Each FGD was unique, reflecting the variation among the two age groups (15-19 years and 20-24 years), sex and marital status. Two consistent themes emerged in all the groups, "obstacles to contraceptive use" and "enabling factors to contraceptive use". The findings are summarized and relevant quotations are used to enrich the results.
Obstacles to contraceptive use
Various obstacles that impede contraceptive use were identified and classified into five categories that included misconceptions and fears, gender power relations, socio-cultural expectations and contradictions, short term planning, and health service barriers (See Table
2).
Table 2
Example of step-wise analysis for the theme: Obstacles to Contraceptives Use.
Pills burn woman's eggs | | |
Pills pile up in body cause swellings, cancer, spoils tubes | | |
Oral methods are abortifacient, and cause birth defects | | |
Coil pierces womb | | |
Condom damages womb, grooves porous, lubricant infectious | | |
Condom break, get stuck, may cause death | Misconceptions | Misconceptions and Fears |
Side effects are permanent | | |
Contraceptives cause infertility, guilty of not bearing children | | |
Lived or peers experiences of side effects | Fears | |
Condom faulty- 'whites' insert HIV in condom | | |
Contraceptives make women sick and fail to work | | |
Men reject discussion, disapprove contraceptives use | | |
Men abusive, violent, abandon women using contraceptives | | |
Women need men's permission | Power relation | Gender power relations |
Men intimidate, manipulate girls into sex without contraceptives | | |
Men use pregnancy to control and attach women in relationships | | |
Couple disagree on use, consensus rare | | |
Men decide on number of children, when to use a method or not | Decision making | |
Male persuasive, girls are shy, ignorant and weak to negotiate for use | and negotiation | |
Men take contraception lightly consider it a woman's problem | | |
Women's purpose in life is child bearing | | |
Women face dilemma, men demand gender distribution of children | Social norms and | Socio-cultural expectations |
Society condemn early sex, pregnancy, contraceptive use by young people | expectations | and contradictions |
Contraceptives for married with enough children | | |
Men want children from different wives | | |
Parents, partners, in-laws have strong negative feelings on contraceptives | | |
Religion oppose use of contraceptives | | |
Society links contraceptive use to promiscuity | | |
Women fear to be seen at health center or shop seeking contraceptives | | |
Young people using contraceptives are spoiled | Stigma | |
Embarrassing to attend FP clinics or to buy condoms | | |
Men suspicious if women brings or knows how to use condom | | |
Men refuse contraception, but say children are women's responsibility | | |
Parents not open on sex matters, but scare youth from contraception | | |
Parents angered when find girls or boys with contraceptives | Contradictions | |
Parents force girl/boy to marry early if pregnant | | |
Abortion option for girls not to have a baby | | |
Religion view contraception as murder, a sin | | |
Pre-marital sex not a problem, men/women start sex early | | |
Apparent trust, men develop trust in women quickly, rarely use FP | | |
Girls perceived to be too young to get pregnant | | |
Male partner's duty to use protection | | |
Contraception not priority, and preference of sex without condom | Emerging attitudes | Short term planning dilemma |
Perceived love of a girl abandon condom use | | |
Pregnancy is a means to acquire a partner for marriage | | |
Poverty-sex with older men and commercial sex | | |
Sex done in a hurry, no time to get condom after convincing the girl | | |
Girls want sex, are not patient during courtship, abstinence outdated | Immediate gratification | |
Young men compete for girls, use pregnancy to win them over | | |
Pleasure from sex overrides fear for pregnancy | | |
Cost burden for transport and contraceptives | | |
Use of condoms expensive with consistent partner | | |
Limited method to choose from and irregular stocks | Uncertainty for continued use | Health systems barriers |
Long distance to health center, queue and waiting time, shops close early | | |
Providers too busy with sick people, seeking service is not convenient | | |
Provider dictate methods for young people, not friendly | | |
Provider advise on abstinence and not contraception | | |
Providers report young people seeking contraception to parent or partner | Provider paternalistic attitudes | |
Fear to collide with parents at Health Center | | |
Misconceptions and fears
Misconceptions surrounding contraception and reproduction were mentioned in all FGDs. The young people believed that contraceptives interfered with fertility, and they were frightened to use something that could harm their ability to reproduce. Most of the married and unmarried women believed that pills burned the woman's eggs. Both male and female participants believed that pills accumulate in the body causing swellings, such as fibroids, cancer, destruction of the fallopian tubes, and when used they are abortifacient. Participants were also convinced that the intra uterine device could pierce the uterus.
