Situation

Uganda has numerous laws that have been enacted to protect the rights of women and fight gender inequality. These include but are not limited to the Constitution of Uganda 1995. For example, Article 32 (2) provides that the “laws, cultures, customs and traditions which are against the dignity, welfare or interest of women or any other marginalized group or which undermines their status, are prohibited by this Constitution”; The Children’s Act (amended in 2016) under Chapter 59 puts into effect the Constitutional provisions on children and emphasises the protection of the child by upholding their rights; The Domestic Violence Act, 2010, is another gender-friendly piece of legislation in Uganda. The Ugandan defilement law within the Penal Code Act (originally from 1950 which Uganda inherited from British colonial rule), has gone through some changes, whereby the age of sexual consent was increased in 1990 from fourteen to eighteen years. The 1990 edition of the law is very clear in the sense that it is not only illegal for a man to have sexual intercourse with a girl regardless of consent under the age of eighteen years, but also punishable by death. Perhaps there is no clearer way of emphasising the law of male sex-right than through the practice of polygamy. As argued by Mayambala (1996), polygamy is against the spirit of equality between men and women because it allows one spouse (the husband) unilaterally to fundamentally change the quality of the couple family life.  Although civil law has banned polygamy in many nations, customary law  in many places still allows it. In many countries with multiple legal systems, the customary law on polygamy allows a man to take multiple wives and it prohibits a current wife from objecting to her husband’s marriage to a new woman. This practice treats women as lesser members of their families and as inferior in status to men. Polygamy forces women to live in poverty by forcing them to share resources. Polygamy also has a detrimental effect on children because when a man has more than one wife, he often has a large number of children in a short period of time. As has been shown, polygamy contributes to severe health conditions in women, thus making its ban necessary for public health purposes.

Rationale of the study

Whereas polygamy is illegal in church and civil marriages in Uganda, this is not the case in Mohammedan and customary marriages. Yet the extent of risk involving multiple marriage partners remains largely unknown. Although government has put policies to ensure safe childbirth, good health care for women and good family planning practices, there are still many cases of violations of women’s sexual and reproductive health rights in polygamous marriages. Every year, more than half a million women die in pregnancy or childbirth, and 99% of those cases are in developing countries (United Nations, 2016). WHO (2016) noted that 50% of polygynous women are less willing than their monogamous counterparts to use contraception. Women in polygamous marriages health is consequently jeopardized by repeated pregnancies spaced too closely together, often as the result of efforts to produce male children (Trowel, 2014). Women who have not borne children may be cast out of marriages on the assumption that they, rather than their male partners, are infertile. About 31% of the women in polygamous marriages in Uganda have been subjected to forced sterilization and forced abortion (UNICEF Report, 2017). The emphasis of this study is to investigate from the multitude of these risks, the sexual reproductive health rights especially of the female partners of polygamous marriages. The study concentrated on the Mohammedan marriages and cited less of the customary marriages given that most of the literature discussed more of the practice in Mohammedan marriages than customary marriages in the selected study areas. The study was limited to selected districts of Uganda that is  Mukono, Buikwe, Gomba Namayingo, Mayuge, Jinja, Iganga and Arua Districts.

 

Sexual reproductive health problems

  • Maternal morbidity
  • Maternal mortality
  • Birth complications
  • Anemia
  • HIV/STI
  • Infant mortality

 

 

Structural factors

  • Culture
  • Religion
  • Poverty
  • Gender
  • Legal and Policy issues

Analytical framework on Sexual and Reproductive Health Problems of Women in Polygamous Marriages

                                                 

 

Health seeking behavior

  • Perceived susceptibility
  • Perceived barriers
  • Perceived benefits
  • Perceived severity

Utilization of services

  • Family planning
  • Emergency obstetric care
  • HIV services
  • Sexuality counseling

 

Health care services

  • Accessibility
  • Availability
  • Affordability
  • Acceptability

Polygamous Marriages

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 1.1: Conceptual framework

 Source: Adopted from Literature review and modified by the researcher

Health promotion involves enabling individuals and communities to increase their control over the determinants of health, and thereby increase their health. Promoting sexual and reproductive health, calls for increasing availability, access and improved quality of the services. This will contribute to the adoption of safe sex practices in societies where social norms play a particularly strong significant role in shaping adolescents’ sexual behaviours.

Literature Review

Sexuality

According to the “Options for Sexual Health Handbook” (2008), sexuality is not just about sex, though people usually define sexuality in terms of genitals, what people do with them, and who they do it with. Sexuality involves and is shaped by many things including values and beliefs, attitudes, experiences, physical attributes, sexual characteristics and societal related issues. Human sexuality can be viewed from different perspectives according to different scholars (Tamale, 2013). In practice, people may not view sexuality from a single lense. Rival views of how sex matters in our pluralistic society often mean that there are few shared understandings, conventions or rules of engagement,” she says. “It is little wonder that there is so much pain arising from misunderstanding and so many disappointed expectations in the sexual realm today. Sexuality further is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles and relationships(Tamale, 2017). While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical, religious and spiritual factors (WHO, 1995). Thus, Deon (2011) reiterated that sexuality is what one does with another person sexually. Sexuality is driven by two perspectives in most African societies to influence sexual behaviour: personal agency and inevitability perspectives. The ideas are supplemented by Kaler (2014) who noted that in an inevitable perspective, sexuality is part and parcel of humanity. Indeed, many times people’s sexual behavior causes problems for them and pain for others. Much of this damage is neither malicious nor intentional. People often simply do not foresee consequences or understand the effect they are having on other sexuality and this may be the case in polygamous marriages in Uganda.

Sexual health

Health is a broad concept which can embody a huge range of meanings ranging from narrowly technical to the all-embracing moral and philosophical (Verstraelen-Gilhuis 2012). The word health has its roots in the word ‘heal’ which originally meant ‘whole,’ and the Greek ‘holos’ which also means ‘whole’(Hoad 1986). Thus, health considers the human in entirety as inner dialogue and a social being. Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled (Verstraelen-Gilhuis 2012).  The holistic perspective represented by Hoad (1986) describes health as a state in which the individual has a repertoire of necessary resources for healthy life. Nordenfeldt (2017) also pursues similar reasoning and describes good health as being related to the extent to which the individual can realise his/her vital goals under normal circumstances. In bridging the gap, sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.

Sexual rights

Sexual rights embrace human rights that are already recognized in national laws, international human rights documents and other consensus statements (Remo, 2015). Sexual rights include “the human right of women to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence” (Greli, 2016). They include the right of all persons, free of coercion, discrimination and violence, to the highest attainable standard of sexual health. This includes access to sexual and reproductive health care services, right to seek, receive and impart information related to sexuality, sexuality education, respect for bodily integrity, right to choose their partner and to decide to be sexually active or not, consensual sexual relations, consensual marriage, right to decide whether or not, and when, to have children and pursue a satisfying, safe and pleasurable sexual life (Dedan, 2014).

Reproductive rights

The inequity in reproductive health is also a compelling reason for international concern about social injustice. There is no area of health in which inequity is as striking as in reproductive (Gwajja, 2016). Dedan (2014) notes that  reproductive rights relate to an individual woman’s or man’s ability to control and make decisions about her or his life which will impact on her or his reproductive and sexual health. According to international consensus no new rights have been created (Health Systems, 2012). Reproductive rights are understood to be entitled to protection for their own sake, but also because they are essential as a precondition for the ability to exercise other rights without discrimination. Reproductive rights mean considering governmental obligations under the human rights documents in a whole new light (Gwajja, 2016). For example, consider the rights to education, health and social services in relation to all of the well-known causes of maternal mortality. A government which fails to provide education, health and social services to young women of reproductive age could well be found to be in violation of these rights now recognized as part of reproductive rights.

