Evelyn Lirri

28 May 2011

Many women in Uganda currently have more children than they want. Low contraceptive use or the lack of access to it is a contributing factor. But the social and economic costs of not filling the family planning gap may be greater for the country, writes Evelyn Lirri.

Hellen Adupa has just given birth to her ninth child. But she’s only 30 years old. The primary school dropout, who lives in Agali village in Lira district, says she doesn’t want to have more children.

However, until now, she hasn’t been on any family planning method. After her sixth pregnancy, Ms Adupa and her husband, a peasant farmer, had decided against having more children. But since she didn’t have access to any birth control methods which she said had run out at the health facility, this resulted in three more babies.

Ms Adupa’s is a case of unintended or unplanned pregnancy, a scenario that plays out too commonly among Ugandan women and which demographers and health experts say is driving the country’s fast growing population.

“I know feeding them is already a big challenge for me. But I wanted maybe five or six children. But now I have nine,”she said resignedly.

“I’m now starting on family planning. The health workers have already counseled me on the different birth control methods,” she added.

Ms Adupa has been given Depo Provera, a contraceptive administered through injection. A health worker explained that it’s the most preferred form of birth control in this remote part of Lira in northern Uganda.

This is because women who use it usually do so even without seeking permission from their husbands, as most men don’t approve of family planning.

While Ms Adupa is lucky to find contraceptives this time round, not many are as fortunate.

Frequent stock-outs, long distances to health facilities and the high cost of some contraceptive methods, especially the long term options, make access prohibitive for many women.

Mr Geoffery Lapat, a senior clinical officer at the Reproductive Health Uganda (RHU) clinic in Lira says although most women now prefer the long-term birth control methods, their high costs are the biggest barrier.

“In many of the public facilities, women only get the short term methods like pills, yet majority of them say they would prefer the long term methods because of its convenience,” explained Mr Lapat.

At the RHU clinic, contraceptives like pills cost Shs500, while longer term contraceptives such as implants go for as high as Shs20,000 – a prohibitive cost for many women who largely depend on subsistence farming.

“For most women this is too high, given that majority are peasant farmers. Many would rather go home without contraceptives than spend as much as Shs20,000 just to get a birth control service,” he said.

With nine children, Ms Adupa already has more than the average number of children a typical Uganda woman has — seven.

Although women admit they want to space or stop producing more children than they already have, the lack of access to contraceptives, especially long term methods, limits then from doing so.

The result has been the high number of unwanted pregnancies and unintended births – at 1.5 million and 519,000 respectively – according to a position paper on family planning in Uganda published by RHU.

“Unintended pregnancies result in high abortions and maternal deaths,” said Prof. Augustus Nuwagaba, a development expert and author of the report by RHU.

One critical factor that influences family planning is contraceptive use.

With fewer women using contraceptives – at 23 percent – many will have unwanted pregnancies and population will grow rapidly.

Prof. Nuwagaba says unintended pregnancies and the high abortion rates could reduce drastically if all the unmet need for family planning, currently at 41 percent, was met.

According to him, the cost of not providing services to women to stop unplanned pregnancies far outweighs the additional investment that would be made in buying family planning commodities.

Explaining the net cost of investing in family planning, Prof. Nuwagaba said that for instance, the government spends about $268 million on managing unintended pregnancies in any financial year.

On the other hand, if up to 50 percent of this unmet need for family planning were met, the cost of managing unintended pregnancies would reduce to $105 million.

And if the entire unmet need was met, that figure would further drop to $32 million annually.

Lower maternal deaths

Besides the economic costs, if Ugandan women had half as many pregnancies, there would be only half as many maternal deaths and the likelihood of achieving Millennium Development Goals (MDGs) four and five, which directly relate to the health of mothers and children, would be within reach.

An estimated 435 Ugandan women die from pregnancy and delivery -related causes for every 100,000 live births. This translates to about 6,000 deaths annually, with induced abortion contributing a greater share of these deaths.

Although legally restricted and only allowed in cases where the pregnancy causes a grave risk to a mother, the high rate of unintended pregnancy has not prevented women from having abortions, which according to the Uganda Demographic and Health Survey contributes 16 percent of all maternal deaths.

A report by the US based Guttmacher Institute shows that addressing the unmet need for family planning in Uganda can potentially avert some 16,877 maternal deaths and more than 1.1 million child deaths by 2015. Besides maternal and child deaths, it could also avert up to 4.6 million unintended pregnancies that could have occurred between 2005 and 2015.

“The use of modern contraceptives enhances maternal and infant health by preventing high-risk births, such as those that are too closely spaced, those that occur among women younger than 18 or older than 35, and those that occur after a woman has already had many children,” notes the report.

The Guttmacher report further reveals that if women delayed their next birth or had fewer children, the rate of population growth would decline, increasing the potential to train, educate and meet the economic demands of the population.

Outgoing state minister for planning Fred Omach agrees that more investment in family planning is needed to avert these deaths, adding that despite government interventions, services have not reached all those who need them, especially in the rural areas

“Our reproductive health and family planning services remain mainly urban-based, yet the majority of our women are in rural areas where accessibility remains poor,” said Mr Omach.

Population boom

The cost of not meeting the huge family planning gap is already having an impact on the country, with population growing at an alarmingly higher rate than planners can handle.

Already at 33 million people and with a 3.2 percent population growth rate, the country is projected to have 60 million people by 2030 and eventually hit the 100 million mark in 2050.

Demographers say much of this bulge is directly the consequence of high fertility rates and an equally high unmet need for family planning services.

In fact a report just released by the United Nation names Uganda among the world’s “high fertility countries.”

Health experts say one underlying reason for the high fertility rate is the equally high teenage pregnancy where women start child bearing as early as 14 years.

As a result, at 25 percent, Uganda has one of the highest rates of teenage pregnancies on the continent.