"Those pills are dangerous; they go through the fallopian tube and go to that area where eggs come from. So, when the pill falls in the middle of all the eggs, it burns them all.....they burn the entire woman's eggs and form a big scar. You may die without ever becoming pregnant" (Married women's group, 15-19 years)
"Family planning causes abnormal swelling in the uterus and cause cancer... my in-law was using these methods, and she was operated because of this. They removed fat and contraceptives ...when you take pills for a long time they pile in your body...that is why I can't use family planning" (Unmarried woman, 15-19 years)
Condoms were believed by both male and female participants to damage the uterus, to get stuck in the reproductive tract and cause death, not to fit properly, to be porous, and to have infectious lubricant. Male participants reported tension and suspicion when using condoms because they thought 'Whites' had infected condoms with HIV. Men were said to have lost confidence in condoms supplied by the government when faulty Ngabu brand of condoms were recalled in 2007. Others believed that the oil on the condoms was infectious to women and feared that condoms had pores or grooves with actual perforations that allowed transmission of HIV.
The participants reported how fear immobilized them in their decision-making. They were afraid of the side effects, afraid of getting pregnant without contraception, afraid of the response from their church, and afraid of parent and family reactions. Fear of partners' and parents' reaction was an obstacle to contraceptive use expressed by many participants.
"It is very hard to take pills every day when you still stay with your parents unless you keep them with friends...parents check suitcases. The person who gave birth to you, if she tells you that something is bad it is bad, parents have a lot of experience, you have to comply with them" (Unmarried women's group 15-19 years)
The participants seemed to worry about the impact of side effects and feared that the side effects were permanent. The fear came from their own and their peers' experiences, and from misinformation given to them by parents/elders to discourage them from having intercourse. Some young unmarried women expressed more fear of the side effects than of pregnancy.
"We want the injection method but it has many problems like palpitation, craving for foods like pregnant woman, and dizziness that can even make you sometimes fall in the garden...we work for long hours in the sun without a meal... pills can make you too weak to work, you eventually stop using ...it is safer to just get pregnant, have a baby (Married women's group 20-24 years).
Gender-power relations
The groups revealed gender inequalities in terms of power, roles, decision making, and negotiation for contraceptive use. The women reported lack of power in decision making as a key obstacle to use. Both men and women reported that women's purpose in marriage is to produce children. The women recounted partner disapproval and verbal or physical abuse including violence if the man discovered that the woman used contraceptives. A man could abandon his girlfriend or wife if she insisted to continue using contraceptives.
"If I ever find my wife using this family planning we would separate, send her away... I have heard very bad things about them." (Married man, 20-24 years)
The women said that initiating a discussion about contraception was generally considered unacceptable, and often the partner rejected such discussions. The young married female participants reported that conflict with the husband and the in-laws was severe when family planning issues were raised. In some male groups, the participants commented that women also oppose contraceptive use and react negatively when men raise contraceptive issues, contending that women fear the risk of not having children following use of contraceptives. Women in polygamous relationships were said to compete for children.
Male participants said that women are weak and easily influenced to have unprotected sex. In contrast females reckoned that men want more children and manipulate women into sexual relations without contraceptives. The women further noted that men who do not want to use contraceptives are inconsiderate of the woman's future, citing that men make women pregnant to make them dependent. Unprotected sex for men enhanced their reputation among other young men in contrast to the situation for women. But men would deny the pregnancy and blame the woman for becoming pregnant. However, some female participants recounted that early pregnancy was perceived as a positive incentive for early marriage and was no longer perceived as a problem. Some girls were said to pierce condoms to get pregnant to compel their partners to marry them.