Reproductive Health

Reproductive health promotion encompasses behaviours essential for countering STIs including HIV/AIDS and unwanted or unplanned pregnancies (UNFPA, 2016). It encompasses many tasks performed in primary care such as provision of contraception, condoms and safer sex advice, psychological counseling and other aspects of mental health care; secondary care such as seeking treatment for STIs, and tertiary care to restore sexual activity (Curtis, 2015). SRH promotion also includes promotion of gender equality, SRH rights and empowerment in sexual matters. In adolescents, SRH promotion also recognises the role of families and communities besides the health facilities (Terez, 2014). Thus, SRH promotion has a social perspective which should challenge the social norms and values that undermine people’s autonomy to control over their SRH(Tones and Tilford, 2016). Sexual health promotion can prevent potentially unhealthy situations such as unwanted pregnancies, STIs, deviant (socially unacceptable) sexual behaviours and sexual abuse. It can also enhance individuals’ quality of life by improving self-esteem, communication and relationships with family, community and sexual partners all of which are crucial for health promotion. In this respect therefore, placing sexual health promotion within wider social, political and cultural contexts and aiming to eliminate the cultural constructions of sexuality that increase the risk of males or females to SRH problems through the elimination of the influences of homosociality, stigma or gender differences could be essential in an effort to promote sexual health. Such conceptualisations of sexual health promotion informed an understanding of reproductive health promotion programming in Uganda.

Legal provisions and their Practical Application pertaining to Sexual Reproductive Rights

Since reproductive health and rights issue has now been accepted as a global problem, thus there are a number of international instruments directly and indirectly protecting the reproductive rights of women (Pearson, 2006). The legal instruments are aimed at influencing the thinking of people for change and general re-orientation. International laws and treaties are the powerful tools that can direct government agencies, individuals and institutions towards influencing changes in their laws and practices (Guttmacher Institute, 2014). The objective of International law is to empower the protection of legitimate interests of persons. Government agencies would use the instrument to propagate social justice for its people. Reproductive rights are founded on a number of international agreements, including human rights instruments such as Bill of Rights, Convention on the Elimination of all forms of Discrimination Against Women (CEDAW), Convention on the Elimination of Racial Discrimination (CERD), African Charter on Human and Peoples Right (African Charter) 2004, Convention Against Torture (CAT), ICPD Declarations etc (Steiner, & Cates, 2006). All these International instruments make provision for the protection of women’s right, thus it is the duty of the government to protect their men and women from exploitation. One of the earliest international documents on family planning (the 1966 Declaration on Population by World Leaders) reflected the liberal tradition by defining family planning as a means of “assuring greater opportunity to each person” and of “freeing man to attain his individual dignity and reach his full potential” (United Nations 2004- 2005).  Article 10 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) recognises the assistance to be given to the family which is the natural and fundamental unit of society. Article 10(2) provides that special protection should be accorded to mothers during the period before and after childbirth. Unfortunately, Uganda entered a reservation on 10(2) indicating that the circumstances obtaining in Uganda do not render it necessary or expedient the imposition of obligation in this particular article. The African Women’s Protocol requires State Parties to ensure the right to health of women by promoting and respecting the right to choose method of contraception and to have family planning education (Article 14 (1) (c) and (f)). In essence therefore, under the international human rights framework, the government has an obligation to respect, protect, and fulfil human rights relevant to family planning. In the concluding observation of the committee mandated to monitor ICESCR in response to Uganda’s periodic report in 2008, Uganda was urged to consider removal of this reservation since it perpetuates violation of women’s rights. Not only do laws relating to women’s legal status reflect societal attitudes that will affect reproductive rights, but such laws often have a direct impact on women’s ability to exercise reproductive rights.

Mukasa (2009) contends that in CEDAW’s 30 Articles, the elimination of all forms of discrimination of women is authenticated. CEDAW sees the exclusion of women as having had an impairing or nullifying the recognition, enjoyment of women rights and fundamental freedom. It also denied them their contribution to political, economic, social, cultural, and civic life.  In CEDAW’s Article 2, all parties are required to commit themselves in ensuring that their respective governments comply with the regulations in eliminating all forms of discrimination in public and private institutions. This Article seeks to abolish all discriminatory laws, regulations, customs and practices. Similarly, CEDAW’s Article 4 authorizes the adoption of special measures that would create temporary inequality in favor of women.  The 1995 Beijing Declaration and Platform for Action aimed at removing all obstacles against women’s active participation in economic, social, civil and political decision-making (Mukasa 2009). The Beijing Declaration and Platform for Action (1995) sought to restore equality and development and peace for all women in the interest of all humanity. However, the focus of the scholars, only acknowledges the voices of women taking note of their diversity, roles and circumstances and yet the text is silent on the elevation of the status of women in some important respects in the past decade despite the fact that there are persisting inequalities between women and men. Therefore, international bodies should commit in ensuring that cultural practices that undermine women’s sexual rights should receive serious attention.

Luyimbazi (2016) noted that many Ugandans indulge in an indefinite multiplication of wives, while on the other hand, there are those who condemn polygamy as the most despicable practice.  Given the centrality of polygamy in shaping family life in the region, it is not surprising that the literature is replete with studies that have assessed its link with reproductive-related outcomes such as fertility and contraception (Mbugua, 2016). Unfortunately, the polygamy-child survival nexus has garnered less attention among the urban populace in Kampala. Although some work has been done on the link between polygamy and sexual reproductive health, prior empirical work has given little consideration to the possibility that the effects of polygamy may not be uniform in all societies. Extant research may not fully assess the effect of polygamy on survival if the interactional dynamics are ignored. It is the aim of this study to address these concerns and contribute to the limited available knowledge.

Methodology

The methodological approach to this study was qualitative in nature where an unstructured questionnaire and unstructured interview guide was adopted. The qualitative aspect not only investigated the “what”, “where” and “when”, but also the “why” and “how” of decision making. Following the decision on the appropriate methodology to use in this study based on the ontological and epistemological assumptions, the next step was to decide on the research design. The choice of research design was influenced largely by the methodology (whether quantitative or qualitative) as well as the philosophical assumptions guiding the research process (ontology and epistemology). The research design adopted was a case study that qualitative methods of research. In line with the research purpose and the unit of analysis in this study, the study population comprised of women and men and in both polygamous and monogamous marriages, religious leaders, local council executive committee members, University lecturers, Elders, community Liaison officers, health officers in hospitals/health centres, Police Officers in Charge of Family affairs, Probation Officers, Sub County chiefs, Sub County Chairpersons and Sub-County Community Development Officers. No controversy so far. A total of 232 respondents were selected for the study of which 142 were female and 90 male. This study employed multiple sampling techniques for specific groups of informants.  Simple random sampling was adopted in sampling the residents.  For Health Officials, and Community Development Officers, multi-stage sampling was done, which began with developing a sampling frame. Purposive sampling was used to sample lecturers and judicial officers. Data was sorted and analyzed using content thematic analysis.

 

Empirical Findings

In Uganda, 62 percent of women and 52 percent of men are in a marital union whereas 18 percent of the married women have co-wives and 9 percent of married men have more than one wife (DHS, 2017-18). The number of polygamous marriages had decreased from 21 percent in 2010 to 18 percent in 2016-17 for women and from 10 percent to 9 percent for men. Furthermore, older women show more likelihood of having co-wives than younger women and women in rural areas are almost twice as likely to be in polygamous marriages as those in urban areas(DHS, 2017-18). Educational indicators related to polygamy show that less educated and poor women are more likely to have co-wives. Similar to women, men with less education in low wealth income households show more likelihood of having more than one wife (DHS, 2015-16). Although, polygamy is recognized by the Law of Marriage Act (1971) as the union in which the husband may marry another woman or women (Section 9: 3), its impact on the right to health has come under question

A polygamous man in Buikwe revealed “Polygamy is violating women’s rights to health. I think individual rights and freedoms are more important (than rights belonging to specific groups.”

CEDAW (Article 16) guarantees women equal rights in deciding “freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights. Findings revealed that the right to health including reproductive health care is subject to progressive realisation. The Committee on Economic, Social and Cultural Rights and the Committee on the Elimination of Discrimination against Women (CEDAW) have both clearly indicated that women’s right to health includes their sexual and reproductive health.

