Table 1
Summary of themes emerging from both focus group and individual interviews for Rubanda and Kiboga Districts
| Themes | Categories | Sub- categories |
| 1. Understanding of Family Planning | Meaning | Child spacing Planning for children Few children |
| Family Planning methods | LARCS Natural Permanent methods Short term FP methods |
| 2. Perception of LARCs | Associated /perceived side effects | Prolonged bleeding Low libido Effect on body organs Infertility Paralysis of arms |
| Positives | Proper planning for family Adequacy of resources |
| Fears | Separation and single mothers Adultery Challenges with removal or management of side effects Fear that land could be usurped by other tribes Complications in subsequent deliveries Excessive weight gain Conceiving while on a FP method Possibility of twins after using some FP methods |
| | Desires | Balanced sex of children To get the desired number of children |
| 3. Belief systems | Cultural | Belief in natural methods Power-related reasoning Source of labour for the family Expanding and strengthening the clan Gender preference for boys for the inheritance of wealth Wealth gained from dowry. Preservation of or strengthening the clan |
| Religious | Fear of losing leadership position in the church. Not to contravene the teachings |
The following abbreviations below are used in this section of results.
FGD
Focus Group discussion
I
Mean Individual interviews.
R
Refers to participants from Rubanda District, Nyamweru Sub-County
RM
Means participant from Rubanda District, Muko Sub-County
K
Refers to Participants from Kiboga District, Bukomero Sub-County
KD
Means participant from Kiboga District, Dwanilo Sub-County
The meaning of family planning
The findings from this study reveal that a few men were able to define family planning in the following ways.
“Me I understand family planning as giving little spacing between the children” (FGD-K8)
“Family planning means using [the] injections to stop the women from producing” (FGD R1)
Family planning is preventing a woman from producing many children (I K15)
Based on these submissions, it can be inferred that some participants in this study thought family planning means producing only a few children, which is partly incorrect. However, a number of men in both Kiboga and Rubanda Districts seem not to understand family planning and therefore could not answer that question when it was put to them by the researcher. There were variations across the sub-counties in both Rubanda district, with a reasonable number of men in the Muko sub-county having a slightly nuanced understanding of family planning compared to those in the Nyamweru sub-county.
The findings from both Kiboga and Rubanda resonate with findings from studies done in Nigeria and Namibia by Adeoye and Olatunji, [38, 39, 40, 41] which found that most men had knowledge about contraception. However, they are in agreement with the findings of the studies done in Uganda by Thummalachetty et al [42]and another one done by Dougherty et al [43] which found that men had little knowledge about contraceptives and LARCs respectively.
Family Planning methods
When participants were asked about contraceptive methods, a few of them were able to name at least two modern contraceptive methods, with injectable and withdrawal being the most mentioned. Only a few men mentioned any of the LARCs. Still, a big number of men were unable to name any contraceptive methods.
“For me the examples of family planning that I know include the coil that they put in the womb, capsules, and implants” (FGD R7)
“I know there is natural where you use safe days and withdraw. The woman can also use tablets as family planning methods” (FGD K5).
“For me, I know cutting tubes for men and women” (FGD KD4 )
It was evident from this study that the knowledge of contraceptive methods and LARCs, in particular, was limited among men since many of them did not know about LARCs. This finding disconfirms the findings from another study done in Uganda by Dougherty et al[24] and Thummalachetty et al [42] which found that the majority of men knew at least one contraceptive method, suggesting little knowledge on contraceptives. However, the above study as well as the current study confirm that injectables were the most known contraceptive methods while in both studies a limited number of men knew about LARCs. This was contrary to the study done by Zendehdel et al [44] in Iraq which found that men and women had knowledge about contraceptive and LARCs.
Perception of LARCs
All participants had negative perceptions that were a barrier to their support for LARCs use by their rural women. These perceptions were:
Prolonged vaginal bleeding
Prolonged vaginal bleeding means monthly periods associated with prolonged bleeding or an extremely heavy period that lasts over seven days. Participants indicated that LARCs cause continuous vaginal bleeding among women that use them and submitted this as one of the reasons they did not support their partners using LARCs. In the following quotations, participants gave their responses.
“When our women use an implant or a capsule (IUD), they make them bleed non-stop. As a man, you can imagine what we feel spending a long time without touching your wife. I cannot allow my wife to use family planning method” (FGD R 7).