"Some woman may pierce the condom with long nails with intention to get pregnant... as long as you get pregnant you no longer waste time...you just go with the man responsible for the pregnancy and start a family" (Unmarried women's group, 15-19 years)
Some married women said they still needed permission from their husband to use contraception, and could be abandoned if it was done without his knowledge.
"Most men do not like contraceptives, they want children, he gets a baby with you and asks you for another....if you tell him about contraceptives he leaves you....so women use it secretly" (Married women's group, 15-19 years)
"One friend was using 'family'-injection without approval of her husband but started bleeding severely and had to tell him to get help to go to the health unit. This caused serious problems for her since her husband wanted more children" (Married woman, 20-24 years)
Both male and female participants expressed views about decision making, and cited power struggles, couples disagreements and rare consensus on contraceptive use. Attempts to negotiate use frequently ended in violence or separation. The final decision depended on the preferred number of children by the man. Men were also reported to make decision to use or not use condoms. Men had the view that women were given to them when they married and the women were obligated to produce children or be thrown out of the house.
"Some men do not want their wives to use contraceptives and are very tough on that. This can even lead to separation...I heard of a scenario where the man reproached the wife who had told him that she was tired of having children. The man said he could still look after his children and wanted more" (Unmarried man, 20-24 years)
On the other hand, some female participants mentioned that some married women with children could actually discuss with their partner and agree on use.
"Some women talk with their partners, some men also notice the finance problems and observe how difficult it is to raise the children and agree to use of family planning" (Married women's group 20-24 years)
Socio-cultural expectations and contradictions
Most male and female participants reported that the purpose of life for women is child bearing but also that traditional societal norms prohibit sexual activity and pregnancy before marriage. Furthermore, cultural norms condemn parents talking with their children about sex. Society expects young people to be virgins till marriage, but many young people reported that in reality they were sexually active. At the same time societal norms/values do not support use of contraceptives and parents were said to use scare tactics about contraceptives for example; contraceptives lead to developing of fibroids and infertility to keep their children from having sex. Parents reject contraception and yet they do not want their unmarried daughters to become pregnant. If an unmarried daughter gets pregnant, the parents might send her away from home, force her to marry the man responsible for pregnancy, or force her to undergo an abortion. The parents may also compel the young man responsible for pregnancy to leave the community, or try to send him to jail.
"Parents and elders are against contraceptives. If they find you with a condom, they lose confidence in you...parents should be made to accept that things are changing to allow these methods...nature is nature, young people need sex, it is better to tell them about contraceptives" (Unmarried men's group, 20-24 years)
Contradictive messages from partners, parents, clergy, teachers, cultural leaders and health workers were identified as key obstacles to use of contraceptives. Young people get mixed messages since the social norms condemn sex, contraceptives and pregnancy before marriage while partners, peers and media encourage sex. The participants said that the Churches added to their confusion with messages of opposition or silence. They all noted that the churches are very pro-natal with statements like "go out and multiply", "contraceptive use is murder" and "children are a blessing".
"The pastor in our church emphasizes that use of family planning methods is killing, it is a big sin in front of God" (Married man, 15-19 years)
It was noted that young people are stigmatized if they use contraceptives. Contraceptives were perceived to be for married couples who have had a number of children. Communities were said to link use of contraceptives to promiscuity and prostitution, and also to future infertility. These values placed young people in a dilemma. The young women also reported experiencing this stigma at points of contraceptive delivery. They revealed fear of being reported to husband/parent if found at health facility or at shops seeking for contraceptives. Unlike men, women were ashamed to buy or carry condoms, it was considered unacceptable. In addition, women were reluctant to seek information about contraceptives since men might become suspicious if a woman knew how to use condoms.
Short term planning
Peer pressure and pleasure from sex was said to override fear for pregnancy, HIV and other sexually transmitted infections. Some male participants said there was no need to use contraceptives with young women who look healthy since there was no apparent risk.
