Family Planning Inadequacy in Uganda

Uganda suffers insufficient Family Planning Services provision mainly in the rural communities which is 86% of the country’s population.
According to the Uganda Demographic and Health Survey 2006, Uganda’s maternal mortality rate stands at 435 per every 100,000 live births, most of which results from frequent unintended pregnancies. This is way above the United Nations' Millennium Development Goals target of 131 deaths per 100,000 live births to be achieved by 2015.

Low contraceptive use has been highlighted as one of the key factors contributing to high maternal mortality rates. Similarly, unsafe abortions which arise from unintended pregnancies also contribute to maternal deaths. Some of the reasons why Uganda has not done well on maternal health include a weak health system as well as inadequate human resources for health, especially reproductive health.

Reproductive health and family planning services still remain mainly urban-based, yet most women live in rural areas. This implies that the majority of women are not accessing quality reproductive health and family planning services, thus contributing to an increase in maternal deaths.
This is corroborated by recent statistics, which reveal that the number of women of reproductive age using contraception in Uganda is only 24 percent, thus contributing to an increase in the number of unwanted pregnancies.

As Uganda finds ways of promoting family planning, specialists are looking to promote natural methods of child spacing to boost the culture of more Ugandans having kids they can afford to look after.
This follows the release of research which shows that 58 percent of the women who go on several medical family
planning methods such as the pill or injections abandon them within a year due to several side effects.

William Nyombi, an official working with Uganda Health Marketing Group (UHMG) says the other methods like male or female condoms have also been met with challenges, since men many times do not want to use condoms.

Family planning methods currently used in Uganda are categorised in two types: Prescriptive methods which are hormonal contraceptives and includes oral contraceptives, both combined (COP), progesterone only pills (POP), levonorgestrel progesterone which are emergency contraceptive pills; injectables such as Depo Provera and Noristerat; implants such as Norplant;
intrauterine contraceptives which includes Copper T 380 A and Multiload; then permanent contraceptives such as tubal ligation and vasectomy.

Nyombi says UHMG is now looking at using more natural methods of family planning in order to encourage both men and women to plan for their families by producing kids they can ably look after. Nonprescriptive alternatives are natural family planning methods (fertility awareness) and are barrier methods such as condoms (both female and male), spermicidal foam and jelly, foaming tablets, diaphragms, lactational amenorrhea (breast feeding) and moon beads.

Moon beads, Nyombi said, offer a natural method of family planning with no side effects. A couple is given a string with beads of different colours indicating safe and unsafe days when a woman may or may not get pregnant. The method is 98% effective if properly used.

Nyombi says it only needs a couple to sit together and agree not to have live sex during the few days in a woman's menstrual cycle when she is
able to get pregnant.

Family planning is being looked at as the best solution to ensuring a better and healthier population in Uganda given that the country's population is growing at 3.4%, the second highest in the world, while the resources to cater for the population are constant.

Doctor Angela Akol of Family Health International says only 24% of sexually active women use family planning. A total of 44% want family planning services but cannot access them. As a result, there is a high rate of unwanted pregnancies.

However the journey of family planning is still a long one in many developing countries, where women do not have a choice but to give birth to as many children as their husbands want. The more children, the more labour for their farms. Even better, female children are seen as sources of wealth since they are sold off to men for bride wealth by the age of 12. Having many children is a pride to the father, and in rural communities having several wives proves that a man is wealthy.

John Okiror, 51, comes from one of the largest families in Uganda. His father, being a sub-county chief, was rich enough to marry as many women as he wanted. He married 24 women and had 64 children in total.

“Most of us did not go to school because there was no enough funds for education. None of the female children went far with education because my father married them off at an early age” said John, born in Amuria District of Eastern Uganda.

Despite the great wealth of children in the family compound, the deadly epidemic of HIV/AIDS could not spare them. John said only five of his father's 64 offspring are alive today. Most of his stepmothers also have died, and others divorced their father after realizing that he was HIV positive. John says they have numerous orphans whereby some struggle to survive independently.

“I have embraced Family Planning because I do not want to leave the legacy my father left. I have gone through a lot of hardships, struggles and massive challenges. At some point I was the breadwinner for my nine siblings. I have six children, and those are enough for me. I will educate them, train them to be responsible adults and live to see my grandchildren,” John said.

In Masindi, where John lives with his family, they have access to family planning services. John does not use condoms; he says they are for young men who are playing games with various girls and need protection from HIV/AIDS. He has never imagined using a condom with his wife.

Instead, they use Injectaplan, a contraceptive injected by a doctor every three months. John's wife used birth-control pills for a while but kept forgetting to take her daily dose, so they decided on Injectaplan.

Speaking on condom use Dr. Moses Muwonge, a reproductive health consultant says unlike other contraceptive, condoms remain the most popular and cheapest means used to check unwanted pregnancies and STDs/ HIV in Uganda, the Government imports about 20 million condoms every month. About 10 million are dispatched by the health ministry every month, Ugandans need over 220 million condoms annually, but only between 80-120 millions are imported.

On the other hand is the story of Adikin Topista, 38, wife of Tadeo Obango of Kisoko subcounty in Tororo district. The distance to and from the health centers that provide adequate services could not favour Adikin's quest for family planning services.

\"I have been struggling to get a family planning method for long in vain,\" she says.

Adikin was 13 when she had her first baby. Over the next 15 years, she became a mother of 10. Tired, she sought the help of herbalists in vain. She was pregnant again before her little one was barely two months.

