Health
Research Links Social Support to Improved Contraceptive Decision-Making for Women
Researchers at Makerere University School of Public Health (MakSPH) are urging the Ugandan government to boost healthcare funding to enhance reproductive health services. Dr. Dinah Amongin, an obstetrics and gynecology expert at MakSPH, has expressed concern about the lack of access to family planning methods, which forces women to use less preferred options due to unavailability.
Dr. Amongin notes that within just six months to a year of using contraception, some women encountered issues and switched methods. This highlights the need for the Ministry of Health to improve the availability of various contraceptive options. A rights-based approach to contraception ensures that women have access to a range of methods, preventing situations where desired options are unavailable at health facilities.
“Stockouts are a significant issue, and this extends to parliamentary discussions on health sector budgets. As we focus on human capital development and improving maternal and newborn health outcomes, we must consider crucial components like preventing unwanted pregnancies through family planning. The budget allocation for the health sector directly impacts this issue. When women cannot access their preferred contraceptive methods due to stockouts, it reflects a failure in our legislative and budgeting processes. This situation forces women to switch to fewer desirable methods, which is not acceptable,” says Dr. Amongin.
Adding that; “These are things we need to continue discussing as a country but we must invest into family planning. We can talk about human capital development but until we step up and actually support women to prevent unwanted pregnancies, support them in their decisions of whether she wants to use a method for contraception or not. That is her choice. We must make sure access to the methods of her choice is actually addressed.”
Dr. Amongin’s comments follow a recent study on the I-CAN/Nsobola/An atwero social support intervention, piloted in Mayuge and Oyam districts in 2023. The study highlights that social support significantly improves women’s ability to make informed contraceptive choices, potentially leading to better reproductive health outcomes.
Part of the Innovations for Choice and Autonomy (ICAN) project, the study shows that self-injection with DMPA-SC (Sayana Press) could increase contraceptive use, especially among women with limited access to healthcare. Despite the rollout of this method in 2017, its use remains low in Uganda. Sayana Press as popularly known is a subcutaneous depot medroxyprogesterone acetate (DMPA-SC). It is a hormonal birth control shot, administered under the skin and is an all-in-one contraceptive that puts women in charge of their reproductive health.
Social support boosts self-efficacy, enhances privacy, and reduces access barriers, making self-management easier. Family planning helps manage the number and timing of children, lowering maternal and infant mortality rates and reducing complications from pregnancy. Conversely, unmet contraceptive needs can lead to unintended pregnancies and their associated risks.
In Uganda, 52% of pregnancies are unwanted or mistimed, with over 43% due to unmet family planning needs. The country’s youthful population complicates the issue, with 50% under 17 years old, at least according to the recent National Population Census. Notably, 10% of girls, one in every 10 girls you encounter, has already had sex before she turns 15 years, and 20% of boys, two in 10 boys have engaged in sexual intercourse by the same age.
Methods of contraception include oral contraceptive pills, implants, injectables, patches, vaginal rings, intra uterine devices, condoms, male and female sterilization, lactational amenorrhea methods, withdrawal and fertility awareness-based methods.
Global statistics show that 77.5% of women aged 15–49 had their family planning needs met with modern methods in 2022, up from 67% in 1990. In sub-Saharan Africa, the proportion of women who have their need for family planning satisfied with modern methods (SDG indicator 3.7.1) continues to be among the lowest in the world at 56 per cent. Nevertheless, it also increased faster than in any other region of the world, having more than doubled since 1990, when this proportion was only 24 per cent.
Among 1.9 billion women of reproductive age (15-49 years), an estimated 874 million women use a modern contraceptive method and 92 million, a traditional contraceptive method. The number of modern contraceptive users has nearly doubled worldwide since 1990 (from 467 million). Yet, there are still 164 million women who want to delay or avoid pregnancy and are not using any contraceptive method, and thus are considered to have an unmet need for family planning.
Slow progress is due to factors like limited method choices, restricted access, fear of side effects, cultural opposition, and gender-based barriers.
