Ethics statement

Ethical approval for the study was granted by the University of Canterbury Human Ethics Committee in August 2017 and by the Mbarara University of Science and Technology Research Ethics Committee in Uganda in October 2017. Participants signed consent forms provided before the FGD (or submitted a thumbprint signature if they were unable to read or write), and were reminded of their right not to answer a question, or to withdraw from the study during the FGD.

Study setting, design and participant recruitment

The Busoga region was selected due to the low contraceptive prevalence rate (31.3%) and high unmet need (36.5%) among married women of reproductive age [2]. The region is home to approximately four million people, mainly of the Basoga tribe, which is the third largest in Uganda [37]. The region spans about 10,000 square kilometres divided into ten districts [38]. Study sites in the districts of interest (Iganga and Luuka) were selected based on low contraception prevalence rates, accessibility and feasibility.

Six FGDs were conducted with 41 women, stratified across age groups (18–24, 25–34, and ≥ 35 years) and place of residence (urban and rural areas); thematic saturation was achieved after the sixth FGD. Age groups were selected due to cultural norms and literature reporting significant differences in contraceptive uptake across these age brackets [8, 16]. Women of reproductive age (unmarried or married, who were fecund and sexually active; and who wanted to space or limit a pregnancy at the time of the study (irrespective of whether they were using or not using traditional/modern methods of contraception) were eligible to participate. Women who were not sexually active, who were pregnant, or who were trying to conceive at the time of the study were excluded.

Twenty-one women had completed their primary school education, with the other 20 respondents having finished some years of secondary education. Thirty-one women were using some form of contraception at the time of the FGDs (most commonly injectables), while 10 were not using any contraceptive method. Except for 3 women aged 18–24 years, all respondents had at least one child, with 4 respondents ≥ 35 years each having 8 children (Table 1, S1 Data).

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Table 1. Focus group discussion (FGD) participant characteristics.

https://doi.org/10.1371/journal.pgph.0000545.t001

Participants were recruited through purposive sampling, followed by convenience sampling with the help of community health workers and village health teams (VHTs) that worked at these sites. Purposive sampling was initially used to identify participants who met the recruitment criteria at the different study sites, and convenience sampling was used thereafter to continue recruitment till each FGD comprised of 5–8 women. Community health workers recruited participants following a briefing on the nature and topic of the study, the inclusion and exclusion criteria for participants, the ethics of recruitment, the number of participants required, as well as the date, time and location of the FGD in the respective district.

Data collection and analysis

The FGDs followed the cultural protocols advised by the local partner organizations, for example ensuring refreshments were provided for participants, and that introductions for everyone present were carried out appropriately. Due to the sensitive nature of the topic, protocols regarding informed consent and confidentiality were addressed at recruitment and reiterated prior to the FGD. As participants were recruited by members of health care teams, care was taken to assure women that their participation in the FGD would not affect future care provided by their local family planning clinic or any other health services in their community. As a token of appreciation, participants were given a bar of soap, which was recommended by the local partner organizations as culturally appropriate.

The FGDs were audio-recorded, and usually lasted between 45 minutes to 1.5 hours. They were held in private, quiet spaces where others in the community could not listen in or disturb the discussions. Discussions were guided by the facilitators in Lusoga following a question schedule. Once no new themes were identified in the FGDs, data collection was stopped. Transcripts and subsequent translations of the transcripts to English were checked by two independent translators as well as the facilitator and first author. During the coding and thematic analysis, members of the research team independently checked through and discussed the codes, categories, patterns and themes as they evolved over time.

Qualitative data collected from the FGDs were analysed thematically, using an inductive approach. This method acknowledges how experiences are shaped by context, while retaining an emphasis on how informants make sense of and attribute meaning to their experiences. In analysing the data, the six stages of thematic analysis suggested by Braun and Clarke were followed. The authors analysed the data primarily at a latent level, first using codes to identify patterns within and across the transcripts [39]. Codes were then organised into themes and sub-themes, representing patterns that were identified in the data, incorporating both latent and semantic content. Finally, connections were subsequently built around the major themes that emerged pertaining to the use of contraception by women.

