Contributors. District health workers attribute the trends to lack of outreaches to familiarise the community with the different family planning methods on the market. Some health workers also lack practical training with permanent family planning methods and drugs writes Gillian Nantume
On average, every month, 10 out of 60 women who report to the maternity ward of Iki Iki Health Centre III in Budaka District for delivery are first-time teenage mothers.
Maureen Nasio, 18, recovering from the delivery of her second child, is one of such women.
“I gave birth to my first child when I was 16 years,” she says, adding: “Many of my schoolmates at the time were also pregnant. None of us knew about family planning. Even now, the midwife has told me about the need to space my children but I want to produce at least four children before I can use family planning.”
Across from Nasio’s bed, is another teenager, Brenda Nawulere, 17, who is cradling her one-day-old baby.
During a constituency field visit to Budaka and Kibuku districts organised by Reproductive Health Uganda (RHU) for Parliamentarians, Ministry of Health (MoH), and Partners in Population and Development (PPD) on September 13-15, 2017, it was discovered that the prevalence of teenage pregnancy is high.
According to the UDHS 2016, in the eastern Uganda, 22 per cent of girls aged 15-19 have had a live birth already, while 7.5 per cent of teenagers are pregnant with their first child.
In Kibuku District alone, 23.6 per cent of the women who attend antenatal care are teenage mothers who were still in school before they got pregnant.
Uganda’s commitment to family planning
Family planning services in Uganda began in 1957 in urban areas, and through the years, there has been integration at the rural level.
According to a Family Planning 2020 (FP2020) Progress Report, Momentum at the Midpoint, 2015-2016, released on November 1, 2016, the demand for family planning across Uganda is growing and contraceptive use is now common. In fact, in the four years from 2012 to 2016, 613,000 women requested for a modern contraceptive method for the first time.
As a result, in the last year alone, the country averted 595,000 unintended pregnancies and prevented 1,000 maternal deaths through the use of modern contraceptives.
At the July 2017 London Summit on Family Planning, the government revised its targets to reduce unmet need for family planning to 10 per cent and to increase the modern contraceptive prevalence rate among all women to 50 per cent.
Family not a priority for districts
However, with a national growth rate of three per cent per year, and a fertility rate of 5.8 per cent, it would appear that Ugandans are not buying family planning. According to the current reproductive health indicators, at 33.9 per cent, the modern contraceptive prevalence rate for the country is low. The median age at first contraceptive use is 21.5, and 70 per cent of sexually active women aged 15-24 do not use contraception.
In Budaka District, it is still common to find women who have delivered 16 children. Iki Iki Health Centre III serves a population of 19,286, however, according to Dr Samuel Lyada, the medical officer, only one midwife is trained in offering permanent family planning methods, such as, injectaplan and IUDs.
“As a result, few mothers use permanent family planning, and even then, we send them to Mbale Hospital. However, Marie Stopes, helps us by coming here to offer other family planning services twice a week.”
Even then, for the last financial year, the health centre only received emergency pills and injectaplan from National Medical Stores. “For the last financial year, we have not received routine family planning pills because we did not request for them. Most women prefer to use injectaplan so if we request for pills they will expire.”
The health centre does not carry out health outreaches to familiarise the community with the different family planning methods on the market. As such, they are conditioning the population to only one method – injectaplan.
“We submit our procurement plans in advance instead of following the current trends of what methods the women what to us,” Dr Lyada says.
The situation is no better in Kibuku District, with a 26.4 per cent contraceptive prevalence rate. Dr Ahmed Bumba, senior medical officer, admits that his health workers do not have practical training with permanent family planning methods. Drug stock outs are also a major problem. In the last financial year, the district did not receive contraceptive pills. Only low quantities of inplants and injectaplan were delivered.
“The quarterly budget for health in the district is Shs5.2m so we cannot prioritise family planning services by requesting for more contraceptives,” Dr Bumba says.