Between 2015 and 2019, there were 121 million unintended pregnancies annually worldwide – 48 per cent of all pregnancies. Despite decreases in the rate of unintended pregnancy in all regions over the past three decades, nearly one in 10 women in sub-Saharan Africa, Western Asia and Northern Africa, and Oceania (excluding Australia and New Zealand) continue to experience an unintended pregnancy every year
In Uganda, where healthcare services are stretched thin and women juggle numerous responsibilities, accessing contraceptives can be challenging.
Dr. Amongin emphasizes that self-injection methods like DMPA-SC, also known as Sayana Press could ease the burden on women facing long queues and logistical challenges at health facilities. “This method allows for discretion and reduces the need for frequent visits, which is crucial for women with busy lives,” she says.
Researchers argue that the health sector’s budget should include substantial funding for family planning. The high cost of inaction is evident: neglecting family planning leads to unplanned pregnancies, which ultimately burdens families and the nation. Addressing this issue early in the life cycle is crucial to prevent these long-term consequences.
“This is the gist of the matter behind all our research, that a woman’s preference needs to be respected. The health facilities must stock commodities so that when a woman is in need, she actually gets it,” noted Dr. Amongin.
Dr. Peter Waiswa, an Associate Professor at MakSPH, stresses the importance of informed choice in family planning. ICAN studies across Kenya, Malawi, Nigeria, and Uganda show that self-injection benefits all women, including young adolescents. “Supporting young people to make informed choices helps prevent unintended pregnancies,” says Prof. Waiswa.
“We spent four years trying to understand which women benefit from injecting themselves. And we found that all women benefit from it, including younger children. Because younger children in Uganda, whether we hide our heads in the sand or not, especially those 12 years and above are having sex and some of them using contraceptives,” Professor Waiswa says.
What is factually true is that by age 18, 60% of Ugandans have reported having sexual intercourse. Despite the benefits, dropout rates from family planning methods remain high due to side effects and lack of support. Dr. Waiswa also, a Public Health specialist, critique and dreamer for better health systems for mothers, newborns and children in Africa calls for better education and support to address these issues.
“As a way of being supported in a safe space whereby people are not asking questions, they are not fearing parents, they are not fearing other people, then they can use the methods. What we did in Mayuge and Oyam, we trained women who are users of family planning. To identify people who need to use family planning but are not currently using and then they go and see whether they can use or not. And we found that when people are supported, those groups which are currently not being reached can be reached by family planning,” argues Prof. Waiswa.
A 2021 study found that contraceptive discontinuation significantly impacts the effectiveness of family planning services, leading to higher fertility rates, unwanted pregnancies, and induced abortions.
Analysis of data from PMA 2020 show that 6.8% of women discontinued contraceptive use, with discontinuation linked to factors such as age, marital status, method type, and health concerns. The study suggests prioritizing interventions to encourage contraceptive use among young people and promoting partner involvement and awareness, as many contraceptive methods are not discreet.
Prof. Waiswa is concerned of the high dropout rate from family planning methods, where many women discontinue use due to side effects, a need for better education and support.
“We need to see how to educate women so that they are informed when they are choosing a method to use. They need to have enough information because when they discontinue, the method can be ineffective, can cause side effects, but also these methods are expensive, so they waste money. There are a lot of those who change to other methods. We are learning a lot on the use of family planning why we still have a large unmet need,” says Prof. Waiswa.
Ms. Roseline Achola, Technical Specialist for Sexual and Reproductive Health and Self-Care at the Ministry of Health, hailed the MakSPH study on self-injection contraception. She noted that the findings will help her enhance support for self-care initiatives. However, she expressed that only 29% of women willing to self-inject as indicated in the study is still low, highlighting a need to address barriers to increase acceptance as well as managing sexually active adolecents. “We must discuss how to handle minors seeking contraception to prevent unintended pregnancies,” she says.