"Girls looking beautiful and healthy, there is no method used...even no HIV test is done we check with our eyes....you look at her and determine if she is okay."(Unmarried man, 20-24 years)
The men stated their preference for sex without a condom claiming that sex was not sweet in 'plastic wrapping'. Male participants further connoted that consistent use of condoms was difficult with stable partners they trusted and loved. Condoms were frequently abandoned after two or three encounters because the couple built trust and confidence in their relationship early.
"You may use condoms sometimes in an extra marital affair but it reaches a time when you stop....woman view using a condom as a sign that she is not clean...over time you stop, also condoms are expensive to obtain...time taken to stop using the condom depends on the individual....till when you 'trust' her" (Married men's group, 20-24 years)
Young men cited reasons for not using contraceptives, for example not having time to find or purchase commodities after convincing the young woman to have sex. The men explained that they usually had to make love quickly outside in the bushes or at the disco and that they were not prepared with contraceptives. Some male participants revealed that women were not patient during courtship. When the man wanted to delay sex, the woman might think that he was not serious about the relationship. Furthermore, poverty and need for money was reported to override need for protection. Male participants reported competing economic demands where they would rather spend money on new shoes or clothes than on contraceptives. It was also mentioned how difficult it was for young women to use contraceptives or negotiate for their use with older men. Similarly women involved in exchange of sex for money, or other incentives had difficulties negotiating contraceptive use. Sex for money in Ugandan context is not only by regularly known sex workers it mostly sporadic.
Health service barriers
Paternalistic, judgmental views by contraceptive service providers, coupled with lack of privacy and confidentiality, were said to inhibit young men and women from seeking contraceptive services and using contraceptives. Multiple examples of providers reporting to parents or husbands if young men or women came to the health unit for contraceptives were given in the focus groups.
"If you come for condoms every day at the health unit, the health worker gets scared that you are having too much sex and can tell your parent. Youth are shy and fear to be reported to their parents" (Unmarried men 15-19 years)
In addition, the clinics were habitually out of stock of contraceptives and had limited choices of methods, making it very difficult to use any method consistently. High costs, particularly in rural areas, were reported as an obstacle by both young men and women. Some male and female participants said that cost was a burden, making contraceptive use dependent on disposable income. Access was further restricted by cost implications in terms of transport, and distance to health facilities.
"Some women agree on use with their partner but the contraceptives are expensive ...people are too poor here ...sometimes you can fail to get them in the near clinic, you have to spend on transport to town...it is very expensive... you may end up defaulting and getting pregnant" (Married women's group, 20-24 years)
Limited opening hours, long waiting time, and lack of youth friendly services were other barriers to access that were mentioned. This resulted in incidents of self prescription identified among participants. Young people also felt ashamed and reluctant to ask for contraceptive services from busy health care professionals attending to sick people. Fear of stigma at the health facility propelled some women to procure contraceptives from private clinics/stores since they provided privacy and confidentiality. Furthermore, young women would sometimes buy commodities from private clinics and drug stores with unqualified staff, which sometimes was said to result in health problems and thus, in discontinued use.
Enabling factors for contraceptive use
The key enabling factors to contraceptive use mentioned during the FGDs were classified into three categories including female strategies to overcome obstacles, changing perceptions, and changing attitude towards a small family size (See Table
3).
Table 3
Step-wise analysis for the theme: Enabling Factors to Contraceptives Use
Secret use of contraceptives, fear of male partner opposition and stigma | | |
Sneak to Health units for contraceptives | | |
Contraceptives bought private units to cope with stigma | | |
Know some contraceptive methods and cost | New Coping strategies | Female strategies to overcome obstacles |
Some women convinced of contraceptive benefits | | |
Some women carry condom in case of emergency | | |
Use contraception to limit pregnancy in unstable relation | | |
Self preservation for women with marriage intentions | | |
Fear pregnancy more than HIV/AIDS | | |
Fear burden of carrying pregnancy, and costs involved | | |
Fear of abortion complications | | |
Men fear jail, forced migration if make a young girls pregnant | Risk perception | Changing perceptions |
Pills back up when condom not used | | |
STI prevention with secondary contraceptive value | | |
Condom used when suspicious of girl | | |
No permission is required for men to use condoms | Selective use | |
Contraceptive use reduce spending | | |
Economic status influence number of children | | |
Belief in small family to sustain good life | | |
Value of children education, health care expenses | | |
Fear early family | | |
Struggle to survive, children are a burden | Small family size | Changing attitude towards a small |
Some men fear responsibility, welfare of children | | family size |
Many children affects employed men and women | | |
Young people debates encourage few children | | |
Choice of long acting method in stable relationship | | |
Female strategies to overcome obstacles
Married and unmarried young women were aware of different contraceptive methods, their cost, and some were also convinced of the benefits of using contraceptives. Some women decided to use or not to use contraceptives independently from their partners. Some unmarried women also reported that they carried condoms in case of emergency in order to avoid pregnancy in unstable relations. Young women recounted using contraceptives secretly as a strategy to protect their interests, and counteract male partner disapproval. Secret use of contraceptives was said to prevent unwanted pregnancy. At the same time conflicts with partners and families were avoided. Secret use was an enabling factor specific for young women.