Navigating contraceptive use within a patriarchal society

The specific gender roles occupied by women and men in a relationship and the dynamics of how those roles play out was identified by participants as an important influence on contraceptive decision-making and uptake. They talked about a woman’s roles of looking after her family and the home, and expectations that they would assume full responsibility of caring for their children. Men, on the other hand, were perceived to want many children but had limited involvement with their upbringing:

They [men] don’t think about it apart from just producing… he doesn’t even take care of educating them, as long he produces ‘full stop’.—R_25–34

Men nowadays don’t think about their responsibilities and you remain with the responsibilities alone so you think of getting many children but for what! You just decide to use family planning.—U_25–34

Contraceptive use was considered to be a woman’s role, but men’s approval was central to women using contraception, as one respondent articulated: “My husband encourages me to go for family planning […] but he almost decides each and everything.” Some younger participants (in the age group 18–24 years) described more egalitarian relationships and shared their partner’s support of contraceptive use. For these women, spousal communication about family size and family planning was more comfortable. For some women, their partner’s instrumental support enabled them to pursue family planning, as described by one participant: “It is my husband who takes me to the health facility for family planning and even if I get problem he takes me back.” This was particularly important in rural settings where participants described long distances and significant transport costs to get to the nearest health facility.

Older women, both in urban and rural areas, were less comfortable or felt unable to discuss contraceptive use with their partners. Partner opposition was framed as a common challenge, despite the burden further births would place on the family. Many older respondents described defying their partners’ wishes, and openly talked about ways in which they subverted partner opposition through covert contraceptive use, mainly through injectable contraceptives. However, the consequences that women face, if discovered by their partners, can be severe and include violence, being abandoned or ‘chased out’ [18, 19, 40]. Many respondents reiterated that attempts at discussing family planning with their partners were unproductive and a source of conflict they sought to avoid:

For me I just go I don’t tell him (laughs)…now why should you tell him? Because he will ask you many questions…so I think among ten men, only one believes in family planning.—U_≥35

Partner opposition was attributed by many women to their own negative experiences with contraceptive side effects (e.g. loss of libido, or excessive bleeding) that subsequently interfered with their partners’ enjoyment of sex. In addition to demonstrating typical power dynamics within spousal relationships, these accounts also highlight the expectations that women should please their partners sexually in a relationship:

Mine does not allow family planning, they will run away from us because of family planning… because some women bleed every day, a month, two months and we don’t have libido so if a man gets another partner, the marriage will break up (laughs)… I am not lying.—U_25–34

A few younger women cited the costs and hassle associated with side effect management as reasons for their partners being opposed to contraceptive use, as one respondent remarked, “I told my partner after delivering that I wanted to go for family planning until the baby is three years but he refused and told me that if I get any problem I would care for my own self, so I was scared.” The sense of apprehension in some younger women’s comments may be reflective of spousal power dynamics that saw them financially vulnerable in relationships, especially if contraceptive side effects had financial ramifications and men were the primary or sole breadwinner in the family. Older women, on the other hand, described the benefits of family planning in managing the financial burden for their family, even though such concerns were conventionally the purview of the man in a family:

For me I decided because of the family status… many children but the affordability was less. Because even if they send a child from school because of lack of a book, he [the husband] will just keep quiet… and the child will go to their mother. You get your money and give to the child. So I decided that if am failing to take care of the six children, what if they become eight, what will happen? So I have to persist on the injectables.—R_≥35

Some women, particularly covert contraceptive users, expressed concern over a lack of confidentiality when interacting with healthcare workers (HCWs), indicating a lack of trust in the provider-client relationship, which then had possible ramifications for their spousal relationships. Low trust with service providers has been reported as an obstacle to seeking out contraceptive services, particularly when providers are part of the same community [25], as one respondent explained:

… some workers in those clinics don’t keep secrets yet you may not want that information to reach your husband… and as you know woman in spreading gossip, it may reach your husband and you get trouble.—U_25–34

The influence of oral testimonials on contraceptive use

Participants discussed some of the societal perceptions of family planning in their communities that either directly or indirectly influenced contraceptive uptake. An example of this was the association of promiscuity and infidelity with women who are contraceptive users, particularly if they were young or unmarried women [see 29, 32, 33, 41]. One participant explained the difficulty such stigma posed for women seeking contraception: “They [young women] face challenges because people talk about them, that what has really forced that young girl to go for family planning! Is it because she is in love with many men?!” Several participants also reiterated that unmarried women who use contraception were perceived to be prostitutes by their community; they explained that the reasoning for this association was driven by the idea that women involved in extra-marital affairs could get pregnant with another man’s child, and therefore used contraceptives to protect themselves.

In discussions about women’s knowledge and opinions about different contraceptive methods, the value and significance of others’ experiences and accounts seemed paramount. Many of the respondents’ comments were preceded by words such as ‘they say’ or ‘people believe’. These accounts were relayed as the beliefs of other women in the community who were either friends, neighbours or relatives of the participants, and was common across women of all ages, and both in urban and rural areas. A few of the testimonies described were positive, and centred on the benefits of family planning. This was particularly common among younger respondents, who highlighted positive aspects such as better health and education of children in a well-spaced family, and an overall better quality of life:

People have a thought that once they go for family planning, their children will attain better education, because they would have planned for them.—R_18–24

People in our community believe in family planning because once you space your children, they don’t fall sick so often, and even if you have a journey [travel], you may not be bothered so much because of the children.—R_18–24

Most participants, however, talked about the harmful consequences of family planning. These centred on negative, sometimes dire health effects heard from other women. Participants’ reliance on other women’s accounts in the community was also apparent from their level of narrative detail around specific family planning methods:

I was somewhere in Busalamu Health Centre II and women who were using [the] injectable method told me that they feel fatigue, their legs pain and even their hands cannot lift a hoe and [they] feel as if the intestines are burning inside the stomach so I do not know what causes that.—R_≥35

Similarly, some respondents related compelling accounts of other negative experiences that they had heard of, for example:

I have my sister-in-law, she used family planning when she had given birth to four children but she now has swellings in her abdomen but she has treated those swelling but they don’t heal and she wants to produce girls but she has failed… because of family planning, an injection.—U_25–34

In many instances, participants spoke of health problems that are not commonly associated with family planning, such as cancer or giving birth to a child with deformities. There was a sense of conviction that contraceptives were to blame for these perceived negative side effects. These accounts were persuasive and convincing that family planning was ‘bad’ because they came from peers, relatives and other women in the community who respondents trusted. However, none of the women seemed to personally know anyone who had experienced these first-hand. A collective, shared sense of fear around possible side effects was embedded in these women’s narratives:

People in this community think that family planning came to affect people like the use of pills, you may swallow and by the time you want to deliver they check when your uterus has been interfered with and say that the eggs (ovaries) are ‘burnt’.—U_18–24

Some of the concerns women had were regarding known contraceptive side effects, such as excessive, continuous bleeding or missed menstrual periods, weight changes and a loss of libido. Women who were covert contraceptive users were fearful of these side effects as it was a way for their partners to potentially discover their contraceptive use. A few women, however, were sceptical about the harms and negative beliefs around contraception. It was evident they based these opinions on their own experiences and the benefits they had derived from family planning:

Some people say that once you go for family planning you don’t produce, you become barren… so they discourage people but I think they are lying because I have used it when I was still at school but when I dropped it, I gave birth immediately.—U_25–34

Women’s contraceptive choices are guided by experience, hardship and motivation

Women who were contraceptive users mentioned a few pivotal considerations in their choice of a contraceptive method. Convenience was a critical factor, particularly when it came to deciding between a short- or long-term method. The hassle of adhering to a daily routine with some short-term methods was emphasized, particularly if this had to be done surreptitiously:

The disadvantages with some methods of family planning is that you get inconvenienced especially when you don’t count the days so well and yet at the same time you have kept it as a secret to your husband. Another one is pills which you may easily forget and miss a day or so.—R_18–24

Respondents who had used long-term methods brought up the inconvenience and costs of having to revisit a trained professional for their implant (or more rarely, intra-uterine device [IUD]) to be removed. Many had since switched to a short-term method:

For me I use Injectaplan but I don’t have any problem […] You don’t suffer to go there, to look for the doctor, as it happens with IUD. With IUD you have to deal with the doctor who inserted it and when you find him, they don’t remove it. An injection is easier to drop.—R_25–34

The reason I prefer an injection is because an IUD takes three years and if you want to remove it before it expires, they tell you to pay 20,000 to remove it… and pills would work better but you may forget to swallow them and even the IUD we fear that it has side effects, making us just left to use injections.—U_25–34

Women’s familiarity and satisfaction with a method was also key in deciding which method to use, as one respondent said, “For me I decide once, say on pills or injectables, because it’s [what] I want… Because I am used to that and I have enough experience in it and it’s what I know and can manage.” When asked if they were satisfied with their current method of choice, participants responses were mixed; some women continued to use a method because the perceived benefits outweighed the challenges they faced, but other women switched or discontinued methods due to side effects. Some participants shared their own personal accounts of the negative side effects of contraceptive use they had experienced. These were mostly related to menstrual irregularities, as well as health effects and pain that interfered with their daily activities, particularly when manual labour was involved:

Family planning makes us women weak, we feel dizzy, back pains and you can’t walk for a long distance because you feel fatigue.—U_≥35

The management of these side effects became problematic when participants had to make repeat visits to the clinic, or bled for very long periods of time; however, on the whole they still benefited from contraceptive use, and therefore persisted despite the challenges they faced:

For me I am not happy because I don’t go into my periods as usual but I may have scanty blood, then after two days, I bleed again and I feel headache and pain in the legs so I have problems with [it] but it has helped me not getting pregnant.—U_18–24

The use of family planning specifically for limiting births was not mentioned by many participants; instead, most women talked about contraceptive use from the perspective of spacing and permanent methods were rarely discussed. When participants talked about long-term methods, they were not discussed in the context of limiting children, but rather in terms of longer spacing between pregnancies.

A few participants, particularly in rural areas, mentioned some of the traditional family planning methods that they had heard of being used ‘in the villages’. Though these accounts had come from other women in the community, the way in which participants described them seemed to imply a sense of certainty in their effectiveness:

There are herbs which you mix with the first menstrual blood, you tie it together, then you hang it up at the front of the door, and once you want to get pregnant, you just remove it and dip it in water.—R_18–24

Some respondents also talked about emergency contraception and abortions as contraceptive options in situations involving unprotected sex and unplanned pregnancies, respectively. However, none of the respondents had personal experience with using these methods themselves; instead, they again described what they had heard from other women. Knowledge around emergency contraception was minimal and in some instances, non-existent. Only a few participants had heard of ‘medicines’ that health workers could give a woman to avoid a pregnancy. The respondents’ reliance on other women’s accounts or experiences as a source of information came through strongly, and most participants talked about home remedies they had heard of or been told about:

I hear that if you have unprotected sex with a man, immediately after sex, squat and squeeze yourself until those things (sperm) get out and a chance may come that you don’t get pregnant.—U_25–34

It is worth noting that these methods were predominantly mentioned by younger participants. Older participants had no information about avoiding a pregnancy after unprotected sex; most of them stated they had no options in such situations.

Where participants supported abortion as an option, often this was restricted to a situation where a woman’s circumstances were considered to justify terminating a pregnancy, such as illness or an extramarital pregnancy. Others considered abortion itself to be unsafe, as one respondent shared: “If I get an unplanned pregnancy, I just wait until I give birth. Because aborting has two options, either to survive or die, so I just deliver”.