On Friday August 23, 2024, the Daily Monitor reported, an increase in young girls adopting family planning to combat teenage pregnancies and school dropouts. Quoting data from the Uganda Health Information System, statistics show that between March 2023 and March 2024, 2,476 girls under 15 had their first antenatal care visit, and 1,755 gave birth. The highest number of pregnancies among this age group was in Oyam district.
In this period, Lango subregion saw 52 pregnancies among this age group, with Oyam district recording the highest at 10 cases. The 2021 UNFPA fact sheet indicates that Busoga region, particularly Kamuli and Mayuge districts, has the highest rates of teenage pregnancies, with 6,535 and 6,205 cases respectively.
“As the country, it’s clear that adolescents are limited to access to contraception because of so many reasons. For us as a Ministry, any woman between the age of 15 to 49 is a woman of reproductive age and that tells you that she is capable of getting pregnant and when such a girl of probably 15 years goes to a facility to seek for contraception, it rings a message that actually she is sexually active. So how do we handle her? So that is a matter of discussion for the country.
It is a matter that the nation needs to decide on, because we all know the girls are getting pregnant, the girls want to use contraception, but they have no access because of the fact that they are children,” wondered Achola.
Unintended pregnancies and Uganda’s abortion paradox
Abortion in Uganda, is largely illegal except in specific circumstances. It contributes to maternal death due to unsafe practices. Between 2010 and 2014, WHO reported that 30.6million abortions conducted were safe and 25.1million were unsafe. 97% of these occurred in developing countries. In East Africa, the total number of abortions per year according to the Lancet are around 2.65million.
The Ministry of Health’s HMIS data show a rise in abortion cases, with 96,620 reported between July 2020 and June 2021in both government and private health facilities.
Another recent study on the quality of post-abortion care by MakSPH researchers Assoc. Prof. Lynn Atuyambe, Dr. Justine Bukenya, Dr. Arthur Bagonza and Mr. Sam Etajak highlights the need for accurate post-abortion care data to improve healthcare planning and policymaking.
Dr. Arthur Bagonza, a Public Health Consultant and Research fellow with specialization in health systems at MakSPH and one of the uality of post-abortion care has called for accurate abortion data to improve healthcare planning and policymaking. He notes that health workers often avoid documenting abortion data due to legal fears and calls for reforms to restrictive laws to ensure accurate reporting without legal repercussions.
“All assessed health facilities reviewed in our study achieved a 100% timeliness rate for report submissions. However, significant disparities were observed in data accuracy between different levels of health facilities, with lower-level facilities (HC IIs and HC IIIs) showing higher rates of data discrepancies,” says Dr. Bagonza.
According to Dr. Amongin, the high incidence of early sexual activity among Uganda’s youth is a pressing public health issue.
“We know as a country many women continue to die following unsafe abortions; abortions for pregnancies that they did not want. And these abortions are highest among adolescents and also other women categories.
We would want to ensure that we actually enhance access to contraceptives, but making it easier for them to have it and putting the power in the hands of a woman to as much extent as we can. So that a woman can practice what we call self-care, but of course she also will need the support of the healthcare system. But we want this power in women’s hands because of all the challenges that the women actually can encounter in accessing these methods,” she said.
On her part, Achola insists that abortion should not be a last resort for women and urges them to abstain or use protective means in order to avoid unwanted pregnancies. She notes that as long as abortion remains illegal in Uganda, many health workers will avoid addressing it, leading people to unsafe alternatives.
“I can’t be happy because abortion means we have failed to give people a method of their choice to prevent that pregnancy. Or the people are not able to access contraception to prevent unintended pregnancies. Abortion is not the last resort, it’s not a solution because it has its own complications as well,” says Achola.
Despite this, Achola, notes most of the women who walk in health facilities with post-abortion complications must be attended to. “Whereas we don’t encourage people to do abortions, as Ministry of Health we are mandated to handle all complications for anyone who walks in our facilities because our priority is to save life. We want to urge women to avoid certain things. Why should you wait for unintended pregnancy to occur and then abort?”
