UGANDA BIRTH SPACING QUALITATIVE RESEARCH STUDY BY REEV CONSULT INTERNATIONAL APEX HOUSE NTINDA, PLO

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UGANDA BIRTH SPACING QUALITATIVE RESEARCH STUDY
BY REEV CONSULT INTERNATIONALAPEX HOUSE
NTINDA, PLOT 897 KIRA ROADP.O. BOX 28224 KAMPALA
UGANDATel 256 41 287779/256 77 2402609EMAIL
reevconsult_at_infocom.co.ug
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Introduction

• Uganda has a population of 28 million people with
  the population growth rate of 3.2 per annum
  (UBOS, 2006)
• The Total Fertility Rate for the country is 6.7
  births per woman. The TFR in urban areas is much
  lower than in the rural areas (4.4 and 7.1
  respectively). This rate is the highest in
  eastern and Southern Africa (UBOS, 2006).
• The median age at first birth in Uganda is 19.1
  with urban women having their first child at a
  later age than others. Also, women with
  secondary education start having children two
  years later than those with less education (20.6
  and 18.5 years)

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Objectives of the Study

• Overall Objective
• To establish the motivation factors and attitudes
  towards birth spacing in Uganda and recommend on
  how birth spacing can be promoted in multiple
  contexts

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Specific Objectives

• To better understand the social and subjective
  norms surrounding birth spacing
• To examine the values and beliefs underlying
  fertility, pregnancy, and birth spacing
• To identify individual, community or macro-social
  factors that might motivate women and couples to
  increase birth intervals
• To identify the individual, community or
  macro-social factors that serve as barriers to
  women and couples who wish to increase birth
  intervals

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Methodology

• The study was carried out in two (2) districts of
  Kampala in the central and Iganga in the eastern
  part of Uganda.
• The reason for choosing Kampala and Iganga was
  due to their significant differences in fertility
  rates Kampala with the smallest (TFR3.7) and
  Iganga with one of the highest fertility levels
  in the country (TFR7.7) (UBOS 2006).
• The study was qualitative and used primary
  sources of data. The major method of data
  collection was focus group discussions with women
  of reproductive age group as well as a selected
  number of men.

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Methodology
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Methodology Contd

• Participants were selected based on the following
  criteria
• Population Mothers and fathers of young children
  (a participant had to have at least one child
  below the age of 5 years)
• Age Women had to be in the reproductive age
  group. The age bracket 18-40 was taken.
• Residence Rural and urban residencies were
  considered. In Kampala district (which served as
  an urban area), two sub categories were selected,
  namely, urban elite and sub urban
• Gender The groups comprised females and males
  who are parents to young children.

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Distribution of respondents
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Findings
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Values and Beliefs Underlying Fertility,
Pregnancy and Birth Spacing

• Child bearing is the number one expectation from
  and by couples. The primary reason for marriage
  is considered to be procreation, and this is a
  widely held value
• Fertility is a womans responsibility and any
  delay or failure to bear children after marriage
  is blamed on the woman and not the man.
• It is still considered strange that a woman can
  choose to delay pregnancy. This is not acceptable
  behaviour that in most cases attract external
  pressure on the couple especially the woman
• When I delayed to conceive after marriage, my
  mother expressed concern. She thought my
  marriage was at risk. Even my workmates got
  concerned- they started asking for prayer on my
  behalf and they told me to stop using
  contraceptives because I could become permanently
  infertile (female, urban elites)

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Values and Beliefs Contd

• Delayed pregnancy threatens the marriage
  relationship and may lead to early separation and
  divorce or the husbands extra marital
  relationships.
• When the pregnancy delays after marriage, the
  man gets another woman. The family and other
  community members put the man under pressure to
  marry another woman. If your husband understands,
  he may not divorce you but will still get another
  woman (Female, Peri-urban)
• Why should she wait? The purpose of getting
  married is to bear children and it has a
  specified period. If she does not want to give
  me children then she goes. I would know she is
  not interested in me (Male, Peri urban, Kampala)