Desperate, she went to Kisoko Health Centre II for contraceptives, but they had only pills. She could not take them because her husband did not approve of contraceptives. She was advised to use Depo Provera, an injectible contraceptive.

However, she discontinued the contraceptive after three months because of prolonged bleeding and frequent headaches. Now a mother of 11 and probably still counting, her only hope lies in a permanent method, tubal ligation, which her local facility cannot provide.

\"My husband was against it because he wanted to have more children,\" Adikin says.

She thinks the situation has improved because NGOs are educating locals about the benefits of family planning. But long-term contraceptives are rarely available in rural communities. \"You have to trek to Tororo Hospital, which is about 10km away,\" she said.

Many women in rural areas want to space or stop their births but have no access to family planning services, especially long-term methods that are favoured by many because they are \"discreet.\"

According to International Conference on Family Planning, in sub-Saharan Africa, there are 23 million couples who wish to limit their childbearing, and 12 million have an unmet need for family planning.

Every year, Uganda loses about 6,000 women as a result of pregnancy related complications. A significant proportion of these deaths occur because women are not able to have healthy, planned pregnancies. According to the Uganda Demographic and Health Survey, 41% of married women wish to space their pregnancies or want to stop childbearing altogether but are not using family planning methods.

A survey by Reproductive Health Uganda to assess reproductive health supplies -- particularly the availability of contraceptives in rural facilities -- confirmed that many women are at a crossroads.

“There are hardly any stocks of family planning drugs in rural health facilities. Even at the district health stores, officials do not know how much to order or do not order them in time. Districts do not have funds to transfer the requirements to rural health centres, leave alone the difficult means of transport and communication. They do not have the capacity, but the services are available,” says Kasule, a Medical Officer in Mukono Health Center.

Kasule’s remarks point to why wealthier women are more likely to use modern contraceptives than poorer women.

He says the disparities are more pronounced in countries with overall low contraceptive use such as Uganda, where contraceptive use may rise, but the poor will always lag behind until it becomes more acceptable and available.

“It’s the poor who are illiterate, holding onto myths and prejudices and cannot afford the service while the rich are exposed, easily embracing contraceptives and affording the service, leave alone the fact that it is readily available in urban areas,” he says.

The Resource Mobilisation Awareness Project (funded by the Bill and Melinda Gates Foundation) also recently organised a media survey to increase access to family planning supplies in upcountry health facilities in several districts in Uganda.

There is general shortage of contraceptives in most of the health centers mainly in the rural communities; the pills and condoms that are mostly available are not favorable to women since their husbands do not support family planning practices. Most of the women would secretly opt for Injectaplan (the three months injection for child spacing) and permanent method, tubal ligation.

Besides supplies shortages, there are other barriers to accessing birth control, including: myths and misconceptions about contraceptives; fear of using contraceptives because of side effects and myths like causing infertility, it is believed that Depo Provera as a family planning method causes delay in conception and excessive bleeding during menstruation; negative attitudes in some communities toward some modern family planning methods, the belief that the people in the ancient days did not use family planning and did not have problems; cultural beliefs that a man should have as many children as his fertility lasts; ignorance among some communities, high illiteracy levels; religious bias against family planning methods; lack of accessibility in remote villages; denial of accurate information by the victims; conservative beliefs about young people and sex; the communication gap between service providers and would-be clients that hinders counseling and decision-making on choice of contraceptive method; and women's inability to control their sexual and reproductive health choices, with the male partners determine contraceptive use and decide which method their partners should use.

It is on record that the government allocates funds for contraceptives, but only a small percentage (10%) of the allocation is actually disbursed annually. Martin Oteba, the Health Ministry’s acting Assistant Commissioner for health services in charge of pharmaceuticals, says family planning drugs are part of essential drugs, but only $600000 is allocated to contraceptives.

“We need ten times this amount,” Oteba says, noting that many times family planning services are invisible on the ground because of mis-prioritisation at the district level.

“We normally send the money to districts with tentative budgets, but the districts re-prioritise and family planning may not get the vote it deserves,” he says.

Critics also argue that family planning should get independent centers throughout the country that provide strictly Family Planning services.

Likewise in West Africa, although millions of dollars have poured in to support Family Planning, it is clear that progress is slow. The World Health Organization’s recent publication “Family Planning in Sub-Saharan Africa: Progress or Stagnation” shows that approval for family planning remains low in West Africa as does demand, particularly for limiting births. Although many people in West Africa report being unwilling or unready to use family planning, many are also uninformed about family planning methods and where to get contraceptives. Bridging the knowledge gap is critical.

If the government of Uganda and the policy makers do not effectively respond to Family Planning Services provision;

Over the next 15 years, the largest generation of young people will enter their reproductive stage, increasing the demand for contraceptives.

Without a balanced population growth, Uganda's economy and many of the goals outlined in the Millennium Development Goals could go backwards.

According to Population Secretariat, Uganda’s population is growing at a very fast rate. By 2025, our population is projected to reach 55 million from an estimate of 32.4 million people currently.

To effectively manage the population pressure and improve the health of women at child bearing age of Uganda and any other developing country, family planning should get independent Family Planning centers throughout the country that provide strictly Family Planning services.

This article is part of a writing assignment for Voices of Our Future, which is providing rigorous web 2.0 and new media training for 30 emerging women leaders. We are speaking out for social change from some of the most unheard regions of the world.