Dr. Charles Olaro, a Senior Consultant Surgeon and the Director Health services – Curative in the Ministry of Health highlights the financial burden on individuals seeking health services and suggests exploring private sector opportunities and community-based approaches to improve access. “We need to balance values and rights while addressing access barriers,” he notes.
According to Dr. Olaro, the autonomy and agency of women in sexual and reproductive health, particularly in African cultures remain a challenge where social norms may require women to defer decisions to their partners.
He notes that there is a high burden of abortion and self-harm, with a significant portion of maternal mortality attributed to sepsis, which is often a result of unsafe abortions in Uganda.
“We still need evidence to ensure that access barriers are addressed. And this is a question I keep on asking Makerere University, yes, we have a young population but how are these people accessing contraceptives. Other issue we have to deal with is complex. I know we have to do a balance between values and rights, but we will be able to look at that when they gain the success to do it.”
Dr. Olaro points out that individuals often face a financial burden in health services, spending more on prescriptions than on the medications themselves. He suggests exploring private sector opportunities and a community-based approach to improve access to healthcare.
NB: The PMA surveys are spearheaded by Associate Professor Fredrick Makumbi and Dr. Simon Kibira of MakSPH, with support from the Uganda Bureau of Statistics and the Ministry of Health. The initiative also receives funding from the Bill & Melinda Gates Foundation, The Children’s Investment Fund Foundation (CIFF), and is supported by the Bill & Melinda Gates Institute for Population and Reproductive Health at Johns Hopkins University and Jhpiego.
On 2nd December 2024, Assoc. Professor Bruce Kirenga officially took over as Principal of the College of Health Sciences, Makerere University (MakCHS) in a handover ceremony held in the College Board Room. Dr. Kirenga succeeds Professor Damalie Nakanjako, who successfully completed her four-year term.
The ceremony was attended by members of the MakCHS Administrative Board and key university leaders, including Ag. Deputy Vice Chancellor (Finance and Administration) Professor Henry Alinaitwe, Chief of Human Resources, Mr. Deus Tayari Mujuni, & Deputy University Secretary Mr. Simon Kizito, among others.
In her remarks, Professor Nakanjako reflected on her time in office with gratitude and pride since she assumed office in December 2020. She expressed her full support for MakCHS in contributing towards training and research in Makerere University.
Professor Nakanjako thanked the university top management for the support rendered to during her term of office as Principal. I thank family, friends and colleagues who supported and allowed me share my time with the college, especially beyond official hours.
Dr. Kirenga, a pulmonologist, researcher, and founding director of the Makerere University Lung Institute, expressed his heartfelt gratitude to the Makerere leadership and the search committee for entrusting him with the responsibility of steering the college. He noted; “It’s a true honour to have been entrusted with this role. The search process was rigorous, but I learned so much from the ideas shared by my colleagues—it was a truly honourable competition.”
With a vision for collaboration and growth, Dr. Kirenga outlined his priorities, including improving staffing, improving relationships with teaching hospitals, and addressing infrastructure needs. He emphasized a leadership style rooted in inclusivity and teamwork, saying, “Let’s create a common vision through consultation and work together. I’ll visit every unit in the college to hear directly from staff about their challenges, needs, and ideas for moving forward.”
Dr. Kirenga also shared plans to establish a forum of past leaders to harness their collective wisdom and ensure continuity in leadership.
Four Makerere University School of Public Health (MakSPH) faculty have been inducted for the 2024 Uganda National Academy of Sciences (UNAS) fellowship, a preeminent nation’s most respected scientific bodies. This is the first time MakSPH is scooping a large number of faculty fellows, which was the highest for a single institution. This prestigious honor was awarded on Friday, November 1, 2024, at Four Points by Sheraton Kampala, Uganda.
The recipients are;
⦿ Professor David Guwatudde, a Professor of Epidemiology and Biostatistics at the MakSPH where he has been teaching for over 32 years. In the last decade, Dr. Guwatudde’s research interest has been on characterising the epidemiology, evaluattion and effectiveness of appropriate interventions for prevention and control of selected non-communicable diseases (NCD) especially diabetes and hypertension.