“I also hear that women bleed too much if they use those methods” (I RM 43)
These findings are consistent with a study done in China by Luo et al., [45, 46] which found irregular vaginal bleeding as a strong barrier to LARCs uptake, leaving the men starved of sex for a long time. The majority of men believed in this and gave it as a reason why they did not recommend their wives using the LARCs. According to Melville [47] about 20% of implant users experience amenorrhea, while up to 50% experience intermittent, regular, or protracted vaginal bleeding. Users of Implanon are more likely to experience infrequent or no menstrual bleeding than experience irregular bleeding [48]. The IUDs users might also experience some prolonged and heavy monthly bleeding or intermittent bleeding [49]. Although prolonged vaginal bleeding is a known side effect of LARCs, it can be well managed by service providers if the women experiencing it visited health facilities [48]. However, when men perceive LARCs as a method that will starve them sexually, the majority cannot accept their wives using such a method. This could be the reason for the low use of LARCs in the two regions that are settings in this study.
Low libido
Low libido is a decrease in sexual desire. The findings from Rubanda and Kiboga districts verified that men perceive LARCs as a method that lowers libido for both women and men. Participants indicated that LARCs make women’s sexual desires lower, subsequently lowering the frequency of sexual intercourse with their husbands. In other cases, some men also end up having their libido lowered. Most participants from both districts expressed their unwillingness to accept the use of LARCs by their women due to the perceived loss of libido as a consequence. The quotations below are representative of the responses of some respondents.
“The LARCs make our women impotent and unresponsive when aroused in preparation for doing the adult game of the bed” (FGD-R1).
“When a woman is using the capsule in the arm and in the womb, she becomes less interested in sexual intercourse and when you touch her, it is as if she is a log in bed” (I-K11).
“When a woman is using family planning, it also affects their husband’s libido which reduces” (I-RM 44)
The loss of libido by women is associated with women using Depot medroxyprogesterone acetate (DMPA), Implants and vaginal rings but not hormonal IUDs or non-hormonal IUDs [50]. However, the concern over loss of libido by men is consistent with a study done in Sweden by Omar et al [51] who raised fears that modern contraceptive use could affect future fertility. As a result of these side effects, male partners find it undesirable for their women to use all the LARCs even when this effect is not experienced by all the women.
There is, however, no literature confirming loss of libido in men whose wives use LARCs. This could be just a psychological belief held by men due to limited knowledge about LARCs [52]. A study by Caruso et al [53] found higher interest in sexual intercourse in Implant users which disproves the views of participants that LARCs cause low libido in women users. This is also supported by the study done Guida et al [54] which found improvement in sexual life among LARCs users.
These revelations suggest great a need to educate both men more on LARCs, including the benefits and possible side effects and where their partner can get help for the management of the side effects in case they arise. If the issue of low libido among men is not managed psychologically and medically, both men and women could continue shunning the use of LARCs, and their utilization may remain low despite the many benefits in reducing unplanned pregnancies.
Effect on the body organs
Under this sub-category, it emerged that a number of men think that LARCs affect the organs of women and theirs too. The participants indicated that the use of LARCs makes the reproductive organ of their women very small and sometimes they are unable to penetrate during a sexual encounter. They also indicated that LARCs make their penis smaller, weaker, and unable to satisfy their women. The participants of this study also thought that when a woman used implants or IUDs, the methods disappear into the stomach and the heart which could cause other problems such as cancers, “pressure” (hypertension), and other swellings in the body. This finding resonates with what Boivin, Carrier, Zulu and Edwards [37] found in their study, in spite of the fact that there is not much published literature to support this assertion.
The incorrect information that men have makes them reluctant to support the use of LARCs by their women [38]. Some participants expressed fears that LARCs can burn the women “eggs” hence rendering them never to produce again. Below are the vignettes from selected participants.
“We have heard some women using the capsule in the arm which disappears and ends up in the heart where it causes heart diseases and pressure” (I-K15).
“Some of the women who use a capsule that is put in the womb end up causing swellings in the stomach and … cancer” (FGD-R10)
“When a woman uses family planning, they become very weak and cannot manage to do day-to-day work like digging in the gardens and going to look for firewood and fetching water. I cannot allow mine to use any family planning because of those bad outcomes” (FGD-RM 13).
This finding correlates with the findings from a study by Boivin et al [55] which found similar fears by men of contraceptives burning the egg. The findings in Rubanda and Kiboga districts resonate with those from a study done in Ethiopia [56] which found that participants feared using LARCs for various reasons such as disappearance of implants in the body to IUDs perceived as causing cancers and damage to the genitals.