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Values and Beliefs Contd

• Similarly a childless marriage almost always ends
  up into polygamy and extramarital relationships
  in search of children
• If the woman cannot produce, I do not chase
  her away because its not her fault, but I have
  to look for children elsewhere. She will remain
  in the home as a decoration and then I find
  another side-woman to produce for me children. I
  cannot afford to die without leaving an heir
  (Male, Kampala urban)
• Fertility decisions such as the number of
  children to have are the preserve of the man,
  while the woman is supposed to implement or
  fulfill the mans desires and wishes
• If a woman wants only 4 children and I want
  7, I leave her to get her children and then I get
  the rest from some where else (Male, peri urban)

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Values and Beliefs Contd

• There is no significant difference between ideal
  and actual number of children particularly in the
  urban areas. Even in the rural areas, the
  difference is minor because of the high fertility
  preference.
• While urban couples can achieve their ideal birth
  spacing intervals due to access to family
  planning services and methods, the rural couples
  have limited options. Subsequent pregnancy is
  left to God to determine.
• The rural women primarily rely on lactational
  amenorrhea for prevention of pregnancy. If this
  does not work, then birth intervals become
  extremely short.

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Values and Beliefs Contd

• Median age at marriage has increased from 17.4 to
  18.3 years of age (UBOS 2006) due to a
  combination of factors. There are laws on
  defilement that are scaring people away from
  marrying girls below 18 years of age, increased
  enrolment at lower levels of schooling and long
  years of schooling. This change is mostly
  apparent in the urban area
• Late age at marriage and the ideal number of
  children overshadow any aspirations for longer
  spacing. Couples who have a choice (urban elites)
  calculate their spacing intervals based on the
  ideal age by which they want to have completed
  child bearing
• Thus, couples who marry at a relatively younger
  age find it more practical to adopt longer
  spacing than those who marry at a relatively
  older age.

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Values and Beliefs Contd

• Polygamous marriages breed competition among
  women for a higher number of children, gender mix
  and frequency of births. They are therefore a
  pressure factor for shorter birth intervals
• If your co wife has more children, you will be
  pressured to reduce the spacing interval in order
  to catch up with her. And if you have same sex
  children, the pressure to be pregnant becomes
  worse. (Peri-urban female, Kampala)
• In terms of locality, urban women are more likely
  to adopt longer birth intervals than their rural
  counterparts. This is attributable to the fact
  that they have better access to information,
  services and methods of birth spacing

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Values and Beliefs Contd

• Religion plays a big part on birth spacing
  through influencing the type of marriage and the
  use of contraception. Islam allows polygamy which
  in turn breeds competition for child bearing
  among women. The Catholic Church has for a long
  time opposed use of modern contraceptives which
  in turn limits womens choices for birth spacing.
• There is limited perceived difference between
  family planning and birth spacing. However,
  women are more likely to think about birth
  spacing than men and they view it as part and
  parcel of the family planning package.
• The men on the other hand, consider the required
  number of children first and view birth spacing
  as an automatic (natural) occurrence, but which
  should fit within their defined norms.

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Values and Beliefs Contd

• Too short intervals and too long intervals are
  not desirable among the society members. This is
  evident in the derogatory concepts used to
  describe such incidences like Kwesera in Lusoga
  meaning pouring, for too short intervals and
  Kizaala gumba for long intervals literally
  meaning producing like a barren woman
• There is no concrete, original equivalent of the
  concept of family planning and Birth Spacing. All
  the concepts used are an attempt to translate the
  English term. Family Planning is commonly refered
  to as Family

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Values and Beliefs Contd

• On average the acceptable birth interval seems to
  be 2-3 years before the subsequent birth (which
  is less than 2 years before the subsequent
  pregnancy)
• While there is close to universal basic awareness
  about family planning, there still is widespread
  bias and myths about modern contraceptive methods
  particularly in relation to the side effects
• One of the most significant factors for low
  adoption and discontinuation of contraception is
  the experienced or anticipated side effects.