Although, here have been numerous attempts to outlaw polygamy in Uganda, the first of which was in 1987, none of the active proposals have been passed. Polygamy was challenged in the Constitutional Court in a petition brought by MIFUMI in January 2010. According to Mifumi, it is hypocritical and unfair for the state to give men the go ahead to marry as many women as they want but bar women from taking more than one husband. However, our society is such that it is men that take wives so how would it be reconciled so that women would be allowed to take more than one husband?

Although many laws and policies have been drafted to outlaw polygamy, many have failed at the first stage. Current polygamy laws in Uganda apply to people differently because Uganda recognizes four types of marriage: customary, church and civil, Muslim, and Hindu. Section 12 of the Customary Marriages Registration Act and Section 2 of the Mohammedans Act validate polygamy. The Domestic Relations Bill was officially drafted in 1987 and the Domestic Relations Bill was reintroduced in 2008 after the President Museveni calling for the Domestic Relations Bill's "speedy passage". On March 29, 2005, over 1,000 Ugandan Muslims rallied against a proposed bill that would require a husband to seek permission from his first wife before marrying any more women.  The bill later died, and similar proposals have yet to be made (Bwogi, 2018). The marriage and Divorce Act provides that polygamous marriages, matrimonial property acquired by the husband and the first wife are owned in common by the husband and the first wife but all subsequent wives take interest only in the husband’s share of property.

More than 20% of married women in Uganda  are in polygamous relationships. Although studies have examined fertility desires and contraceptive use in such marriages, they have not taken into account differences that may exist among the co-wives in these unions. Relatedly a respondent noted “one co-wife may desire a future birth, but another may not; similarly, a husband may want to have another child, but only with a specific wife, this may be a form of violence to the rest of the women who may be feel sidelined” Tamale(2013) notes that polygyny constitutes an infringement of women’s right to reproductive health care. It is important to note that polygamy has never been categorized as one of the factors which affect the reproductive health status of women; it is hereby submitted that it is one of them. The environment in Uganda has not been sympathetic to the development of women because of the patriarchal nature of the society and the practice of polygamy is embedded in patriarchy.

  Uganda’s commitment

Sexual and reproductive health rights are among the most sensitive and controversial issues in international human rights law, but are also among the most important. These rights are guaranteed in various treaty documents and other instruments which clearly delineate government obligations to protect these rights. Implementation of these rights at the regional level is shaped by the socio- cultural beliefs and practices that determine the extent to which the rights are respected, protected and realised. A lawyer noted that “this beliefs either violate or protect individual’s rights.  Uganda’s commitment to address SRHR for women living with HIV is within the broad legal framework for addressing sexual and reproductive health rights founded on the principles of human dignity and equality provided for in the 1995 Uganda Constitution. SRHR for women living with HIV is a human rights issue in terms of the right to life (Article 22), liberty and security (Article 23); the right to health, respect for human dignity and protection from cruel, inhuman and degrading treatment or punishment (Article 24); the right to privacy of person (Article 27); the right to a fair hearing (Article 28); the right to education (Article 30); family rights (Article 31); the right to access information (Article 41); and the right to freedom from any harmful cultural practices (laws, customs, beliefs) that are against the dignity, welfare or interest of women or undermine their status (Article 33 (6). The Constitution provides for non-discrimination and equality for all, as well as protection and promotion of women’s rights (Articles 20, 26, 30, 31, 40 (b and c) and 50 (Republic of Uganda, 1995). Under the National Objectives and Directive Principles of State Policy, the Constitution commits the state to take all practical measures to ensure the provision of basic medical services to the population (Objective XX).

Reproductive and maternal health care/Fertility

Study findings revealed that the proportion of respondents who wanted to stop childbearing was higher in polygamous marriages than in monogamous unions, among both wives (54% vs. 46%) and husbands (61% vs. 39%). Similarly, both partners reported wanting to stop childbearing in 37% of polygamous husband-wife pairs, but in only 27% of monogamous pairs. None of these differences were significant, however, after adjustment for the older age and higher parity of polygamous respondents. Men and women in polygamous marriages were more likely than those in monogamous unions to think that their fertility preference matched that of their spouse; in reality, agreement in fertility desires was lower among polygamous couples than among monogamous ones. The prevalence of contraceptive use was lower among respondents in polygamous marriages than among those in monogamous marriages. Clandestine contraceptive use appeared to be greater in polygamous than in monogamous marriages; among husband-wife pairs in which the wife reported contraceptive use, 61% of monogamous husbands, but only 39% of polygamous husbands, also reported use. Women in polygamous marriages face many barriers in accessing family planning services: some common to all women, such as stock shortages and opposition from sexual partners, and some specific to women with disabilities, such as negative attitudes of health care personnel.   A respondent noted that “I was told by a medical officer to avoid birth control, stating erroneously that birth control would result in the birth of a child with a disability. As a result, I stopped taking birth control.

A respondent similarly opined that

 “low contraceptive use means that more and more African women are at risk of unwanted pregnancy and unsafe abortion. The lack of access to contraception diminishes decision making about sexual activities. In the developing world, women’s reasons for not using contraceptives commonly include concerns about possible side-effects, the belief that they are not at risk of getting pregnant, poor access to family planning, and their partners’ opposition to contraception.

Although findings revealed that the odds of contraceptive use were lower among couples in which only one spouse wanted to stop childbearing than among those in which both partners wanted to stop, the results did not differ substantially according to the sex of the partner who wanted to stop. However, the odds of use were reduced to a greater extent when polygamous women and men disagreed about continued childbearing than when monogamous partners disagreed. Among polygamous couples, monogamous couples or both, contraceptive use was negatively associated with age and positively associated with level of education and number of living children. If the husband had HIV, monogamous couples were more likely to practice contraception, whereas polygamous couples were less likely to do so.

Gibbin (2018) noted that continued gender inequality throughout Africa, particularly in more rural and traditional communities, has a significant effect on prevention of unwanted pregnancy and women’s access to family planning services and care. Women’s partners, spouses or other family members may discourage them from using contraception. In many communities, women cannot seek medical treatment without the permission of their husbands, mothers-in-law, or other family members, even when they may be experiencing severe complications. This practice often delays the woman’s access to care and can lead to serious complications or death, having unwanted children etc. Furthermore, women’s limited economic resources also contribute to delays in seeking services.

The findings suggest that although polygamous couples are at least as likely as monogamous couples to want to stop childbearing, “the translation of preferences into behaviour is less strong in these couples, leading to a lower use of contraception.” While the study was not designed to elucidate the reasons for this, the researcher speculate that the ability of women in polygamous marriages to share responsibilities (including child care) with their co-wives softens the impact of having an unplanned birth, and thus may reduce women’s motivation to practice contraception.

In general, women with infertility agreed that within polygamous households there are many tensions and disputes between the different parties involved: the husband, the co-wives and the children. While women commonly mentioned verbal conflicts, few admitted that they experienced physical violence from the co-wife or husband. Findings further established that there were many women with infertility issues mainly in Iganga who said they had a good relationship with their co-wives who respected and supported them with their daily household chores enabling them to engage in activities outside the compound. They also expressed that they had a good relationship with their husband. These women regularly referred to their faith and situated the practice of polygyny in a religious framework: ‘The prophet had four wives and we are following in his footsteps.

