Understanding the contextual and cultural influences on women's modern contraceptive use in East Uganda: A qualitative study.

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 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 qualitative study sought to understand women's contraceptive use and identify strategies to strengthen contraceptive uptake among women in the Busoga region of east Uganda (chosen due to its low contraceptive prevalence of 31.3% and high unmet need of 36.5% among married women of reproductive age). Six focus group discussions were conducted with single and married women across different age groups (18-24, 25-34, and ≥ 35 years), living in three urban and three rural districts. Thematic analyses of the data highlighted three major themes pertaining to the complex, multi-level nature of contributors to unmet need and women'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; and service delivery limitations. Changing community narratives about family planning through testimonies from satisfied users, increasing male acceptance of contraception, and encouraging joint-decision making on matters of reproductive health are strategic focal areas for family planning initiatives to effectively tackle the problem of unmet need among women, and make contraceptives more accessible to women in Uganda.

Predictors of modern contraceptive use among women and men in Uganda: a population-level analysis.

OBJECTIVES: Despite substantial and rapid improvements in contraceptive uptake in Uganda, many women continue to have unmet need for contraception. As factors affecting contraceptive use are dynamic and complex, this study seeks to identify current predictors and provide effect size estimates of contraceptive use among women and men in Uganda. STUDY DESIGN: A nationally representative cross-sectional population survey, using secondary data from Uganda's 2016 Demographic and Health Survey. Stratified by sex, weighted bivariable and multivariable logistic regression models were derived from a suite of potential predictor variables. Predictive abilities were assessed via 10-fold cross-validated area under the receiver operating characteristic curves (AUCs). SETTING: Uganda. PARTICIPANTS: All women aged 15-49 years who were permanent residents of the selected households or stayed in the household the night before the survey were eligible to participate. In one-third of the sampled households, all men aged 15-54 years who met the same residence criteria were also eligible. PRIMARY OUTCOME MEASURES: Modern contraceptive use. RESULTS: Overall, 4914 (26.6%) women and 1897 (35.6%) men reported using a modern contraceptive method. For women and men, both demographic and proximate variables were significantly associated with contraceptive use, although notable differences in effect sizes existed between sexes-especially for age, level of education and parity. Predictively, the multivariable model was acceptable for women with AUC=0.714 (95% CI 0.704 to 0.720) but less so for men with AUC=0.654 (95% CI 0.636 to 0.666). CONCLUSIONS: Contemporary significant predictors of contraceptive use among women and men were reported, thereby enabling key Ugandan subpopulations who would benefit from more targeted family planning initiatives to be identified. However, the acceptable AUC for women and modest AUC for men suggest that other important unmeasured predictors may exist. Nonetheless, these evidence-based findings remain important for informing future programmatic and policy directions for family planning in Uganda.

Improved contraceptive use among women and men in Uganda between 1995-2016: A repeated cross-sectional population study.

BACKGROUND: Research on contraceptive behaviour changes over time in Uganda is scarce, yet it has among the highest fertility and maternal mortality rates of any country in the East African region. Understanding temporal patterns of contraceptive use for both women and men is vital in evaluating the effectiveness of family planning interventions and strategies, and identifying those with the most unmet need. Using repeated nationally representative cross-sectional samples, this study charts the changes in Uganda's population-based contraceptive use over recent years. METHODS: Five Demographic and Health Survey datasets for Uganda over 21 years, from 1995 to 2016, were sourced and interrogated. Eligible participants included all women aged 15-49 years and men aged 15-54 years. Responses to questions on modern and any (modern or traditional) contraceptive use were analysed. Stratified by gender, weighted regression analyses were employed to detect change over time. The patterns associated with key demographic variables were also investigated. RESULTS: Overall, 50,027 women and 14,092 men were included within the study. In 2016, 30.3% of women and 39.9% of men were using any contraceptive method, a significant non-linear increase from 13.4% of women and 20.3% of men in 1995. Furthermore, 27.3% of women and 35.9% of men were using modern contraceptive methods in 2016, an increase from 7.4% of women and 10.4% of men in 1995. All considered demographic variables were significantly associated with contraceptive use for both women and men (all P<0.001); and for women, all variables differentially changed over time (all P<0.001). CONCLUSION: This study showed a significant increase and dynamism across key demographic variables in contraceptive uptake by both women and men. Sustained family planning programs and interventions have successfully resulted in behaviour change across the Ugandan population. However, continued efforts are needed to further reduce Uganda's relatively high fertility and associated maternal mortality rates.

The Effect of Armed Conflict on the Utilization of Maternal Health Services in Uganda: A Population-based Study.

INTRODUCTION: Maternal mortality rates can be adversely affected by armed conflict, implying a greater level of vulnerability among women, and is often linked to the lack of or limited access to maternal healthcare during conflict. Previous research in Uganda has shown that armed conflict negatively impacts women's utilization of maternal healthcare services for a multitude of reasons at the individual, health-system and political levels. METHODS: This study compared aggregated Demographic and Health Surveys data from 13 districts in Northern Uganda, a conflict-affected region, with data from the rest of the country, for the use of maternal healthcare services for the years 1988, 1995, 2000, 2006 and 2011, using statistical analyses and logistic regression. Specific indicators for maternal healthcare utilization included contraceptive use, antenatal care, skilled assistance at birth and institutional delivery. RESULTS: Use of contraception and institutional deliveries among women in Northern Uganda was significantly lower compared to the rest of the country. However, skilled assistance at birth among women in Northern Uganda was significantly higher. CONCLUSIONS: The findings in this study show that armed conflict can have a negative impact on aspects of maternal healthcare such as contraceptive use and institutional deliveries; however, other indicators such as skilled assistance at birth were seen to be better among conflict-affected populations. This reiterates the complex nature of armed conflict and the interplay of different factors such as conflict intensity, existing health systems and services, and humanitarian interventions that could influence maternal healthcare utilization. KEY WORDS: Armed conflict, maternal health utilization, Northern Uganda, contraception, skilled assistance at birth, antenatal care, institutional delivery.

The role of gender inequities in women's access to reproductive health care: a population-level study of Namibia, Kenya, Nepal, and India.

BACKGROUND: The role of gender inequities in explaining women's access to reproductive health care was examined in four countries (two sub-Saharan African and two South Asian countries). The extent of gender inequities varies across and within countries, and is rooted in the different cultural practices and gender norms within these different countries, and differences in the status and autonomy of women. METHODS: Demographic and Health Survey data from women aged 15-49 years within these countries were analyzed with multivariate logistic regression analysis to examine the role of multidimensional characteristics of gender inequities, operationalized as access to skilled antenatal care, tetanus toxoid injection during pregnancy, and access to skilled antenatal care. RESULTS: Significant associations were found between several dimensions of gender inequities (with the exception of decision-making autonomy) and reported use of maternal reproductive health care services. Several pathways of influence between the outcome and exposure variables were also identified. CONCLUSION: Dimensions of gender inequities (with the exception of decision-making autonomy) differentially influenced woman's use of reproductive health care services, thus highlighting the urgent need for concerted and sustained efforts to change these harmful traditional values if several of these countries are to meet Millennium Development Goal-5.