Understanding unmet need for contraception in Uganda : a mixed methods study of contraceptive use among women and men

Background Unmet need for contraception, defined as the percentage of women who are sexually active and want to avoid, space or limit pregnancies, but are not using a method of contraception, stands at 28.4% of all married women in Uganda. An understanding of women’s and men’s contraceptive behaviours, and the motivations that drive these, are key to tackling unmet need, by way of designing, implementing and improving family planning programs to effectively meet the needs of different population groups. This study sought to examine contraceptive use among women and men in Uganda, and identify strategies to strengthen contraceptive uptake in the Busoga region (chosen due to its low contraceptive prevalence of 31.3% and high unmet need of 36.5% among married women of reproductive age). The specific aims of the thesis were to analyse national data for population-level changes and predictors of contraceptive use among both women and men; understand the contextual and cultural enablers and barriers that affect contraceptive use among women in the Busoga region; explore in-depth men’s perspectives on male involvement and/or partner opposition to contraceptive use in this region; and provide recommendations to better engage women and men in family planning discussions and initiatives, in order to ultimately improve contraceptive uptake. Methods An explanatory sequential mixed methods approach was employed in this study. The first phase comprised of two separate but related quantitative studies. Data from five Uganda Demographic and Health surveys (DHS) were first analysed for changes in contraceptive use among women and men across the years 1995-2016. Data from the most recent 2016 DHS were then used to identify current predictors of contraceptive use among women and men. Informed by these findings, the qualitative phase comprised of focus group discussions (FGDs) with women and in-depth interviews with men in the Busoga region, to explore reasons for unmet need and low contraceptive uptake in this region, as well as to understand the drivers and challenges around contraceptive use. Results The analysis of Uganda DHS survey data across 21 years indicated an increase in contraceptive use over time, among both women and men. In 2016, 27.3% of women and 35.9% of men were using a modern method of contraception, an increase from 7.4% and 10.4%, respectively, in 1995. A steeper rate of increase in contraceptive use was also observed among certain sub- populations, such women who were less educated, those living in rural areas, and men; however, overall contraceptive uptake among these groups remained well below their more educated, urban, and female counterparts, respectively. Significant country-level predictors of contraceptive use among women included education, parity, marital status, wealth index, region of residence and distance to healthcare services. For men, education, number of children, wealth index, hearing about family planning through the media and discussions about family planning with a health worker were significantly associated with contraceptive use. Thematic analyses of data from FGDs with women and interviews with men highlighted the complex, multi-level nature of contributors to unmet need, and women’s and men’s use of contraception in the Busoga region. Within a largely patriarchal society, women had to navigate many obstacles; some of these included fears about contraceptive side effects; partner opposition, community beliefs and stigma that dissuaded contraceptive use, traditional gender and socio-cultural norms that dictated women’s fertility choices; service delivery limitations; and difficulties with contraceptive access due to unavailability, costs or distance. Among men, views on contraception were mixed. The majority of male respondents were opposed to contraceptive use because they wanted more children, or were fearful of or inconvenienced by contraceptive side effects that affected their partner. Most men were not in favour of the male contraceptive methods available to them; condom use was largely perceived to be for casual relationships outside one’s marriage, or as protection against sexually transmitted infections (STIs)/human immunodeficiency virus (HIV) infections, while the implications of vasectomy on men’s virility were too drastic for them to consider it a viable contraceptive option. Men’s views on family size and gender roles were largely shaped by patriarchal values of Ugandan society, which determined their own notions of male identity, masculinity and social status. These perspectives also influenced their views of women’s roles in a marriage, family and society, as well as their ideas around male involvement in family planning. Conclusions The results of this mixed methods study point to increases in contraceptive use in Uganda, particularly among men, and less educated, rural populations, which likely reflect the success of family planning programs and policy directives in recent years. Yet despite these successes, much work remains to be done in addressing multiple barriers to contraceptive use that still exist. The findings suggest that increasing male acceptance of contraception, rather than involvement, may be more effective in enabling women’s contraceptive use. Recognising the gender norms and patriarchal traditions that dictate contraceptive decisions and behaviours is important in efforts around promoting communication and joint decision-making around fertility choices and regulation among couples. Changing community narratives about family planning through testimonies from satisfied users may be effective in allaying some of the fears that remain associated with contraceptive use. Finally, improving family planning service delivery through increased provider training and better side effects management, as well as scaling up the community-based distribution model of service provision, could make contraceptives more accessible to women in Uganda.