In polygamous marriages women within fertility were in a vulnerable position when their husband died. In Bugembe Jinja a predominantly moslem area,  local interpretation of Sharia law was often followed closely when it came to polygamy and fertility concerns. Moslem men are justified to take another woman if the first one is infertile, a respondent said. It was explained that men often referred to their religious right and duty to have multiple wives. When the woman with infertility was the first wife of the husband, it might be difficult for her to sustain the culturally expected position as the manager of the household. This is explained by the already weak position of the woman in the household resulting from fertility problems. Women within fertility talked about a negative self-image and stress in polygamous marriages: A respondent noted  ‘When I go to the compound I get sad and angry because of the attitude of my co-wife”. Making an agreement about polygamy before getting married remains difficult for women even when they are highly educated and have a secure job. Women with infertility described how in the broader society it is perceived to be normal for men to get a second wife when the first one is not able to have children or if there is no son who can continue the family lineage. Several women associated their husband’s decision to engage in a polygynous marriage with their fertility problems. In this study, three women with infertility encouraged their husband to take another wife. The first respondent said she wanted to have a co-wife so she would be able to share the responsibilities of the household and have more freedom to travel. The second woman wanted her husband to remarry since she was beaten severely due to her infertility and hoped this would decrease the pressure on her to become pregnant, but her husband never remarried. The last woman expressed how her husband supported her during her fertility problems and said that she hoped that having a co-wife would make her womb jealous. Several women with infertility in polygamous marriages were not informed about their husband’s decision to marry a second, third or fourth wife until the day of the marriage itself, which was an upsetting experience: A respondent noted that ‘my husband knows that more than me, sometimes he would marry them without letting me know. In most situations, the decision to engage in polygamy was made by the husband, sometimes under pressure of his family who also find it very important that their brother or son has children. These findings resonate with the view of anthropologists and feminist scholars stressing that culture and religion can be both a source of oppression and support for women (Tamale, 2017). Individuals are able to contest, change and conform to aspects of their culture and religion, resulting in diverse and sometimes contradictory experiences and discourses. Although, in general, polygamous marriages had a negative influence on the social, financial and emotional well-being of many women with infertility, the practice is not a topic of public debate. Most of the interviewed women with in-fertility thought it was unlikely that the practice would change and found infertility the major challenge in their life. They wanted to have more opportunities to empower themselves and better access to reproductive health care to prevent and cure infertility. A strength of this study is that, being a qualitative study, it delves into real life experiences showing the complexities of polygamous marriages from the perspective of women with infertility (sexuality challenges).

Polygamy and HIV/AIDS related Concerns

The Ugandan Constitution is doubtlessly a victory for women, in its explicit guarantees of nondiscrimination on the basis of gender, sex, pregnancy, marital status, the right to be free from both public and private violence,' and the right to bodily and psychological integrity. Yet, despite the triumph of equality at the constitutional level, marriage is often the site of women's legal, social, and sexual subordination, as well as vulnerability to domestic violence and HIV/AIDS, all of which are exacerbated by poverty. Although it is well-known that Uganda faces one of the fastest growing rates of HIV/ AIDS in the world, it is less widely known that women in Uganda are significantly more likely to be HIV-positive than men. Disclosure of one’s HIV status appeared to be a significant issue causing marital instabilities in polygamous marriages. The findings reveal that all the interviewed women had disclosed their HIV test results. A large proportion of the women (45%) disclosed to an adult family member; 37% disclosed to a parent; and 35% disclosed to a spouse. Other women disclosed to friends (23%), children (7%) and religious leaders . The majority of the women disclosed at will (77%) while the rest (23%) felt they were pressurized. Thirty six percent were pressured to disclose by health workers (36%), and family members (31%). Others were pressured to disclose by people living with HIV (12%), non-HIV people (7.2%), neighbours (2.7%), spouse (9%) and friends (5.4%). Disclosure was associated with abandonment, discrimination and stigma as illustrated in the following voice: Stigma is a major issue; they do not access health services, so they might not very well follow what you are telling them. Three women in polygamous marriages kept privy of their HIV status from husbands in some areas in Namayingo that is Dolwe sub county. They would breast feed babies to two years for fear of husbands knowing that they are HIV positive.  Two of them feared disclosing to their sexual partner because they fear that they will be abandoned or blamed for infecting their partners. So, there cited some bit of gender-based violence in their homes. She wants to use a condom and the other one does not want; so, in that process, they could fight at night. One wanted the husband to go for testing and he did not want, and they fight over it.

Polygamous women in Buikwe emphasized the fear of HIV/AIDS which has 'poured cold water' on the institution of marriage. In Iganga, the male and the female elders held the view that AIDS is discouraging polygamous marriages among young people. The male elders say that 'one who forgets marriage altogether is now better off'. Findings revealed that women living with HIV are sexually abused or coerced into unprotected sex when they try to insist on safe sex use. Women do not only face rejection and hostility from husbands but also from their relatives, especially the in-laws. In support a respondent pointed out that “Women living with HIV have also reported experience of abuse and ostracism from other community members”. Such hostility, blame and rejection is noted to cause sexual double standards and stigma which are sustained by women’s economic dependence on men for their own and their children’s well-being, especially in rural areas where women’s rights to land are often derived from husbands.

Further, it is unfortunate that women in polygamous marriages are being stigmatized by the society because it is scared of the disease. Although research so far has indicated that women are more affected by HIV/AIDS than men with an odds ratio of 1.4 times , it is not true that they are the only carriers of the virus. The stigmatization of women as 'virus carriers' by some focus groups is a relic of the traditional belief that any evil in the home was brought there by women, who are regarded in some of the societies as outsiders to the husband's extended family. In addition, there are disturbing reports of an 'I don't care' attitude, mostly among young men and women who may already be HIV-infected.

Findings revealed that despite the efforts of service providers, many women were unable to access HIV/AIDS information and treatment because of domestic violence. Women explained how they were afraid to discuss HIV/AIDS with husbands who were clearly unwell, how a fear of violence prevented them from openly attending HIV/AIDS sensitization programs, and how, despite feeling unwell themselves, they were unable to go for HIV testing or were too scared to pick up the results. A respondent found to be  HIV-positive in 2016  never revealed her HIV-positive status to her husband. She explained:

"I am married but I came alone. I never informed him. He said, 'if I know you're positive I'm going to kill you. 'We used to quarrel. He beat me. I never talked about it.

"Another respondent explained why she felt compelled to conceal her test results despite her husband's own HIV-positive status: "I got tested in 2017.  I went to get tested. I didn't tell him. The type of person he is scared me. I had no idea how to approach him. I was scared to tell him I was HIV-positive." Some women managed to attend HIV/AIDS clinics secretly or joined support groups without their husbands' knowledge.

This implies that if the man is HIV-negative and the woman is HIV-positive, chances are that the man will chase the woman away. It is surprising  seeing a high incidence of forced sex in discordant couples where the man tested HIV-positive. Men say that the woman cannot deny them sex. They ask how can you deny me sex when you are in my house. Despite their trepidation that their husbands were openly having sex with other women and infecting them, a fear of violence and abandonment compels many women to remain in a sexual relationship with polygamous unfaithful husbands. The presumption of consent to sex in marriage is contrary to international understanding of sexual rights and bodily autonomy. Both the International Conference on Population and Development (ICPD) Programme of Action 1 and the Beijing Platform for Action 2 reflect an international consensus recognizing the inalienable nature of sexual rights. Paragraph 96 of the Fourth World Conference on Women Platform for Action states, "The human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence." According to the Committee on Economic, Social and Cultural Rights (ESCR Committee), the right to health includes the right to control one's body and embraces sexual and reproductive freedom. International protections for the right of women to have autonomy over their sexuality can also be found in the principle of bodily integrity enumerated in the ICCPR that provides for the right to liberty and security of the person.

As distinct from women in discordant relationships whose husbands had tested HIV negative, women whose husbands had never been for testing, or had also tested HIV-positive, reported that they were experiencing violence because of their own HIV-positive status.

A respondent noted that

Women are battered and killed when husbands or boyfriends find out that they have AIDS." I lost a sister who was a young HIV-positive widow. She didn't tell her boyfriend. When he found out he strangled her." HIV-positive women whose husbands were also infected hid their status, explaining that they were fearful of being accused of adultery and being blamed for the illness.

Some women who are fearful of revealing their HIV-positive status to violent husbands will go ahead and breastfeed their children because either their husbands or female in-laws may notice. In an environment where breastfeeding is traditional, members of the community or relatives may interpret a mother's failure to breastfeed as an admission of her HIV-positive status. A 2001 report by the International AIDS Vaccine Initiative found that breastfeeding in Uganda remained prevalent among infected women "partly due to social stigma: formula feeding can be tantamount to a public declaration of HIV infection."

