The increasing population of South Sudan refugees in Adjumani is a major worry for Ugandans living in the West Nile district.
Government and different NGOs have started sensitising refugees about the importance of family planning. Nearly 100 newborns are registered every month across the many refugee camps dotted around Adjumani.
Some say this unsustainably high birth rate is mainly down to majority of refugee men discouraging their wives from using family planning facilities.
"Adjumani district has more than seven refugee camps with a bigger population than the local community. Majority of women in refugee camps fear to use any method of birth control since their husbands are against it due to their cultural beliefs, and claims that they are producing children to replace their parents and relatives who have died in South-Sudan's wars," Loice Abiria, a comprehensive nurse here told The Observer.
She said the refugees' main worry at the moment is about what to eat. Available food is not enough.
Fights over rations distributed by World Food Programme and the United Nations High Commission for Refugees are common.
Ugandan police personnel located in the camps spend a lot of time breaking up fights over food. There is also the cultural dilemma where, in the face of such scarcity, men feel compelled to take on more women and produce even more children, worsening an already impossible burden.
"As Ugandans compete for education, our husbands compete for more wives and children. What annoys is that they don't work to support our families. After impregnating us, they return to South Sudan to fight, then return again when we have given birth; spend some time, make us pregnant again and go back," Annet Aldra, a refugee in Pagirinya camp, said.
People like Aldra are in Adjumani because of the conflict back home in South Sudan. Over one million South Sudanese have fled their country and majority of them have settled in northern Uganda, a situation that worries Uganda over population increase.
In December 2013, South Sudan President Salva Kiir accused his former deputy Riek Machar and ten others of attempting a coup d'état. Shortly thereafter, fighting broke out between forces loyal to either man, triggering one of the world's worst humanitarian crises. Thousands of Sudanese have died, more continue to flee into exile.
Humanitarian organisations like WFP and UNHCR are struggling to keep these refugees alive on a hugely underfunded budget. With so much suffering amongst the women given the daily struggle to find food for their many children, some are quietly taking up tubal ligation as the best option to control the birth rate.
Tubal ligation is a method that prevents pregnancy permanently. A woman's fallopian tubes are clamped, cutting off her eggs from reaching the uterus for implantation. However the process doesn't protect partners from sexually transmitted infections.
When I walked into Pagirinya Health Centre III, located in Pagirinya refugee camp, Jaipi sub-county, Adjumani district, I found doctors and nurses performing a 30-minute tubal ligation surgery on Grace Asianzo, 37, a South Sudanese refugee.
After the surgery, Asianzo, who has lived in the camp for over a year, said she chose tubal ligation since her husband has two wives, and she had already given birth to seven children although two died in the war.
Her surviving five children are more than enough for her. Asianzo cannot afford school fees, food, clothes because she is not working. Asianzo also said that she developed complications in her uterus while giving birth to her seventh baby and doesn't want to risk her life again.
"My husband is also not working; we agreed to have tubal ligation as the best option, with minimal side effects, for us to control the high birth rate and get enough time for digging to grow food for our children and school fees," she said.
Her last born is two months old. Maria Jane, 36, joined this camp last year and underwent similar surgery. She had also given birth to seven children. Her husband suffers from the virulent Hepatitis B, and she saw no reason to produce more children.
High birth rates
Milly Akello, a nursing officer at Pagirinya health centre, said on average about 80 babies are delivered monthly at health centres in the camps of Adjumani.
"Last month, we got 86 deliveries at Pagirinya camp yet we are only four midwives. Sometimes we can't manage when a big number of women come to the hospital to deliver at the same time. At Baratuku camp, about 20 babies were delivered. Adjumani district has more than seven large camps but there are also other [smaller] camps where more than 20 babies were produced," she said.
Akello sees some hope now that, with constant sensitisation about family planning, refugee women have started accepting birth control.
Majority of these women were married off at the tender age of 13, which partly explains why the fertility rate is so high.
Inevitably, by the time they reach 35 years, they have many children, most of whom are malnourished. Coupled with the fact that their children generally miss school, this portends an even bigger problem to the community in future.
"They depend on refugee food aid which is not enough and sometimes when they get it, they sell it to get money to buy other things like soap, clothes and also pay school fees," she said.
The 'population explosion' in the camps is one of the reasons tensions with the local community are bubbling under the surface.
"Most of these refugees are also arrogant, brutal, they demand that we do what they want. They prefer giving birth at home due to their cultures and immediately after giving birth, they come to hospital with their new-borns and the placenta to get Mama Kits. If you refuse to give them, they can abuse you or almost beat you," Abiria said.
Dr Kenneth Kyanu, a medical officer with Gulu district local government, says many women in the camps who have given birth at least to five children have started sneaking into their clinics for tubal ligation.
Family planning dislikes
Agnes Fridah Lanyero in Baratuku refugee camp told The Observer that of all the South Sudan refugees, those belonging to the Dinka tribe are most negative about family planning uptake compared to Acholi, Madi, Kuku, Nuer, Lolubo and Lotuku.
"The Dinkas are so ignorant about family planning and their culture is totally against it. This is because after a woman gives birth, she separates with the husband for two years and stays with her parents while breastfeeding. They return to their marriages to get pregnant again. So, the Dinka men consider the separation period as family planning. But their wives complain of men cheating on them during this breastfeeding period which has increased HIV and Hepatitis B infections," she said.
Lanyero said Dinkas grow very tall, which makes many young girls enter marriage when below 16 years because when they reach 18 years before getting married, they are considered to be too old.
"In our antenatal register, we have many girls of 10 to 18 years giving birth. In their culture, they are not allowed to give birth after 35 years, because they are considered as old people. So, we have changed the health education talk to men to stop having sex with these young girls," she said.
Lanyero said some Dinka men have started appreciating the importance of family planning and allowed their wives to use it as they breastfeed since they can have sex with them instead of looking for other women.
Lanyero has also requested Reproductive Health Uganda (RHU) to constantly provide them with family planning commodities to avoid stock-outs.
She requested RHU to introduce public access to condoms in communities to reduce on sexually transmitted infections (STIs).
Lanyero further said they still have the challenge of Dinkas, who complain about condom size; that they are too short for them.
"A lot of patients in the camps have STIs. If I screen 900 patients for cervical cancer per day, I treat 700 of them with cervicitis and candidiasis infections. These patients also have yellowish and greenish offensive discharge. Last month, out of 600 women we screened for cervical cancer, 11 of them were positive and four had advanced cancer. The doctors had to remove the cervix because they were going to die,"Lanyero said.
Filda Anicia, the Service Provider in Charge of RHU Gulu, said although they advise refugees to have planned sex and avoid unwanted pregnancies, the Dinkas demand that their wives produce many children or refund the many cows they paid while marrying them.
"To encourage them to use family planning and fight misconceptions against it, we have changed our package of message sensitisation from women and encourage more men to attend and also use kind words like child spacing, instead of family planning. Because by child spacing, they know that they will produce later yet with family planning, they take it as if they are permanently stopped from producing... ," she said.
Anne Mary Adunia, the district Health Officer in Charge of Maternal Child Health, said the turn up for family planning in the district is poor since majority of the men are against it claiming women were created to give birth.
According to Richard Mugenyi of Reproductive Health Uganda, an average of 3,000 refugees cross the borders from South Sudan into Uganda each day and more than 5,000 were recorded in a single day on March 9, 2017.
UNHCR statistics released in September show that 51 per cent of South Sudan refugees are in Uganda and they now number at least 1m of whom 81 percent of them are women and 61 per cent are children under 18 years.