There are still women determined to reproduce and fill the earth

Justine Mukamusoni, 27, had been seated at the entrance but disappeared into the two-bedroom house at the sight of “uninvited” guests making way to her home. Besides, the group was led by the Village Health Team (VHT) member whose visits she dreads because of her constant calls for, among other things, adherence to family planning.
Five of her children, dressed in tattered dirty tattered clothes, are all over the place running up and down. There are two others seated on a stone next to the kitchen, crying because their elder brother, 13-year-old Allan, has eaten all the potatoes their mother had reserved for all of them.
The VHT member, Seforoza Iyakaremye, settles down on the Veranda calling out loud to Mukamusoni by name. “Come out and greet the visitors from Kampala,” Iyakaremye says, as if that would make a difference on whether she will come out or not. But a few minutes later, Mukamusoni comes out holding a mat which she lays down for us to sit.

The 27 year old with eight children Just when I was wondering how she manages to feed the seven children whose age difference you can hardly tell, Mukamusoni rushes back into the house and returns holding another baby, a two-week-old baby girl, her eighth child. She is visibly happy about her newest addition although she knows she has nothing to offer them in terms of a good life.
Mukamusoni and her husband both work in other people’s fields to earn a living. For food, the couple has half an acre of land near their home on which they grow potatoes and beans.
When the season allows, they sell the surplus harvest to raise fees for their 13-year-old first born in Primary Three, at a school near their home in Rukoro village Kyani Sub-county, Kisoro District. He is the only one going to school, although five of his siblings aged six to 12 are also of school-going age.
The family feeds on their produce of potatoes and beans for days, weeks and months, except on special occasions where they may buy meat or rice.
At 27, Mukamusoni has already had eight children. This can only mean that she started having children as early 18. She, however, tells us she had her first born at 16. She also admits to having had endless talk about family planning but she doesn’t see the reason she should go for it, justifying her stance with the Biblical order to “produce and multiply”.
“My husband and I plan to continue giving birth until God says we should stop. For now, we haven’t seen such a sign,” she says, proudly adding that her neighbour just had her eleventh child.
Iyakaremye, says she has educated several women and men in Rukono and three other villages. “Some women, with support from their men have actually understood what family planning is about and have taken up the service for different reasons ranging from economic to social reasons,” Iyakaremye says.
Others, however, are still skeptical about it even when it is evident that they have limited resources, and they are having children too frequently – putting their lives at an increased risk of maternal or child death.
If her attitude towards family planning does not change, Mukamusoni will likely have 14 children by the time she is 38 when the natural biological clock sets in.

In Namutumba, the women do not know any better
While Mukamusoni says she is fulfilling God’s commandment to fill the earth, other women like Florence Kagoya, a resident of Magada Sub-county in Namutumba District, simply lack family planning information, which is also shrouded in myths and misconceptions.
The 35-year-old mother of seven admits that while she has heard “good things” about family planning on radio, and the VHT, Julius Byantuya, she is adamant because she has also heard scary things about it. “My friend told me her relative got wounds on the uterus after she took an injection for family planning. Now I’m scared of taking the injection,” she says.
Her husband does not want anything to do with family planning either, of which he has only heard negative things.
In fact, he swears he will leave his wife if he finds out she is using family planning. “Women who take pills or injections for family planning bleed a lot and for a long time. This leaves men with no choice but to find other women for sexual pleasure,” explains Kagoya’s husband, who prefers not to be named.
Clearly, the fear of being abandoned by their husbands is another reason for women in rural areas to shun family planning.
According to Dr Zainab Akol, the Principal Medical Officer in charge of Family Planning in the Department of Reproductive Health at the Ministry of Health, the biggest challenge remains the inadequacy of quality information on contraception among the population.
“People are beginning to understand what family planning is about but the progress is still slow,” she explains.

Need for male involvement
Other challenges include the lack of male involvement and the absence of youth friendly services at health facilities. “Men need to appreciate that we are not trying to stop their women from having children but we are working hard to promote the quality of life of that woman by empowering her to avoid too many pregnancies too often as well as improve the quality of life for that child,” urges Akol.
Currently, only 300 health facilities are providing youth friendly services out of nearly 10,000 health facilities in the country. Dr Akol says this is a major hindrance because young women and girls don’t want to be seen getting certain services and yet without having facilities that take care of such special needs, the uptake will remain low.
She adds that side effects which come with some contraceptives especially the hormonal options are beyond the policy makers. “But science is not sleeping. Researchers are now focusing on more non-hormonal contraceptive solutions because we are aware that while many women would want to take family planning, the side effects have played a big role in discouraging them.”

Way forward
The need to scale up the service has led the key players to come up with a multi-sectoral plan with the Ministry of Health and Education taking lead. For instance, the secondary curriculum at the start of 2014 introduced and now addresses reproductive health issues from Senior One to Senior Four.
At health facility level, more health workers are being trained to offer the services while in rural areas and at village level, the ministry is using the VHT members to educate women but also offer the simple contraceptives such as condom distribution and pills.
In some cases, the VHTs have been trained to give injectable contraceptive – all in a bid to scale up the service as well as reduce the unmet need.