Infertility
Infertility refers to inability to conceive and have a baby which could happen either in men or women. Under this sub-category, the majority of men believe that using LARCs leads to a delayed return to fertility or permanent infertility. For this reason, most men indicated a preference for short-term or natural family planning to LARCs. Even though the LARCs are reversible, it appears many men lack that enlightment, hence the negative perceptions they have based on the wrong information. Below are some of the submissions from men under this sub-category as indicated below.
“Some women take longer to get pregnant when the period of using the long-term family method is done which is not good when a man wants another child” (FGD-KD1).
“Women who use long-acting family planning do not produce again when they stop the method because all the eggs in a woman are already destroyed. This is bad when they still have few children …making family planning bad” (FGD-R1).
“Child may die and if there is a need to produce another one and the woman has been on a long-acting family planning it may be hard to reverse the process” (I KD15)
The current study arrived at similar findings to one conducted in Malawi [57] which verified the fear of side effects as a barrier to the uptake of Implants and IUDs. The fear of barrenness and delayed conception from the current study concurs with the findings of a study done in Ethiopia [58] which found the husband’s support for contraception was closely related to the belief that they cause infertility, in tandem with the study done in Uganda [42] which found that men were concerned about infertility caused by IUDs.
The available literature shows that both Implants and IUDs do not cause infertility, nor do they delay the return to fertility after stopping their use since they are reversible contraceptives [48]. Since a significant number of men seem not to understand the reversibility of LARCs, it could be the reason why they do not support their wives using the same contraceptive methods as supported by the two studies [59, 45] which found that non-use of LARCs by women was due to fear of impairing future fertility and harming the body by the same method.
The findings from the current study also agree with a study done in Uganda which confirmed that contraceptive use was lower among women who were convinced the methods affected their future fertility [60]. The finding in the current study also relates to those in studies done in California and Kenya [61, 46], which verified that fears of infertility among the participants are significant barriers to use them. Similarly, a study done in China [45] found that the concern about future infertility was a major barrier to the uptake of IUDs.
Separation of couples and single mothers
Participants felt that LARCs could cause the separation of couples as a result of domestic violence, especially when the woman used the method without approval from her husband. This is echoed in the following submission: “A woman using family planning (LARCs) becomes less interested in having a sexual meeting with her husband and when a man tries to eat things by force, a fight erupts, and the woman ends up separating from the husband to become a single mother” (I-K 13)
Some participants also thought that the use of LARCs leads to low libido in women when the men want to have sex with them, and they refuse. As a result, the men could end up abandoning such women and finding solace in alternative women and those abandoned end up as single mothers. The following vignette captures this sentiment: “When your woman is using a family planning method that takes long in the body, her power in bed reduces and this can cause a man to look for another woman leading to separation of the couple” (FGD KD 3).
To avoid such a scenario of separation, participants mentioned that they would rather not allow their women to use a LARC in favour of short-term and natural contraceptive methods. Some of the participants felt that when women are using LARCs, they end up having very few children and should they disagree with their husbands, the women move on. This is because they are still attractive as they have not produced many children, hence easily find other men to remarry. For this reason, participants were not in favour of their wives using LARCs. This assertion came out in Kiboga District but was not as voiced in Rubanda District. This could be attributed to the fact that the Bakiga men despise women who are separated from their husbands, unlike Buganda cultures where separation is something normal.
“Women who use long-acting family planning may leave marriages because they don’t have many children there and they are still attractive to other men” (FGD K4).
“A woman easily leaves the marriage if they don’t have many children with the man” (FGD K5)
This current finding correlates with the one study conducted in Ethiopia [58] which established that women feared using contraceptives because they believed they would become infertile leading to their husbands abandoning them. This is, however, different from the finding in the current study where men are the ones fearing that their wives would leave them for new men. Similarly, a study done in Nigeria found that some men send away women using contraceptives from their homes, leading to separation [40]. Separation is also identified in another study done in Kenya [46] which found the same fears among men.
Adultery
The findings from the current study indicate that men feel that once their wives use LARCs, they know they are safe from getting pregnant from extra-marital sexual affairs. Participants from both Rubanda and Kiboga Districts, therefore, felt that LARCs can lead to adultery amongst the women. The same assertion is also true for men who think that once their women use LARCs, the perceived low libido of the men leads them to go for other women who are sexy and therefore able to satisfy them. Participants indicated that this has resulted in both men and women acquiring sexually transmitted diseases including HIV/AIDS.
“Because the woman knows that she cannot be impregnated by another man when she goes out while using a long-term family planning method, this encourages her to continue cheating” (FGD R4).
“Women who are using a long-acting family planning method, tend to be cheaters because they are not worried of being impregnated by other men. So, family planning encourages cheating and I do not support it” (FGD RM 35).
