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.
Health
Makerere University Public Health students recount hands-on experience in Ebola case finding in Uganda
On Tuesday January 14, 2025, under the radiant rays of the Ugandan sun, Laura Silovsky crossed the stage at Makerere University’s 75th Graduation Ceremony to receive her master’s degree in Public Health Disaster Management (MDM). Hers is a story of passion, dedication, and curiosity to rewrite the narrative of global education. Among 1,813 master’s graduates, Laura’s story stood out, as a blend of refugee roots, firefighting bravery, and a drive to decolonize learning.
Laura’s journey began long before her arrival in Kampala. Born in the UK to a father who fled from Czechoslovakia’s dictatorship in the 1970s, she grew up understanding displacement intimately. “My father was a refugee. Why would I fear refugees?” she once asked during her research fieldwork in Uganda’s West Nile, where her empathy bridged divides.
“People in Uganda may not expect that a muzungu could be the child of a refugee, but my family experienced displacement from (what was then) Czechoslovakia as well as the effects of the protracted conflict in Northern Ireland. Fortunate to have been born in the UK, I was raised to appreciate that disasters can affect anyone, anywhere, anytime.
After studying Sustainable Development at the University of Edinburgh, I worked on a behavior change project tackling non-communicable diseases in Scotland,” Laura says.
Her journey twisted through battling Australia’s bushfires and volunteering in a COVID pandemic, but it was Uganda’s welcoming refugee policies and Makerere University’s academic excellence that pulled her in next.
“In 2020, I relocated to Australia, just after the worst bushfires since records began and before the COVID-19 pandemic. The following two years, I qualified as a firefighter and supported bushfire recovery by volunteering with a community-based organization. After gaining some insight into these different disasters, I made the decision to return to higher education, and so I applied for the MDM programme at Makerere in 2022,” says Laura.
Armed with experience in emergency response, Laura was drawn to the field’s multidisciplinary nature and was convinced she needed to expand her expertise beyond immediate recovery efforts. She aimed to explore the full disaster management cycle and the intricate connection between health and environment.
“I needed to combine gaining academic knowledge with developing practical skills, so the field placement offered within the master’s degree in Public Health Disaster Management programme was a major motivator for me,” she shared.
The love for Uganda
Studying at the University of Edinburgh, Laura took a class in Kiswahili, that included a field-based short course on the Tanzanian shores of Lake Victoria. This experience sparked a desire to spend more time in the region, but she knew she needed to expand her skill set in order to genuinely add value to an organisation, if she was on the continent.
“I hoped studying at an East African university would teach me invaluable soft skills needed to work more effectively as an international team member. Makerere University School of Public Health (MakSPH) has a strong reputation, and I wanted to study somewhere that was locally grounded but globally recognized. Uganda’s progressive refugee policies were an added incentive to learn from experts here,” Laura says.
Laura’s intentional choice to decolonize her education
“I came to Uganda to learn from the experts here,” Laura declared, rejecting Eurocentric frameworks. “A big factor for me wanting to study at Makerere University was to decolonize my education, to recognize that the knowledge about responding to public health disasters and supporting refugees is here in Uganda,” she says.
She adds, “When I first arrived, I was quite vocal with my classmates about wanting to challenge that bias and truly acknowledge the wealth of knowledge within institutions like Makerere. The expertise here is invaluable, and I was intentional about decolonizing my education.”
At MakSPH, Laura immersed herself in courses like epidemiology, struggled briefly with statistics, but thrived on critical discussion groups and consultation with lecturers.
Collaborating with classmates from Uganda and across East Africa, she learned Luganda phrases and Somali proverbs, and built a “family” united by late-night study sessions and shared ambitions.
Beyond expectations
For Laura, studying at MakSPH was the best decision she could have made. She is still struck by the faculties’ wealth of academic and professional experience in public health and disaster management.
“I anticipated the programme would focus on applying the knowledge we gain to real-world scenarios. Of course, there were cultural differences that took me time to adjust to. I am grateful to faculty members such as Prof. Christopher Garimoi Orach, for his dedication and support, Prof. Elizeus Rutembemberwa for leading by example and valuing students’ time, and Dr. Justine Bukenya and Dr. Simon Kibira for offering their extensive support as my dissertation supervisors.”
The Fieldwork Attachment that Transformed Laura’s Research Experience
At Rhino Camp refugee settlement in West Nile, Laura’s work took on new meaning. Partnering with the Uganda Red Cross Society, she helped digitize data tools and walked long distances through Tika Zone, inspecting latrines and speaking with South Sudanese girls about their challenges in managing their menstrual health through their project that focused on schools.