However, William Sango, the Acting in-charge of Kibuku Health Centre IV puts the blame on NMS. “We order for drugs and NMS tells us they do not have supplies of these drugs. Then, out of nowhere, they bring the drugs, but when you open the boxes, you discover they have a shelf life of only one month.”
In both districts, the shortfalls of family planning commodities are met by Marie Stopes and RHU.
Family planning has been left to development partners. Marie Stopes is carrying the burden of providing family planning services – especially the permanent methods – at almost every health centre in the country.
While it is good that development partners are complimenting government’s work this cannot be sustained. These organisations work within specific time frames which are funded by donor money. When the funds periods come to an end, government health centres will be left bereft of the personnel offering family planning services.
The youth are being neglected
In both Budaka and Kibuku, none of the health centres have youth friendly corners where they offer tailor-made family planning services to the youth. Even the youth who attend the Antiretroviral Treatment (ART) clinics are attended to with the adults in the clinics.
At Iki Iki, in July 2017, 10 girls below the age of 18 gave birth. In August, 8 girls below 18 gave birth. According to Dr Lyada, every month, the health centre deals with about 10 abortion cases.
“These are the ones who come to us, but there are many who carry out abortions in their homes and never visit the health centre for treatment. As a health centre, we do not have the skills in managing post-abortion care.”
Agnes Baku Chandia, a senior principal nursing officer, reproductive health, with the Ministry of Health advises that the only way to save youths from the dangers of abortion is to strengthen family planning services.
“There is a need to offer age-appropriate information to children who are between 10-14 years so that by the time they reach 15 years they can be taken through family planning information.”
Hon Dr Michael Bukenya, chairperson of the Parliamentary Committee on Health, says the fact that children as young as 13 years are having sex means the high school dropout rate must be dealt with.
“Teenage pregnancy is a big issue all over the country and family planning alone cannot stop it. It needs a multi-sectoral approach. This is a conservative society that does not want to use science to do some things. MoH is struggling to come up with a policy that can cater for both conservatism and what is on the ground. Should we give children contraceptives? Should we give them family planning information or give it to their parents? As a country, we need to agree on a way forward.”
Jackson Chekweko, the executive director, RHU, says although family planning is being embraced by some of the youth, there are still misconceptions.
“Young people are moving faster than the system although they have challenges in managing the side effects of different family planning methods. Unfortunately, health centres are moving slowly to address them, yet family planning is the only hope that can reverse high prevalence of teenage pregnancy.”
How the situation can be improved. Family planning reduces maternal mortality rates and is an area that the country can use to reach the middle income status. In November 2014, the government through MoH developed the Uganda Costed Implementation Plan (CIP) 2015-2020 for family planning with a goal to reduce unmet need for family planning to 10 per cent (from 34 per cent) and to increase the modern contraceptive prevalence rate among married women to 50 per cent (from 30 per cent) by 2020.
One of the strategic priorities of the CIP is to increase age-appropriate information, access and utilization of family planning among young people aged 10-24 years. The second priority is to promote and nurture change in social and individual behaviour to address myths and misconceptions, side effects, and improve acceptance and continued use of family planning to prevent unintended pregnancies.
This shows that government still has some commitment towards the provision of family planning services. However, there is need for districts to look at extra budgetary sources to supply family planning commodities to women and girls.
Chandia advises that districts should seek alternative distribution from UHMG to bridge the gaps in delivery of family planning commodities. “Commodity and supply is core and MoH has ensured that family planning commodities are on the list of the essential drugs. However, the districts have to request for those commodities from NMS according to the needs of the beneficiaries. Districts that cannot appropriate how much they need, such as Budaka and Kibuku, should be supported by MoH in their planning sessions and in cascading the commodities thoughout the quarters of the year. NMS can only supply what the district has requested for.”
District health officials should also take advantage of family planning training offered by the MoH throughout the year so that their staff can update their skills.
To solve the problem of community outreaches, MoH is developing a policy of community health workers who will be trained for six months, and then released to take the services to the communities they come from.