⦿ Dr. Fredrick Edward Makumbi, an Associate Professor of Biostatistics at MakSPH in the Department of Epidemiology and Biostatistics. A seasoned public health professional in Uganda, he is also a Gates Fellow. Through his expertise in population health and the evaluation of public health interventions, Dr. Makumbi has generated significant evidence that impacts the field. He has published over 300 journal articles and leads the PMA project, which focuses on evaluating schistosomiasis and family planning initiatives in Uganda.
⦿ Dr. David Musoke, a Senior Lecturer in the Department of Disease Control and Environmental Health at MakSPH. He serves as the Chair of the Grants and Research Capacity Building Committee at MakSPH and is the President Elect of the International Federation of Environmental Health (IFEH). A graduate of Makerere University, his research interests include environmental health, malaria prevention and community health. He organized the first International Community Health Workers symposium which was held in Uganda, and is an academic editor and reviewer for several journals.
⦿ Dr. Victoria Nankabirwa, an experienced clinical researcher and Lecturer in the Department of Epidemiology and Biostatistics at MakSPH. She holds a PhD from the University of Bergen and is also a member of the WHO Immunization and Vaccine-related Implementation Research (IVIR) Advisory Committee. Her key interests include mother and child outcomes, particularly survival and the impact of immunization.
UNAS is an independent, non-profit, and non-political organization, established and founded in October 2000 to provide Uganda with credible, balanced, and evidence-driven guidance on matters of science and development. Membership is drawn from distinguished scientists and scholars who have made significant, lifelong contributions across diverse fields, including natural and social sciences, arts, and humanities.
The UNAS Fellowship remains one of the nation’s most respected scientific bodies, with over 200 members working collaboratively in interdisciplinary and transdisciplinary fields to address Uganda’s challenges through science and innovation.
Every year, Fellows of the Uganda National Academy of Sciences (FUNAS) have an opportunity to nominate potential fellows into the academy based on their merit, impact and contribution of the world of Science. A nomination stands substantive once it is seconded by another FUNAS, after which the nominees go through a rigorous selection process by a highly competent committee of scholars in the academy.
Once selected and inducted, fellows in the academy devote their time on honorific activities and service provision through arbitrating on contentious national debates such as whether to provide free social services to refugees and whether to use DDT to control Malaria. Since inception on October 20, 2000, the UNAS has distinguished itself as a premier honorific society for eminent scientists in Uganda. It leverages on the expertise and stature of its members to provide pro bono evidence-informed advice to government and Ugandans on science, technology, innovation and sustainable development.
Dr. David Serwadda, an Exemplar Scholar of Makerere University who this year received the prestigious Professor Emeritus title presented the new fellows to the UNAS convention. He described Dr. Nankabirwa as a prolific researcher, with over 80 publications in peer-reviewed journals and an impressive funding portfolio that includes a number of highly competitive research grants.
On her part, Dr. Victoria Nankabirwa said she was grateful for the recognition and pledged to uphold UNAS values.
“I am very thankful for this recognition, and as I reflect on the journey that has brought me to this point, I am reminded that this is not the result of solitary work but of shared aspirations, collaborations, and partnerships. As such, I am very thankful to my nominators and seconders, Prof. David Serwadda and Prof. Rhoda Wanyenze, as well as to my colleagues, my students, and my family, represented by my mum. To these people and to you, I extend my deepest gratitude. I pledge to uphold the academy’s values, advocate for science-driven policies, and mentor future generations. I will work as hard as I can within this FUNAS,” said Dr. Nankabirwa.
Dr. Fredrick Edward Makumbi expressed his gratitude and commitment during his recent induction as a fellow of the Uganda National Academy of Sciences (FUNAS). “I am delighted to have been nominated and accepted as a FUNAS. I am truly appreciative and acknowledge the support of all those who have helped me, from my family to my teachers and colleagues—many of whom are here today. They have supported me and brought me to this great podium. I pledge to continue working, supporting, and promoting the health and well-being of the people of Uganda and beyond through science, as well as mentoring others to ensure a sustainable generation that can uphold the health and well-being of Uganda and beyond. I am glad to be here, and thank you very much,” Dr. Makumbi stated.