The reproductive health rights of women are not so much executed; they have been abused because of lack of knowledge. They do not have much information about their rights, and because of that, they are not being given the services in the context of their rights. This is again made worse by HIV. At times, people think that reproductive health rights are not an obligation for people who have HIV, maybe because they are already sick and for now do not have a clear future. All these challenges are associated with women’s low education levels and economic status.

Women with disabilities are particularly vulnerable to HIV infection, and especially unlikely to have access to antiretroviral drugs. All of the risk factors associated with HIV, already numerous in the post-conflict north, are compounded for women with disabilities: poverty, inability to negotiate safe sex, and increased risk of violence and rape. Women with disabilities are repeatedly abandoned by their partners, and each new partner brings a heightened risk of HIV infection. Two women with disabilities in Mbiiko Town in Bukwe who were raped said that they did not undergo HIV testing afterward because they were unable to reach a health clinic. In another case, hospital staff were uncooperative and told the rape victim to go to police instead. Under the CRPD, the government has an obligation to provide persons with disabilities with the same quality of health care and programs as others, including in the areas of sexual and reproductive health. Uganda’s domestic law guarantees fundamental rights to persons with disabilities. The constitution states that, “Persons with disabilities have a right to respect and human dignity, and the State and society shall take appropriate measures to ensure that they realize their full mental and physical potential.” Uganda also has several domestic statutes in place that prohibit discrimination and codify the rights of persons with disabilities.

A woman in Mayuge in a polygamous relationship who lost her legs in an accident in 2016 pointed out that

Given my condition, my husband treats me like a chattel whenever he comes back home, he carries me from where he has found me to the bed for sex. I have had a baby in the last one year yet doctors given to my condition advised me to wait and despite my pleas to use a condom he refused

International law does not weigh in on the question of recognition of marriage, allowing states to determine what constitutes a valid marriage according to domestic norms. At thesame time, the Convention on the Elimination of All Forms of Discrimination Against Women ("CEDAW" or "Convention") and the newly ratified Protocol to the African Charter on the Rights of Women in Africa ("African Protocol" or "Protocol") unambiguously require gender equality in both marriage and divorce. With respect to marriage, States Parties are obliged to ensure that men and women enjoy equal rights and are regarded as equal partners in marriage.  Appropriate legislative measures must guarantee the free and full consent of parties, as well as the minimum age of marriage to be eighteen years.

Aids Treatment and HIV Drugs accessibility in Polygamous Marriages

Challenges with inadequate quality of facilities and poor patient-provider communication were also raised. Participants’ preference for matched gender and older age for care providers that serve older patients were identified. Majority (34.5%) of the respondents indicated that condoms were accessible when needed and 70.1% revealed that circumcision services were available in the area of residence. Most respondents reported that they had access to TB drugs (40.5%), antiretroviral drugs (41.6%), lubricants (19.5%). About half (52.8%) of the respondents who had undertaken HIV test prior to this study reported that they got pretest and posttest counseling while 11.0% got only pretest counseling, 6.9% got only posttest counseling, and 3.6% had no counseling. A quarter of the respondents declined to answer the question on HIV treatment and drug access. The majority of the respondents who said they could visit any health facility for medical attention actually visited drug shops and private clinics instead of public hospitals and attributed this tendency to relatively better services offered provided the service had been paid for. Those who had visited public health facilities complained of what they termed unfriendly health staff.

A respondent noted

I had a health problem, an anal wart and then I went to a public health facility. After the nurse realized I was having gonorrhea, she called other nurses, laughing, to come and see, like a movie, like drama, Even in hospitals, a nurse told me to go for prayer otherwise I will go to hell, the nurses just gossip about us and you are on the line waiting we feel very bad. 

However in contrast a nurse noted “Some of them are hard-core. They don’t want to be told and even if you schedule them for follow-up clinic they will not come and will come later when they develop problems. Some even come when they have stopped taking medicine. Adherence to treatment is a big challenge for us”.

A respondent in Bugembe during interviews said that

 he did not attend public health facilities unless he has been referred to it, preferring to be discrete about their networks and activities. He reported being kept in long queues while other patients were being attended to including those who had arrived after them, as reported by one participant.

A woman said that her colleagues with HIV in polygamous marriage looked at social stigma as the second-most-serious barrier to accessing health facilities. They experienced social stigma from health workers in the public health facilities that some of them visited on referral.

Similarly, Muhanguzi(2009) points out that the he challenge is that these people are marginalized and they fear seeking health care in facilities because of stigma and the law because legally they are not accepted within society. But they find private facilities more friendly because the services are paid for. 

When asked whether they use condoms when involved in sex outside marriage, a respondent in Mbiiko noted for me I use condom on women I  have sex with outside the polygamous relationship but condom use reduces pleasure. Pleasure and money are more important so the risks of not using protection are an afterthought

The African Women’s Protocol addresses various manifestations of gender inequality, many of which are the root causes of the disproportionate spread of HIV among young women in Africa, such as sexual violence and early marriage, as well as factors that exacerbate the effects of HIV infection on the enjoyment of human rights, including the denial of inheritance. It has been hailed for its innovations beyond existing treaties, such as CEDAW.

Article 14 goes further than any other legally binding human rights treaty to protect the health and reproductive rights of women. This includes (d) the right to self-protection and to be protected against sexually transmitted infections, including HIV/AIDS; (e) the right to be informed on one’s health status and on the health status of one’s partner, particularly if affected with sexually-transmitted infections, including HIV/AIDS, in accordance with internationally-recognised standards and best practices.

 

Polygamous marriages and Mental Health 

Mental health problems resulting from polygamy can be more pervasive than meets the eye. Survivors themselves may not realise that their emotional problems are related to sexuality related issues. Women’s distress was exacerbated by the latent hostility and aggression between co-wives described by anthropologists, which includes use of terms denoting anxiety and jealousy and of snide remarks and threats; covert competitive strategies, secretly indulging a husband against whom they had collectively decided to ‘‘strike’’; and accusations of witchcraft and poisoning.

Polygamous marriages and Abortion

With the exception of the African Women’s Protocol, the right to safe abortion under the international human rights system has mainly evolved from interpretations provided by treaty-monitoring bodies. Findings further  indicate that the abortion rate in Africa is 29 abortions per 1 000 women of childbearing age. At 15 abortions per 1 000 women, the report shows that the Southern African region is the sub region with the lowest abortion rates in Africa. East Africa has the highest rate, at 38 abortion per 1 000 women, followed by Central Africa, at 36 abortions per 1 000 women, West Africa, at 28 abortions per 1 000 women, and North Africa, at 18 abortions per 1 000 women. The criminalisation of abortion impacts negatively on the sexual autonomy of women in Africa. The WHO Report (2017) reveals that highly-restrictive abortion laws are not associated with lower abortion rates. For example, the abortion rate is 29 per 1 000 women of childbearing age in Africa and 32 per 1 000 women in Latin America. These are regions in which abortion is highly restricted in the majority of countries. This contrasts with Western Europe, where abortion is liberalised in the majority of countries, but the abortion rate is only 12 per 1 000 women. The criminalisation of abortion also impacts on the health and lives of women. Highly-restrictive abortion laws are associated with significant levels of unsafe abortion-related mortality and morbidity. A local leader on the issue of abortion noted

 “A woman aged 40 years in a polygamous marriage was held at Mafubira police station for allegedly procuring an abortion died after she developed complications. The women was said to have terminated the pregnancy by swallowing some chemical. She was locked at the police station. Police said she developed complications while at the police station, was rushed to hospital and died en route.” The experts argued that if the police had immediately taken the woman to a health care professional, instead of holding her in remand at the police station, she could have survived”.