“That experience in West Nile influenced my own research ideas, and it was a privilege to later return to Rhino Camp for data collection. I will always remember the long days walking with my research assistants through villages and being graciously welcomed by so many respondents,” she recalls, noting that the experiences crystallized her resolve to advocate for refugee dignity globally.
Life in Kampala
Life in Kampala, with its vibrant energy and unique challenges, was truly a ‘full sensory experience’ for Laura. “My parents live in a small village, so Edinburgh felt like a big city when I moved there. And Edinburgh is much smaller and quieter than Kampala! But on weekends, I loved going downtown to shop at Owino Market or heading to Kyadondo Rugby Club for some pork.”
These spaces were perfect for Laura, offering new cultural experiences, including matooke, a starchy dish not found in the UK, which is mainly eaten in Uganda as a local delicacy and staple meal. Despite the differences in culture, sharing meals with classmates provided Laura with a comforting sense of connection.
Back to academics, navigating the university administrative processes wasn’t seamless initially for Laura, though. She says administrative hurdles such as paper-based systems, could change for the university to comfortably enjoy its strong reputation.
She recalls, right at the beginning, when she couldn’t find sufficient information online to support her to complete her application to join Makerere University. However, she later received support from the University’s International Office that deals with the welfare of international students.
Other university officials, from finance, librarians, program administrators, to academic registrars, played a key role in supporting her in her research and postgraduate training. “The system relies on dedicated individuals,” she noted, calling for digital reforms while praising MakSPH’s “atmosphere of innovation.”
“From my experience, such as when obtaining my transcript, the system relies heavily on individual staff members working around these administrative challenges. I’m grateful for those who helped me navigate this, and I’m interested to see how the university continues its digital transition, as it could greatly streamline processes in the future,” says Laura.
A Bittersweet Graduation Day
On graduation day, Laura’s pride mingled with melancholy. Watching families cheer on graduates, she reflected on classmates sidelined by finances or family crises.
Having gone through the course and interacted with Ugandan students, Laura hints on the common financial and personal challenges preventing many from graduating: family illness, new children, sponsorship falling through.
“I know so many of my classmates had worked so hard and were almost over the finish line but, due to financial challenges or other commitments at home, it wasn’t possible for them to graduate this year,” she says.
“For me, I was able to make the choice to pursue this program before having children, so I had fewer responsibilities at home, and I had also been saving for many years to get the money to pay tuition. Because I knew I had the money for tuition before I started, I could focus on studying. As you know, the reality for many people is that that’s not always possible.
“Small supports can transform student experiences,” Laura emphasized, advocating for systemic empathy. She sees great potential for more pastoral support at the university, citing peers from UCU and Kyambogo who benefited from accommodations like private breastfeeding spaces and flexible deadlines in special circumstances. Such initiatives, alongside financial aid, could significantly improve student welfare.
Still, the ceremony’s electric energy—watched via livestream by her parents in Europe—symbolized hope. “Uganda taught me that collaboration transcends borders,” she reflected.
“You could feel this sense of how hard everyone had worked to reach up to that point and that this was really an opportunity for them to celebrate, particularly by having family and friends around to be able to see. I love the PhD awards, when you see the PhD students coming out and their families rushing up to greet them. To me, that’s the best part of the ceremony, because a PhD requires so much work and commitment, and I think it’s really emotional to see everyone share this moment with their support networks,” she says.
Adding that; “…I was so grateful that the ceremony was streamed online. My family were watching live at home in Europe and it was so special that they could see me on camera and participate in the ceremony that way as well.”
Laura noted striking similarities between Makerere and Edinburgh’s ceremonies, especially the moment when students were asked to turn and thank their families, an emotional and powerful tradition.
Looking Ahead
Now in Tanzania, Laura eyes roles with international NGOs, armed with Ugandan-taught pragmatism and a zeal to challenge Europe’s refugee policies. “MakSPH gifted me more than a degree—it reshaped my worldview,” she says.
“As a muzungu with a Ugandan postgraduate education, I feel privileged to have benefitted from different educational perspectives, and I hope that the skills and knowledge I acquired during my time at Makerere will help me to secure a role with an international NGO. After witnessing the incredible support that Uganda provides to refugees, I also hope to advocate for more dignified policies concerning refugees in Europe,” she shares.
“There’s a spirit of innovation and dedication at Makerere, particularly when passionate lecturers like Prof. Orach, Dr. Roy Mayega, or Dr. Victoria Nankabirwa engaged students through discussion and sharing lived experiences. You could really see a different level of engagement within the students as well. Overall, I’ve had such a fantastic experience at Makerere University.”
“I wouldn’t change a thing,” she smiles.“Except maybe convince more Europeans to study here. Africa’s wisdom is the future.”
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