"For me I have to take the pills secretly as I study the man I love, because he might leave you if you become pregnant and then you begin thinking of abortion... that is why most youth hide first time using contraceptives" (Unmarried women's group 15-19 years)
Some female participants, regardless of marital status, reported going secretly to health facilities for contraceptives. As a result the injection method was said to be the most common method used both by married and unmarried young women.
"Some married women use contraceptives in secret, most men don't like contraceptives and refuse women from using. Pregnancy is so stressful for women, your husband may not be supportive financially but only interested in alcohol...you need to work and save money from farming for your children, so you sneak in the health unit for injection when coming from the garden" (Married women's group, 20-24 years)
Changing perceptions
Male and female participants reported that they feared pregnancy more than HIV/AIDS, contending that HIV/AIDS is like having a common fever. Participants in the focus groups claimed that previously people were more scared of HIV than pregnancy. Fear of pregnancy and not HIV was reported to slowly aid adoption of contraceptive methods. HIV/AIDS prevention campaigns emphasizing condom use were reported to improve decision-making towards use of condoms for prevention of pregnancy as well.
"Young women fear pregnancy not AIDS, they consider the burden to carrying pregnancy for nine month, costs involved during pregnancy and when baby is born...they fear pregnancy but HIV who knows when you get it... AIDS takes long to show compared to pregnancy so you would rather have that than pregnancy that shows soon" (Unmarried women's group 15-19 years)
Female participants reported that self preservation from pregnancy before marriage led to contraceptive use. Furthermore, worries of carrying a pregnancy, looking after the baby, the costs involved, and fear of negative consequences of abortion were enablers to contraceptives use.
"Pregnancy is tough, one considers cost involved in carrying pregnancy, food and others...it is so worrying to young women. Most of them fear the burden of looking after the child. Taking care of yourself and pregnancy is tough" (Unmarried women's group 20-24 years)
Male counterparts reported fear of early forced marriage, being forced to leave school or being put in jail if found to have made a young girl pregnant as motivators for contraceptive use. Selective contraceptive use was also reported with "on and off" partners and when the man suspected that the woman had a sexually transmitted infection.
Changing attitude towards a small family size
Both male and female participants recognized that having many children is difficult for working men and women. This was a common view among those living in trading centers/towns and these young people were motivated to use contraceptives. Men did not want to have the responsibility of many children in terms of education and health care expenses. Young men and women stated that they often debated among peers about having fewer children.
"There are some seminars around encouraging young people to have few children...so that kind of thinking is the one that has been common in young people's debates" (Unmarried men's, 20-24 years)
Women also reported that there were a few men who did not want many children and demanded that women use contraception.
"But there are some men interested in contraceptives, they ask a woman to use such that they don't have frequent birth like a rabbit... he may not manage many children, so he demands that the woman uses or else she assumes responsibility of pregnancy on her own" (Married women's group 20-24 years)
Female participants recounted desire for a small family, and awareness of contraceptive methods, as incentives to contraceptive use. They further reported that free contraceptives in the public facilities helped use. The women who already had children also stated that antenatal clinics were an important source of information to encourage contraceptive use.