Kampala — IN the run-up to World Population Day, June 11, Woman will be covering a series of topics all under the theme of reproductive health. With contraceptive use in Uganda standing at a miserable 24%, there is need for mass sensitisation on the importance of family planning to curb the population explosion, which in turn, will reduce maternal and infant mortality

NOT everyone who comes to your rescue is your friend, and no one understands this better than Florence Othieno, a 19-year-old orphan and mother of three. Born in Manyatta Village, Kisumu, Kenya, Othieno had her first baby when she was a child herself - at 14 years old. She was impregnated by her caretaker, who employed her as a house help.

Afraid of the charge of defilement, he fled, leaving Othieno to fend for herself and the baby. Perhaps understanding the adage 'survival of the fittest', Othieno did not think twice when 'luck' unfolded again in the name of a lover. She accepted the hand-outs he offered her and the baby, but it was not long before she had two more children. Not long after the second baby was born, he also vanished.

Now seated on a long bench, the first in a row, along with other mothers at the Kisumu Medical & Education Trust (K-MET), an organisation promoting development of underserved communities through innovative health and education programmes, Othieno says her world is about children and pain.

"In fact, the two are synonymous," she says with an innocent smile. Quite oblivious of her future, she has brought her malnourished toddlers for nutritional supplements at the centre which also provides family planning services.

Asked whether she has considered using modern contraception to space or limit her births, Othieno responds: "I do not know whether I even need it. I should have had it yesterday."

"But, had you ever heard of family planning?" I probe.

"Yes, but I heard that it makes you barren. That it's for malayas (prostitutes) who do not want to give birth, but I've come anyway because I'm not any different from a malaya now," Othieno says.

Seated next to her is Emily Anyango, an 18-year-old mother of two from Nyalunga Village, who says her religion does not permit use of modern contraception. "It's evil. It encourages promiscuity," her pastor reportedly told her.

Carol Nyandati, a K-MET nurse, says Othieno and Anyango are just some of the many women who lack the correct information to plan their births. "It's the reason we integrated nutrition into family planning services; to give it a practical face for them to understand the problem of unplanned births," Nyandati says.

The centre, located on the outskirts of Kisumu town, runs outpatient therapeutic clinics where they feed malnourished children, an effect of the 2007 post-election violence.

Next door to the main clinic is a grinding mill for maize, soya, millet, mukene (silver fish) and nkejje (small fish) for the nutritious meals.

K-MET employs elderly female village healthcare workers to make the meals and help educate the mothers on healthy feeding. "We also give them flour to carry home, but ask them to bring the children so that we can monitor their progress and also encourage them to use family planning," Nyandati says.

She says the programme that started in June 2008 has fed 91 children. On this particular day, there were 19 children ranging from the age of six months to five years.

"From January to mid-May, we registered 40 children, 10 of whom also suffer from HIV and TB," Nyandati discloses. "Most of these mothers come from villages where access to the clinic is difficult. So is access to food, yet they are still having children. This ups the infant and child mortality because the spacing does not allow sufficient time for breastfeeding and food production. The children are not well-fed," she adds.

It is the community health teams which identify the malnourished children, most suffering from kwashiorkor and marasmus, then refer them to the centre. Rose Ochieng, a 40-year old community worker, says they conduct door-to-door visits in the villages to identify the children.

"When their children are fed, they are able to comfortably seat and learn about family planning. We get mothers who are old in the programme to share their experiences using modern contraceptives and the effect it has on nutrition and food security," Ochieng says.

"Many mothers confess that they were unable to feed their children well because of the pressure of another child on the way, limited income and lack of correct family planning information.

"Many mothers have misconceptions about modern contraception, but after we comprehensively educate them, most of them start family planning and also refer their colleagues," Ochieng says.

"We advised Othieno to use Norplant because it is long-lasting. It will give her more time to refocus because she seems to be in a crisis. She wants no more children because she dreads men and dating, yet she is vulnerable," she adds.

Monica Ogutu, the executive director K-Met, says data from the world fertility surveys and the demographic and health surveys have illustrated clearly the benefits of increasing birth intervals to reduce infant and child mortality. She notes that improvements in both maternal and child nutrition have also been shown to be related to increase birth spacing.

"Few programmes, however, link nutrition and family planning activities," Ogutu argues. "Family planning programmes focus primarily on women while nutrition programmes focus principally on the child. We hardly bring them under the same umbrella but it has tremendously worked for us, using one to tap into the other," she says.

Ogutu argues that national programmes should go an extra mile to bring family planning information to the rural families living in biting poverty. Our project has affirmed that it is knowledge not cost, which is the major challenge to use of modern contraceptive methods. She says they run a voucher programme, where couples buy a prepaid card at sh3,000 to access any type of family planning method and hospitalised deliveries when pregnant.

"Hospital deliveries which stood at 40% have increased tremendously, to over 70%, in the pilot areas, but family planning uptake was not as good. So is male involvement. 80% of the women accessing family planning do not come with their husbands, with most of them asking for methods that men cannot find out about," Ogutu explains. She adds that for mothers who have the desired number of children, they ask for tubaligation and 'we no longer seek the husband's consent.'

In Uganda, the uptake of modern contraceptive methods for family planning is still low. The 2007 Uganda Demographic and Health Survey (UDHS) shows that the contraceptive prevalence rate was 24%, with only 18% women using modern contraceptives. There is a high unmet need for family planning, with 41% of women of reproductive age, who want to delay, stop or space their children, unable to access modern contraceptives. Like in Kisumu, they lack correct information.

Dr Henry Kakande, the deputy chief of party, Management Sciences for Health, advises that family planning programmes focus more on education, counselling and follow-up of users to help women deal with incorrect information and various obstacles to continued use.

"Many women come asking for a particular method of family planning because a friend is using it, yet it may not be a convenient one for them. This is sign enough that she does not have adequate information. Women need to understand what they are consuming," Kakande says.

He adds that for long, family planning has failed to pick up because of effective education challenges. Family planning is cheaper than most health conditions like malaria, but it is because people have been given the wrong information and inadequate counselling.

Dr. Kakande says programmes should embrace innovative approaches by integrating related services like nutrition, prevention of mother-to-child transmission and antiretroviral treatment to tap into new clients.