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Values and Beliefs Contd

• While most urban women consult medical
  professionals before and during use of
  contraception, the rural and peri- urban women do
  self prescription or rely on their friends for
  information and decision making on whether or not
  to use contraception and which method to adopt

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Social and Subjective Norms Surrounding Birth
Spacing

• Fertility and birth spacing are viewed primarily
  as a womans role. The man takes the upper hand
  in determining the number of children that the
  woman should produce for him. Joint discussion
  and decision making on birth spacing are rare
  among couples.
• There is still a clearly cut preference for boys
  as heirs and propagators of the family name and
  clan. However, the majority of couples still want
  a gender mix in the family (i.e. both boys and
  girls).
• Due to this, one sex in consecutive births
  influences women to continue getting pregnant in
  search of either a girl or boy.

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Social and Subjective Norms Contd

• The health status of a previous child may
  influence birth spacing in either direction
  depending on the nature of the health problem.
• For example, if the parents suspect that the
  problem is likely to be carried onto the next
  child or if the condition is too demanding on the
  parents time and resources, the subsequent
  pregnancy may be delayed (among the couples that
  have choice).
• If the condition is permanent such as physical
  disability, the next pregnancy is immediate as
  consolation and in the hope that the next child
  will be okay

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Social and Subjective Norms Contd

• A lost pregnancy or infant is a much greater
  influence on birth spacing (normally leads to
  immediate pregnancy) than the health of a child.
• Pressure to have children can either be internal
  (Husband) or external (extended family and
  community). The women find it relatively easier
  to handle external pressure than internal
  pressure.
• There is also recognition that the husband is in
  turn influenced by community norms and
  expectations over child bearing.

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Social and Subjective Norms Contd

• One of the outstanding advantages of short birth
  intervals is the ability to compress child
  bearing and rearing into fewer years and also
  avoid the disadvantages of advanced maternal age
  in child bearing. Both the educated and
  uneducated people seem to value this strength.
• The identified disadvantages of short birth
  intervals are the financial and time resource
  stress related to child rearing. The health
  risks on the mother and the child are
  acknowledged but there does not seem to be strong
  convictions on this matter among the population.
  It is tied to economic ability to take care of
  the children, as well as the age of the mother

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Social and Subjective Norms Contd

• Under favorable circumstances (younger age at
  marriage, minimal side effects of contraception)
  urban women prefer to have longer birth spacing.
  Some of the highlighted disadvantages are the
  prolonged period of child rearing as well as the
  risk of pregnancy and birth at an advanced age
  (considered at 35).
• On the other hand, the majority of urban males
  prefer short spacing intervals and their major
  reasons are associated with the targeted age of
  child bearing termination. They associate the
  risk of short birth intervals to the age of the
  women and not so much about the birth interval

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Social and Subjective Norms Contd

• These days women are getting married at 30. So,
  if I want 4 children and you want me to have 2 to
  5 years spacing, when will she have time to
  produce them? After 35, we all know it is risky
  to engage in child bearing. (Urban elite males,
  October 2007)
• Most participants noted that birth spacing is
  more appropriate for people living in rural
  settings because that is where women get married
  at a young age and household income limited.

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Individual, Community and Macro-Social factors
that might facilitate or hinder increased birth
intervals.

• There are a number of supportive policies and
  strategies on reproductive health and family
  planning that provide a framework for promotion
  of birth spacing activities and programs.
• However, birth spacing is not mainstreamed as a
  goal or objective in its own right
• This can serve as a barrier to increased birth
  spacing, unless there are efforts to increase the
  visibility of birth spacing as key component of
  the family planning strategies and programs

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Individual, Community and Macro-Social factors
Contd

• At institutional level, though there is an
  institutional framework for promotion of family
  planning, coordinated by Ministry of healths
  reproductive health unit, there are still limited
  organizations engaged in family planning
  activities. There is hardly any organization
  that specifically promotes adoption of healthy
  birth intervals in the communities.
• Access to information and services/methods to
  enable increased birth spacing is still limited.
  Though there is a wide network of government
  health facilities, they are constrained by lack
  of basic equipment, trained personnel and drug
  supplies to offer basic services.