This incident “clearly demonstrates the impact of criminalisation of abortion on women’s health and lives”, said one of the experts. Legal obstacles to the provision of safe abortion services give women little choice but to resort to unsafe abortion when faced with an unintended pregnancy. Cook (2018) addresses the problem of unsafe abortion using a human rights framework that would reduce unsafe abortion and its harmful consequences for women and their families. The application of human rights to reduce unsafe abortion includes the right to be free from inhuman and degrading treatment, and the rights to equal protection of the law, to liberty and security of the person, to health, and to non-discrimination on grounds of sex and race.

Respondents in Jinja noted that ‘when I got pregnant after discovering that the man we were married to could not sustain three wives, I aborted under difficult conditions and almost lost my life”. I kept on aborting each pregnancy and never let my husband know about it. 

Women undergoing abortions performed under unsafe conditions are at greater risk of serious and life-threatening complications. Women who have had an induced abortion for an unintended pregnancy may have a repeat abortion unless they receive appropriate family planning counselling and services. There is need to increase awareness about use of contraceptive and make them available to reduce cases of unwanted pregnancy.

Quality of Maternal Health Care

Findings indicate that the quality of maternal health services in the study areas remains an issue of concern. The lack of basic supplies such as cotton wool, pads, gloves, syringes, surgical blades, material to wrap babies, anaesthesia, disinfectant, medicines, bed sheets, and blankets; dirty and unhygienic conditions; women forced to share beds or sleep on the floor; and the lack of food and hot water for bathing are some of the key quality issues that have been highlighted.  Shortage of staff, coupled with negative attitudes, lack of supervision. Many of the complaints relating to complications and deaths in health facilities were frequently due to negligence and malpractice, and the majority of these complications were related to obstetric cases.  Some of the complaints bring to the fore issues of professional responsibility to patients, including availability when needed and providing adequate information concerning the treatment procedure. Negligent actions by doctors and midwives in the context of delivery included: forgetting items such as surgical forceps or swabs in a patient’s abdomen; poorly managed labour resulting in a stillbirth or a mentally handicapped child; maternal morbidity such as obstetric fistula and maternal death. Witnesses also complained about long waiting periods and delays in getting attended to in health facilities, especially in hospitals. Sometimes this was occasioned by doctors or midwives on call refusing to come when summoned, or due to shortage of staff. A respondent gave an example “ of a woman who waited in the casualty department from 5am to 4pm before being admitted to the labour ward, and ended up having a stillbirth”.

Women in polygamous marriage noted that the high cost of hospital delivery, especially the fees charged at health centre, was a key hindrance to accessing skilled maternal health services. For example, the nurse-in-charge at Buphadengo health centre II noted that women who experienced life-threatening pregnancy complications that could not be handled at the centre often resist being referred to private Hospital because they cannot not afford. Findings during the inquiry indicated that the costs of delivery in public hospitals varied. In private facilities, fees for a normal delivery varied from 500,000 in some faith-based hospitals to 3,000,000 in for-profit hospitals.  A witness during the inquiry stated thus: ‘Many women deliver at home because they do not have enough money to go to the hospital’. Evidence from all regions suggested that the costs of delivery include ‘hidden costs’ such as costs of equipment, commodities, and select supplies that patients in public hospitals are required to purchase such as cotton wool, gloves, blades, bleach etc.

Culture and Quality of Maternal Health care

As Ekirikubinza (2006) noted that different communities have different cultural norms and practices regarding pregnancy and child birth which should be taken into account by health care providers while designing and delivering maternal health care services. Failure to take this into consideration has often meant that such communities would not utilise such services. Evidence indicated that some communities did not utilise skilled delivery services because they went against their cultural norms and practices. For instance, among some communities, it is a taboo for male nurses to attend to expectant women, while among the Basoga, a woman is not supposed to be seen naked by any male ‘stranger’ other than the spouse. The same practice was cited among the Muslims. A local councilor from Idudi noted thus:

“Among the Muslims, there is a belief that only female health care providers should attend to the women during delivery and even during pregnancy. This in essence makes it difficult  for men to allow their wives to deliver with the assistance of a professional, hence high prevalence of home deliveries”.

In General Recommendation 14 of the Committee on Economic, Social and Cultural Rights, the health care providers have a duty to give information and to seek informed consent for treatment and procedures. The government has the obligation to provide education and access to information concerning the main health problems in the community, including methods of preventing and controlling them.

Polygamy and Family Planning

The findings showed that the most popular method of family planning was the injection as reported by the majority of the participants, followed by implant and sterilization. While women living with HIV observed that there were multiple methods of family planning, they noted a number of challenges that limited their right to reproduction and family planning use. These challenges were mainly associated with refusal by spouse, gender-based factors and limited information provided by health workers in clinical settings. Sterilization is one of the permanent methods of family planning available to women who have had the number of children they desire or if there is a serious medical condition that requires a permanent method. It is normally a choice made by women and their partners and a consent form must be signed as evidence that the person has consented. However, the literature across the different countries in Africa reveals that a number of women in polygamous marriages are sterilized without their consent. Forced sterilization during childbirth was the most common form of violation that women living with HIV experienced. In such circumstances, women were under pain, and were taken to the theatre without being given an opportunity to make informed consent. They were neither given information about the procedure nor did they sign a consent form. Others were not given any opportunity to ask questions because of the language barrier (they could not speak or understand English which the doctors used).

Evidence from the case studies of women who had experienced forced and/or coerced sterilization, interviews and discussions with other women and men and key informants revealed a number of effects of forced/coerced sterilization on women and their families. These effects are attributed to their inability to give birth which is negatively perceived by the communities.

When asked about sterilization, a respondent  noted that

 sterilization affects sexual relations including reduced sexual desire, painful sexual intercourse and feeling weak. My sexual relationship is no longer the same; I am no longer happy. All the time we are quarrelling and at times I ask myself: do others feel the same?. I am not sexually active. It has affected me because my body is very weak.

Sterilization is very painful; therefore, it affects the sexual urge of a woman. As a result, she may deny her husband sex and this will lead to issues of domestic violence. (a woman noted). Sterilization makes some women lose their sexual desire for men, which in most cases leads to family breakdown. Some become weak and one cannot have children anymore. Sterilization affects women farmers because they will not be able to do farming as they used to since they have become weak. Once these fallopian tubes are cut, that means she has become disabled. There is no way she can be as strong as she was before. She won’t be able to take care of her family very well and she won’t be able to handle some chores at home, do any hard work. (a respondent noted). However, there were opposing views that sterilization has no financial and economic effects but rather gains for the family. While some women and men in the communities believed that sterilization has financial and economic effects on women’s lives. They argued that there are instead economic and financial gains after undergoing the sterilization. Most of the key informants took a medical view and argued that there are no effects referring to the process as simple and having nothing to do with body weakness and inability to work or productivity.

The intention to  use contraceptive among  women in polygamous marriages remains wanting.  It was found out in this study that the intention to  use contraceptives among  nonusers varies dramatically and it was revealed  from the  results.  The  variations might  be  partly  because  of the  population  size  but  most  importantly  are associated with the  difference in  individual and  neighbourhood characteristics.    One of  the individual  characteristics that have  been consistently related  to intention  to use contraceptive  among  nonusers was age (Solanke, 2017) and studies  have found  that maternal age remains crucial  and relevant  in the use of  contraceptive (Barbieri  & Hertrich  2002;  Ibisomi 2014; Hambissa, Sena,  Hiko, &  Merga, 2018; Saloojee &  Coovadia, 2015) .  This study also  shows that intention to use contraceptive varies with  age. The intention to use contraceptive among  women who were nonuser decreases  with increase in age, this was found in the study in the study areas of Arua, Buikwe, Iganga, Jinja, Namayingo and Mayuge. The findings suggested that for an increase in the  achievement  of family  planning  programmes in  these  countries the  need  to target  young  reproductive  women  is  an  important  strategy  to  be  adopted.    Marital  status  and  the  number  of  living  children  previously born alive  play a  crucial role as factors  in intention to  use contraceptive among  women who  yet to be  using contraceptive and studies have shown that parity  and marital status as some of the factors  responsible  for  contraceptive  use (Adam,  2015; Dasgupta,  2015). Women  in  some polygamous marriages a  union  have shown  no  intention  to use contraceptive  though they  were likely  to  use contraceptive.  Previous  studies  (Caldwell,2000; Bankole,2004;  Fadeyibi,  2013; Ogu,  Agholor,  & Okonofua,  2016)  generally  found  that more  children mean more income and none use of the contraceptive method in less developing countries such as Uganda.  Though this  study shows  that  women  who  had  more  than  three living  children have  the intention to use contraceptive, this might be  as a result of an  increase in the  cost  of  childbearing,  parent’s  psychological  benefits  of  having  few  successful  children  and  access  to family planning services.

