Thirty-year-old Grace Openy has an aching pain. As long as her husband wants children, Openy will continue getting pregnant until he tells her to stop.
When she tried to reason him out that she was tired of getting pregnant constantly, he told her to go back to her parents' home if she doesn't want to bear children. As if that was not enough, as a mother it is painful for Openy that there is a huge chance that every child she gives birth to might have sickle cell anaemia. Two of her seven children died due to the blood disorder.
"I want to stop having children because I see my sick children suffering but my husband doesn't allow. The fourth and fifth have signs of sickle cells but I fear to check and confirm. My husband thinks we should deliver many so that some are safe while some might be sick and die. He says itís better to have many so that some may remain," Openy says.
This P.7 school dropout has no one but her husband Charles Okot to rely on for decision-making. She says because it is him who will take care of children, she will not use family planning but continue to produce. According to the 2006 Demographic and Health Survey, Mid-Acholi and Lango region which make up mid-northern Uganda has the second highest fertility rate in the country, at 7.5 % percent; after Eastern Uganda at 7.7% Dr Peter Kusolo Mupuya, the District Health Officer Lira, says Openy is the perfect mirror imagine of why women in Mid-Acholi, Teso and Lango sub-regions are having many children.
They are not well-educated to take their own decisions and neither do they and their husbands realise the danger of constant pregnancy to a woman. The levels of education of women in northern Uganda are lower than that of men. According to the 2006 survey, 35 percent of women in northern Uganda have not received any form of education compare to 17 percent of men. This is the second highest in Uganda after Karamoja sub-region. Only three percent of women in northern Uganda complete primary education and 0.1 percent complete secondary school because women get out of school early and have children early.
Education makes difference
Dr Mupuya says once you increase the level of education of girls, you will be amazed at the change it creates. The more women go to school, the more likely they are to take care of their families. Three quarters of women who go for family planning, antenatal services and who deliver in hospital are the educated.
"If you gave me money and told me to do what I want with it for this country, I would use it in educating all women and in two decades you would have a wonderful change. When you educate a girl child, you protect her from early pregnancy. Educated women are all-rounders; they take care of nutrition, sanitation, health, and educate their children," Mupuya says.
He says telling people in northern Uganda to have few children will only make them resent family planning because their culture requires them to have many.
"Don't say that family planning should be practised to reduce fertility because when you tell people to stop having many children they will ask you why" he said.
Little wonder that only one woman in every ten uses any method of family planning in northern Uganda, the lowest in the whole of Uganda. What health service providers should be advocating in this region is the reduction of pregnancy-related complications like ruptured uterus, or bleeding that leads to death of a pregnant woman. Family planning should be used to reduce maternal mortality rates by reducing complications in pregnancy. Mothers should be interested in having healthy children in a healthy state.
Delaying pregnancy helps women because they are more likely to get complications when they are too young or having frequent pregnancies. Women who have children too late after 35 years are at risk of complications like obstructed labour and bleeding. Her uterus is stretched and thin; so, a baby swims freely and causes obstructed labour. Family planning can also be used to prevent women from having children at an early age when they cannot even look after themselves, let alone the baby.
"When you say that family planning is to control the number of children they will resist. When you tell them that it is to avoid complication or ill-health to the mother and baby, they listen. What is the use of a woman dying and leaving four children to a man who cannot even look after himself?" Mupuya said.
He notes that even a millionaire's wife can die due to complications in childbirth when they are not aware of the risks of having many children.
"The idea should be to have children and that a woman will survive to look after them. Bleeding due to pregnancy complications does evade a millionaire however much money she may have to take care of her children," Dr Mupuya says.
Because men are not the ones who are bleeding or dying from obstructed labour, eclampsia, or sepsis, they will continue to demand their wives to have more children without realising they are endangering the woman's life.
"They also consider women as their property because they paid bride price. They have been heard saying that if she dies, he will marry another one. They are not immediately aware of complications of childbirth. They are not aware that family planning can change aspects of a woman who is at risk," Mupuya says.
He says besides the cultural practices, the high infant mortality rate pushes families to have many children. The area is returning from a long war where rebels abducted so many children as child soldiers and women to be rebels' wives. When people returned home, children started dying due to malaria, respiratory tract infections and diarrhoea, the three major killers of children in northern Uganda. Under-five mortality is highest in northern Uganda at 106 deaths per 1,000 live births.
A woman cannot stop having children when her baby has just died. Many have produced ten children but only four are alive.
"This takes us back to the level of education of a woman. More educated women are more likely to keep hygiene, immunise their babies, have latrines, take their children to health centres instead of shrines for treatment," Mupuya says.
Complications of the side effects of using contraceptives cannot be swept under the rug but Dr Mupuya says but it is a give and take situation: should you have non-lethal controllable side effects which you can even get when you are not using contraceptives or should you get pregnancy with more side effects and more chances of dying?
Many of the side effects like stomachache, backache, and headache are acquired with or without using contraceptives; even men who don't use contraceptives get blood pressure. However, he notes, people are looking for all sorts of reasons to stop contraception. Access to reproductive health services is also an issue because service points are few. In a district like Lira, the nearest health centre for a woman is in a radius of five kilometres.
Ray of hope
All that notwithstanding, the absorption of family planning services in Acholi and Lango sub-regions is beginning to improve. Ten years ago, contraceptive prevalence rate was at 9% but today it is at 37% according to Dr Mupuya. Overtime, the levels of education have increased and awareness of family planning has increased too. Availability of family planning services has increased, making access possible for women who want to use family planning. The number of health centres has increased from 25% to 35% coverage over ten years according to the DHO.
The outreach strategy where services are taken to people who don't have them in their villages has also taken family planning closer to the villages