In Gulu, women are giving birth to replace lives lost

Filda Anicia arrives early in the morning at her office at Auma Lane in Gulu Municipality to plan for her organisation’s community activities. She works with Reproductive Health Uganda (RHU). Auma Lane is a former Internally Displaced Peoples’(IDP) camp. Gulu is one of central areas that bore the brunt of the Lord’s Resistance Army (LRA) two-decade conflict in northern Uganda. The guns might have gone silent in Gulu but the marks of the LRA war can still be traced in people’s way of life, including matters of reproductive health.
RHU provides family planning services, treatment of sexually transmitted infections (STIs) including HIV/Aids and fertility management, among other reproductive health services. Anicia believes post-war Gulu needs family planning. “The war caused devastating effects in this area which are still vivid in people’s mind but for us to move forward, we need our children in school and one cannot do that with a large family that he cannot even feed,” she says. “Not that we’re forcing it (family planning) on them,” adds Anicia, “But guiding them so they can make appropriate decisions.”
Dr Paul Onek, the Gulu District Health Officer, says despite the low incomes of the people in Gulu, the fertility rate is worryingly high, at 7.4. The national statistics indicate that an average Ugandan woman produces seven children which means women in Gulu produce more children than other Ugandan woman.
Dr Onek says 40 babies are born in Gulu District every day. But, as Anicia plans to take this same message to the communities beginning with this very area, she understands the opposition the message faces. “They say ‘the war killed us, our numbers were reduced so we need to produce and replace those who died’. This affects the uptake of family planning services,” she says. Anicia notes that there is particularly low male participation in family planning.
Dr Kenneth Cana, the In-charge of Awach Health Centre IV in Aswa Health Sub Region, Gulu, put the rate of male participation in family planning at 19.3 per cent meaning that only 19 out of 100 men get involved in using family planning services. With low male participation in family planning, uptake of such services is low for women because most women need consent from their husbands to use family planning services. If they do not do so, Dr Cana says conflicts in the homes are bound to rise.
It is cultural and religious beliefs mainly hindering reproductive health and family planning service reception, including the stigma especially on the part of young people. At Laro Health Centre III, a nurse says for fear of being stigmatised, teenagers followed her at night to her house to get contraceptive. They could not buy from open-place service providers. This happens amid high cases of teenage pregnancies. At Awach Health Centre IV, 436 deliveries were made in the year 2013/2014. Dr Cana says that of 436 deliveries, 32 per cent accounting for 140 deliveries were by mothers under the age of 18, the youngest at 15 years.
While the centre has registered considerable success in reducing maternal deaths, reporting only one case in the last five years, the challenges of handling such mothers are immense as Francis Okoya, the Senior Clinical Officer explains, “They come late for the first antennal care visit so they deliver before completing the fourth visit, which affects the delivery plan.” But that’s for those who have managed to come anyway. Many keep in their villages.

The way to reach the youth
Jackson Chekweko, the Executive Director of RHU, says the solution lies in reorienting services to target the young people. “It is girls who are married off young and have runway fathers,” he says. “They need confidentiality and trust. A young girl for example needs an assurance that nobody else will know when she girl confides in you.”
In April 2014, Gulu District Council made a declaration committing political leaders to reconcile and embrace, through their messages to the masses, family planning services. This came after it was observed that while one section of leaders went out to advocate for family planning services, another would speak against the same. Martin Ojara Mapenduzi, the Gulu District chairman while acknowledging that it is not easy to work in a post conflict area, says it is possible through partnerships to cause change including attitude towards family planning.
One best practice might be in establishing youth corners at health centres as one established at Patiko Health Centre III seems, slowly, to attract youths for reproductive health information. At the RHU Gulu Centre, Anicia, while conceding that the task is not light, is optimistic that their efforts might bear fruit. “Change does not happen instantly,” she says. “It is a process of learning. I am optimistic that people will gradually appreciate the importance of family planning. and make informed decisions.” Informed decisions are what teenagers in Aswa need and perhaps individual fathers too in this part of the country before each one of them equals Ayella’s 17th child mark.

I wanted three children but now I have six

Margaret Adong (right), a resident of Akwii village in Gulu District, walked 2km to Patiko Health Centre III to deliver her baby. At 30, Adong is nursing her sixth child. But what she has always wanted was to have three children. “My husband was against family planning, because he believed having a large family would extend his lineage. Besides, some of his relatives were killed during the LRA war, and children are a source of pride in our culture,” she says, adding, “After a visit to the RHU clinic, he has promised we can stop at six children. I hope he honours his promise.” Adong says she wants to stop because it is difficult for her to feed and educate them. The couples are now discussing which birth control method they will use.
Robinson Ayella, 50, a peasant in Keyo village with three wives, only sought family planning services after his 17th child was born. “I realised the trend I took was not good for me,” he confesses. Ayella, who went for a vasectomy, a permanent method of birth control where his tubes were cut making him unable to impregnate a woman, says it was fear and misconceptions that kept him away before. “I thought I would cease to function as a man if I got a vasectomy,” he says. “But I have found out that vasectomy doesn’t stop me from sleeping with my wife.”