Dr. David Musoke is a promising researcher and Senior Lecturer in the Department of Disease Control and Environmental Health at Makerere University’s School of Public Health. He serves as the Chair of the Grants and Research Capacity Building Committee and is the President Elect of the International Federation of Environmental Health (IFEH).
“I am really delighted and humbled to be joining this elite class of academics and scholars as a fellow of UNAS. It is an honor to join many of my mentors from over the years, including my very own father, who is also a fellow of UNAS and is here today, Prof. Miph Musoke. I wish to thank my family—my parents, wife, and children—for all their support, as well as the research teams we have worked with,” said Dr. David Musoke.
Adding that; “I also extend my gratitude to my mentors from the university, Professor David Serwadda and Professor Rhoda Wanyenze, for nominating me, along with all the others who have contributed throughout this journey, including funders, collaborators, the community, and everyone else we work with. I look forward to serving in this capacity and upholding the goals and aims of UNAS, especially in the field of Environmental Health and Community Health.”
Professor Guwatudde, a lead investigator in two national surveys assessing non-communicable disease (NCD) risk factors in his country—first in 2014 and again in 2023—expressed his commitment to tackling NCDs as he was recognized by the Uganda National Academy of Sciences (UNAS).
“I would like to thank the UNAS council, the secretariat, and all members for accepting me as a member,” Prof. Guwatudde said.
“I pledge to contribute in the area of non-communicable diseases. We have conducted extensive research in this country, giving us a clear picture of the NCD burden, a reality that affects us all. I would be glad to share this insight with fellow members,” added Guwatudde.
National academies worldwide provide neutral platforms for experts across disciplines to tackle societal challenges and clarify emerging issues in science, technology, and policy. These institutions play a crucial role in preparing for and responding to global threats such as pandemics. Since its inception, the Uganda National Academy of Sciences (UNAS) has been led by four presidents: Prof. Paul Mugambi (2000-2014), Prof. Nelson Sewankambo (2014-2019), Prof. Peter Mugyenyi (2019-2022), and, since October 2022, Prof. Grace Bantebya-Kyomuhendo, a Professor of Women and Gender Studies at Makerere University—the first female head of the academy.
Prof. Bantebya extended her congratulations to the newly inducted fellows. She emphasized the responsibilities UNAS fellows carry, including upholding the academy’s constitution and contributing to its vision, mission, and objectives. “Our fellows play a critical role in advancing the academy’s goals, and their dedication is vital to our impact on science and policy,” Prof. Bantebya stated.
“Remain academically active. Please listen to that. In meaningful pursuit of academic excellence in your respective areas of expertise. Do not say that now that you have become a fellow, you will stop being academically active. We expect you to continue,” she emphasised.
She also called on the fellows to actively participate in the academy’s conventions, consensus-building efforts, and other activities. Prof. Bantebya emphasized the importance of consensus studies to the academy’s mission, urging fellows to make themselves available when called upon.
“Ensure high standards of conduct based on national and international best practices. We expect you to maintain and ensure high standards yourselves and foster good relations among members as well as with the academy, the general science community, and the public. You also need to meet all the obligations as a fellow of UNAS, whether financial or otherwise, as stipulated,” the Academy President said
A fellow may lose their membership in the academy if they act against the UNAS constitution or bring disrepute to its goals, name, or vision. Membership can also be terminated if a member is convicted by a competent court or authority of a felony or serious crime, or if they are declared bankrupt or of unsound mind.
UNAS’s mission is to foster the welfare and prosperity of the Ugandan people by generating, sharing, and utilizing robust knowledge and insights to deliver independent, merit-based scientific counsel to government and society. As part of the global scientific community, UNAS maintains strong ties with the Network of African Science Academies (NASAC), Network of Science Academies in Islamic Countries (NASIC), the U.S. National Academies, IAP, and TWAS.
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