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Individual, Community and Macro-Social factors
Contd

• At community level, the religious factor can
  either slow down or promote adoption of increased
  birth intervals. The Roman Catholic Church has
  for a long time opposed the use of modern
  contraception which facilitates longer birth
  intervals
• However, religious leaders wield a lot of
  authority and influence on individual and
  community behaviour. They still have a large
  following in Ugandas society. They can thus be
  used as entry points to influence attitude change
  and promote adoption of healthy birth spacing
  intervals.

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Individual, Community and Macro-Social factors
Contd

• At family level, a major barrier to adoption of
  longer birth spacing is the low involvement of
  men in reproductive health in general. Open
  discussion and joint decision making and action
  on fertility and family planning can facilitate
  increase in birth intervals.
• High levels of unemployment and low involvement
  of women in economic activity may continue to
  serve as barriers to adoption of longer birth
  spacing because the opportunity cost of rearing
  children is low
• Womens education was found to influence birth
  spacing in either direction. Women who are
  educated easily adopt family planning. On the
  other hand, it delays age at first marriage often
  leading to compression of child bearing to a few
  years to avoid age related complications

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Recommendations

• Programs to increase birth spacing in Uganda need
  to engage in systematic and deliberate policy
  advocacy to mainstream birth spacing
• To achieve this, the government will need to be
  lobbied to increase the financial allocations for
  the reproductive health division in the Ministry
  of Health. Civil Society Organizations should
  initiate the lobbying
• In addition, government should be lobbied to
  pronounce itself and flag healthy birth spacing
  as crucial components of the strategies aiming at
  improving maternal and child health in the
  country.

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Recommendations

• Programs to improve birth spacing also need to
  incorporate a strong element of information,
  education and communication (IEC) as well as
  behavioural change communication (BCC).
• This is because a critical gap in adoption of
  health birth intervals is inadequate knowledge of
  the disadvantages of short birth intervals but
  also most commonly the methods of achieving the
  desired birth intervals.
• It is pertinent for the government and other
  stakeholders to improve access to reproductive
  health services as a whole and family planning
  services in particular.

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Recommendations Contd

• One way through which access to quality services
  can be improved is by designing mechanisms to
  retain qualified staff in lower level health
  facilities particularly in remote areas.
• The medical personnel particularly at lower
  levels need to be reoriented in birth spacing and
  family planning counseling and guidance. This is
  crucial for attitude change and proper delivery
  of the full package of family planning services
  that mainstream birth spacing.
• Birth spacing counseling, guidance and other
  services should be integrated in the antenatal
  care (ANC) services as an entry point

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Recommendations Contd

• This is because, whereas most women seek ANC
  services, very few deliver from health units, and
  only a bare minority in the urban areas seek post
  natal care. Therefore as part of the ANC
  services, counseling, guidance and marketing of
  healthy birth intervals should be emphasized.
• While over 90 of pregnant women attend ANC, only
  26 deliver in health units leaving 74
  deliveries through TBAs (UNFPA 2005)
• Institutions and organizations involved in family
  planning advocacy should package messages in such
  a way that they do not just promote reduced
  family size but also directly market longer birth
  interval

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Recommendations Contd

• Such messages should be compatible to the extent
  possible with all religious teachings, local
  norms and beliefs in order to minimize outright
  resistance to the campaigns
• Other messages should focus on promotion of
  gender equity particularly the promotion of
  education of a girl child.
• The program should also identify model couples
  and involve them in sensitization campaigns
• One long term strategy to improve birth spacing
  should be the promotion of womens education,
  entrepreneurship and enterprise development.

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End

• THANKS !