Maternal education  remains a significant indicator for women to  intend to  use contraceptive  in Uganda. Previous  studies found  that  maternal  education  as a  significant tool  to  have  few children by encouraging more years  of schooling for females, and  also serve as a means for empowering  women  to  take  decisions  even  on  their  reproductive  health  (White  &  Speizer 2017). This  study  provides  results  and  information  supporting  previous  research  on  the  importance  of  increasing female education  (Larsson & Stanffors 2014; Abiodun, Usman, Olomide, Hamza, &  Adesina, 2016)  and  suggesting that increasing  women’s desire for  learning unlocks the  intention to use  contraceptives. This further  emphasis education  as an  ingredient  that  should  be incorporated  along  with providing  family planning  services and  support  for women  in  both  country.  However, an  effective  policy on  women’s education  will drive more intention to  use contraceptive  and complement family planning services and programmes.  This  policy  will  help  to  reduce  the  rate of unwanted  pregnancy,  unsafe abortion,  spousal domestic violence and increase women’ social status. Women  educational  status  provides  opportunities  for  women  to  be  employable  and  generally increase  their  social  status  (Larsson  &  Stanffors,  2014).    Employment  status  of  women  was  found  associated  with  intention  to  use  contraceptive  in  this  study.  Similarly,  studies  have  shown  that  professional, and career  women  tend to  negotiate for  time for childbearing  and were more likely  to use contraceptive  more  than  unemployed  or  non-career  women  (Sarah,  Blackstone  &  Uchenoma,  2017; Mondal, & Khatun, 2016; Wong, 2000). Intention to use a contraceptive is therefore, a function of women  seeking  for  an  opportunity  that  will  improve  her  social  status  and  alternative  for  forgone  of  childbearing. This  study, however, iterates  that educational status  though plays a  significantly  large role  in  driving  intention  of  women  to  use  a  contraceptive  but  not  sufficient  to  explain  the  variations  in women’s intention to use contraceptive without women‘s employment status as women in Mayuge, Arua and Namayingo noted.

Furthermore,  women  wealth  status  in  Uganda was  found  significantly  associated  with  intention  to  use  contraceptive while it was  insignificant to  explain variations  observed in  women’s intention  to use  contraceptive  in Uganda. Many  studies have  shown  that  wealth  status and  fertility rate were  likely  to have an  inverse relationship,  which suggested  that wealthy  women were likely to use contraceptive than women with poor social status  .  Similarly, this study  has  found that women intending to use contraceptives increase with women wealth status through a  different  result  was  obtained  Women  who  are  being  wealthier  have  relatively  very  low intention to use contraceptives; this might  be due to  the difference in cultural belief about the desire  for  children  irrespective  of  the  women’s  socioeconomic  status  within  the  neighbourhood. In  general,  the  relevancy  of  individual  characteristics  in  developing  family  planning  programmes will help in providing the needed services and information on sexual and reproductive health  for women of divers’ socio-demographic and economic characteristics.  Individuals cannot live  in isolation but  within a given  neighbourhood from which many  social and  health behaviour is  learnt and  modified. The importance of  socio characteristics  in explaining variations  in  sexual  and  reproductive  health  cannot  but  be  overemphasized.  This  study  found  that  characteristics  such  as  education  significantly  predict  the  patterns  and  variations of women intention  to use  contraceptives. In  a  with higher education  women  tends  to  pursue  education  and  become  a  career  oriented  individual.  Thus they are likely to  use  contraceptive more than women who resided in a with low education. Studies have shown that education  or literacy  level is  key in the  use of contraceptives. Intention to use contraceptive among women are  sometimes derived  from  health behaviour  learnt,  or  information  heard  from or  within the   and not  necessarily  determined  by  their  characteristics.  Thus the  need  to  ascertain  the  level  of  education  and  specific  level  of  awareness  of  family  planning  within  could  be  a  guide  for  designing  health policies for a different group of women concerning their level of education.   Access to a health facility with little or no distance or road challenges has  been found to  improve the use  of health facility  among women for their  sexual and reproductive  health needs. This study found that women intention to use contraceptive can be shifted from intention  to action  to use contraceptive where access to health  facility can be substituted for the excellent  road network  and  low cost of transportation.

A study has also found that proximity  of health  facility can help to determine  the level of health care utilisation for contraceptives especially in a route area where distance and cost of  transportation remains a barrier. Also, studies have found a significant association between  distance  to  health  facilities,  availability  of  health  facility  and  it  impacts  on  contraceptive utilisation  .  The  improvement on  family planning  in  the  area  of  service delivery regarding  door to door services  or mobile services  is yet to be  addressed. Women who  have  the intention to use  contraceptive have  higher chances  of using  contraceptives where  services are  delivered in a nearby health facility or where clinic were available. These  results in  this study harmonized  findings in previous studies  on  the need to address issues related to health facility equipment, proximity and health attitudes that  generally  affect  health-seeking  behaviour  most  importantly  among reproductive women.  Within neighbourhood  with the high-income level, it was found that women  in such  neighbourhood have the intention to use a contraceptive, this was more pronounced. In  relation  to  this  study  results , the importance of  the  results  in  this  study  has  reinforced  the  need  to  provide  free  family  planning  services  delivery  within  a  neighbourhood where  women of low socioeconomic status are residing. This will  not only  turn intention  to act on  the use  of  contraceptive devoid of  socioeconomic status  but  will also reduce  low coverage  of contraceptive usage emanating from unmet needs.  Studies  have shown  that sociocultural factors are  critical  in  understanding the  patterns of  contraceptive  use  and fertility  behaviours    

It was found  that individual characteristics such  as maternal age, marital status,  parity, maternal  education and  wealth status  could to  some extent statistically  explain  the  variations  in  women  intention to  use  contraceptive  . Despite this weakness, this study and other  previous studies  have emphasized the need to examine factors beyond individual characteristics and also suggested holistic approach  for  implementing  family  planning  programmes. 

Marital Rape in Polygamous marriages

When asked very specifically if their partners forced them to have sex, one in four (28%) of the women taking part affirmed that they were forced. It was also recorded that of those forced to have sex with their partners, 42% were forced sometimes, 38% once in a while, 9% often and 12% very often. Although an individual need only experience rape once to bear the full impact of it, these statistics indicate that some women are subjected to rape on a regular basis. Research indicates that the impacts of marital rape are profound and interconnected, leaving physical, emotional and economic scars which can be and often are long lasting. The myth that marital rape is less traumatic than stranger rape is clearly refuted by evidence that survivors suffer even more severe consequences than survivors of stranger rape. Such women suffer from “persistent terror” as they are forced to endure multiple offences whilst being exposed to a generalised environment of physical, emotional, economic and verbal abuse which renders them vulnerable to experiencing flashbacks, on-going nightmares and long-term sexual dysfunction.

According to Tasobya(2016), cases of marital rape are common but women rarely identify or reveal the cause of their physical injuries or psychological symptoms of such trauma. Often, only when a medical practitioner takes the initiative to delve deeper in order to tackle the root cause of a women’s health problems, will she divulge what may be happening to her. Even then she may merely say that “when he lies on me I just pray that he finishes and gets off.

The emphasis is on timely access, with a requirement that a woman who is eligible for abortion be guaranteed access to safe abortion services within a period of three working days. This period is intended to facilitate diagnostic procedures and non-directive counselling. The fact that a request for abortion on the ground of rape does not require corroboration is an important advancement in removing law as a barrier, avoiding secondary victimisation and securing substantive equality for women. Given the trauma of rape, it is not surprising that women who are denied access to abortion go to lengths to procure abortion, including having recourse to unsafe abortion. Article 14(2)(c) of the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (African Women’s Protocol) permits abortion on the ground of rape. Support for an enabling environment for access to safe abortion is also contained in soft law consensus documents, especially the African Women’s Plan of Action, which commits African governments to review laws that constitute barriers to safe abortion, and to offer abortion services to the full extent of the law. In the case of terminating pregnancy in accordance with sub-article (1)(a) of Article 551, the mere statement by the woman is adequate to prove that her pregnancy is the result of rape or incest. This provision on rape is clearly liberal.

 

A respondent, a twenty-seven-year-old, cried quietly when she narrated how her HIV-positive polygamous husband would force her to have unprotected sex with him and would beat her with his "special stick" (the handle of a hoe). She told us, he wanted to hit my head but I would hide under the bed so that he beat the other parts of the body.

A respondent noted My first husband forced me to have sex with him . When I was expecting and didn't want to have sex with him. When I was pregnant, I didn't feel like sex. He interpreted it as infidelity. He would first threaten, then use force. He would rape me and I would vomit. He finally realized it was a problem. It would be a woman's duty to have sex with her husband if you have struck a compromise. But the man shouldn't rape you.  None of the women interviewed complained to authorities about being raped. A respondent said that was just one such example: We never used a condom in marriage. They weren't very common. There were times he forced me to have sex. He would always do it if you refused. He would use force. There were times when he would want me to have sex with him even when I was on my period. Sometimes he forced me because he wanted to have forced sex. She suspected that he beat her co-wife and had forced sex with her too because of reports that she would receive from the neighbors. She was unable to get help from the local court because her husband was in the army and they were afraid of him. The worst occurrence was when his rape of her resulted in a miscarriage. The worst time? she asked.

A number of women in polygamous marriages were not even aware of their husband's HIV status. Most of the women in polygamous marriages interviewed noted that the brutal sexual violence that some women endured was within their own homes. Many of the women explained that their husbands often forced them to have unprotected sex in order to have children. Unable to dissuade their husbands from having extramarital affairs, these women became highly vulnerable to HIV infection. A respondent whose husband died of AIDS. She was the first of two wives. The respondent, who tested HIV-positive , started living with a man who was also HIV-positive. Despite her fear of reinfection, he forced her to have unprotected sex because he wanted to have a child. My boyfriend wanted me to have a child. I wanted to use condoms so we don't re-infect. I am now five months pregnant. You know when you are in the house you are in the house alone. He said nobody would hear me. He forced me to have sex with him. That's how I got pregnant. I wanted to separate because I started hating him. Their husbands' unremitting insistence on having children and their fear of violence drove some women to use undetectable contraceptive methods that nevertheless did not protect them from sexually transmitted diseases.

Conclusion

Polygamy is not expressly prohibited by any international instrument but is implicitly forbidden because it discriminates against women and violates their right to dignity.  Furthermore, polygamy as practiced in many jurisdictions, infringes additional human rights such as the right to privacy, the right to protection from violence and harmful traditional practices and the right to an adequate standard of living. Moreover, polygamy places women and girls at greater risk of contracting HIV/AIDS when their husband has multiple sexual partners, and they have less power to negotiate safe sex. It also risks excluding additional wives from asserting their marital and inheritance rights. In doing so, it is essential that states recognize parties may circumvent laws by consummating multiple marriages under different systems. For example, a husband may marry under the civil law system, then take a second wife through a Nikoh/Nikkah, or Muslim, ceremony. Laws should prohibit multiple marriages, as well as prohibit marriage under one system if the party is already married under another system. In other cases, a husband may be living in an unregistered union with multiple wives. Where no official marriage ceremony has taken place, drafters should consider adopting laws on common law marriage to hold polygynous husbands accountable. A common law marriage recognizes an informal union as a marriage although no formal civil ceremony or contract has been executed nor the marriage registered; such laws can be used to establish the existence of these de facto marriages.

The CEDAW Committee’s General Recommendation 29 reaffirms the goal of abolishing polygamy and makes clear that “, with regard to women in existing polygamous marriages, States parties should take the necessary measures to ensure the protection of their economic rights.” While prohibiting polygamous marriages is important to promoting women’s human rights, drafters should consider the negative consequences it may hold for additional wives.

Recommendations

The better way to protect the rights of the women in polygamous marriages would be by the enactment of laws which promote and protect their rights as proposed by article 6 of the Protocol on the Rights of Women in Africa. An example of a law which regulates rather than prohibits polygamy is the  Marriage Act of 2014.

The government should enact new laws or modify existing statutes in order to afford women greater equality before the law, protect women from violence, uphold women's sexual autonomy, and ultimately minimize women's vulnerability to HIV infection. The Domestic Relations Bill (Draft) and the Sexual Offences (Miscellaneous Amendments) Bill should be passed without delay. The government should enact domestic violence legislation that, at a minimum, provides for punitive measures to curb domestic violence, and addresses issues of enforcement and compensation. Customary law abuses should be addressed, and the government should support civil society's efforts to empower women at the rural level. Training in appropriate responses to domestic violence should be provided to police, court officials, and medical officers. The government should support nongovernmental organizations that provide shelters, legal aid, counseling, and medical care to female victims of domestic violence.

The protection of women's rights must be central to the HIV/AIDS strategies of government and international donors. The Ugandan government should respond to this challenge with all the courage and energy it showed in its initial response to the HIV/AIDS epidemic and support a countrywide response to domestic violence and women's vulnerability to HIV at the highest levels. The government should not use traditional practices or the sanctity of the family to ignore the plight of these women and to abdicate its responsibilities under national and international law. Other regional governments should identify and examine national parallels within their own legislation and/or HIV/AIDS national programming and implement comparable reforms.

 

There should provision of free access to reproductive health services. The national response to reproductive health concerns and HIV-AIDS needs to be continuously assessed, to provide all stakeholders with constant feedback on progress with implementation, by identifying actual or potential successes and problems so as to facilitate timely adjustments to implementation. The existing management information system needs to be made more effective by enhancing its capacity (human, technical and financial) with clear statements of measurable objectives in order to serve as an indispensable tool to assess and improve performance. Most countries, as parties to international human rights treaties, have recognized the fundamental rights of women and girls. These rights must be enshrined in national-level constitutions, which carry a force of law superior to other parliamentary and executive acts, and to customary and religious law. Finally, reproductive health contributes enormously to physical and psychological comfort and closeness and to personal and social maturation while poor reproductive health is frequently associated with disease, abuse, exploitation, unwanted pregnancy and even death. Ultimately, it is only a healthy population that can ensure a sustainable economic development in a stable democratic environment.

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Comments 4

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Jill Langhus
Oct 21
Oct 21

Hello Ashah,

How are you doing, dear? Thanks for sharing your detailed abstract on polygamy in Uganda. It seems this is a topic near, and dear, to your heart? Can you tell us if you did this for work, school, etc, and why it's so important to you, personally? I'm curious to know:-)

Nini Mappo
Oct 23
Oct 23

Hello Ashah,
This is indeed sad and problematic. Is reproductive and sexual health freedom only biased against women in polygamous marriages while those in monogamous union have better access to it? Just wondering about disparities is all. Yours is a heavy article, but we keep hoping for better days.

Hello, Ashah,

This is a great study you've written. Is this a thesis or a dissertation? Thank you for sharing this with us.

JacklineWolley
Nov 09
Nov 09

Great article Ashah. Keep it flowing.
I am a new writer here. Would be great if you can give me your comments as well 2.https://www.worldpulse.com/comment/257187?comment=257187#comment-257187
Thanks
Jackline