“A woman who is using a family planning method especially those that take long will engage in going out for other men because she knows she will not get pregnant since she is protected” (FGD-KD 1).
“A woman who is using a long-term family planning method is very tricky; she can easily sleep with other men as she is sure she can never get pregnant” (I-K14).
The fear of adultery by men in this study relates to the finding in another study [63] done in Kenya which indicated that participants feared using contraceptives because they thought their partners would suspect them of infidelity. In the same study, women had the same fear that using contraceptives would drive their male partners into extra-marital affairs. The fear of infidelity is also identified by Mwaisaka et al [46].
Therefore, participants of the current study had reservations in allowing their women to use the LARCs to avoid adultery and cheating in their families. These findings from Rubanda and Kiboga Districts also is supported by findings from a study [64] that found allowing women to use contraceptives would make them healthy, pretty and attractive to other men. Due to this belief, men in Rubanda and Kiboga Districts cannot allow their wives to use LARCs.
Challenges with removal or management of side effects
Participants in this study were concerned about their wives using LARCs because they are inserted for free at health facilities. However, when they get problems while using the same methods, they are not helped at the same health facilities. They confirmed that the health providers at the health facilities tell them to wait for people (organizations) that inserted them. This is also true for women who wanted to remove the LARCs.
As a result, men indicated spending a lot of money to have their women get managed for side effects and removal of the devices. This made the participants discourage their wives from using the LARCs.
The quotation below reflects some sentiments expressed by participants.
“When they are calling women to come for family planning to the health centres, they tell them that the services are free but when they get problems and they want the methods removed, they are asked a lot of money or referred to places which require payment” (FGD K 5).
“Usually, women who get family planning services get them for free from Marie Stopes but when women get problems and they want to remove them, they cannot be helped by the health workers at the health centres. We end up spending a lot to remove them from private clinics” (FGD-RM 5).
The finding above is related to that of a study done [65] in South Africa which found that nurses lacked experience with Implanon NXT removals, leading to low uptake of the same method. Lack of LARCs removal services was also verified by women in a study done in Kenya [66]. This, could therefore, mean that the fears that men have are also shared by their women and all contribute to the low uptake of LARCs. It can be deduced that this practice also contributes to the low uptake of LARCs unless the health care providers at the health facilities are well trained in the recommended method.
Fear to lose their land to non-Baganda tribes.
According to some participants in Kiboga District, they felt the government of Uganda was encouraging the Baganda to use LARCs so that they produce few children while other tribes that live in the same district continue without limitations. They thought this could lead to their tribe having a very small population that could lead to their land and wealth being taken over by the non-Baganda tribes, especially the Westerners (Banyakore, Bakiga, Banyarwanda). Some participants indicated that there were many organisations promoting family planning in central Uganda where Kiboga is located, and they thought there were sinister intentions to reduce the population of Baganda in Uganda. Therefore, some Baganda in Kiboga District do not support the use of LARCs so that they could keep their population numbers high. This assertion was from participants in the two sub-counties of Bukomero and Dwanilo in the Kiboga district. Some of the quotations are stated below.
“You see the problem they are telling us Baganda to use family planning (LARCs) when the Banyankole and Banyarwanda are busy producing as many children as they can. They will end up taking our land as many non-Baganda are already owning a very big chunk of land in our district” (FGD-K7).
“Why do they want us to use a long-term type of family planning (LARCs) when other tribes in our sub-county are producing like rabbits? Don’t you think there is a motive for stealing our land as it is already happening? We cannot support such methods of family planning” (FGD-KD 5).
“The population of Baganda is still small and therefore no need to use family planning, especially those methods that work for a long time” (I-K15).
This finding in Kiboga district is not supported by any available literature from studies done both within and outside Uganda. This could be a myth that has spread through the region based on ethnicity and tribal distrust.
Disabled children
According to the findings from both Rubanda and Kiboga Districts, participants feared that their wives could bear disabled children because of LARC use. They stated that some of the women that have used family planning end up not having normal babies. As a result of that, they indicated that they cannot support the use of LARCs as they all desire having healthy children in their families and communities.
“As a man, I cannot allow my wife to use a long-term family planning because when she is to produce again, she may end up producing a disabled child” (FGD-RM 19).
“Some women who use a coil and capsules produce lame babies and therefore I cannot encourage my wife to use them” (I-KD 14)
“Long-acting family planning is not good as they cause disability. Therefore, as a man, I encourage my wife to use natural family planning to avoid problems of such children who are difficult to care for” (FGD-R8).
The fear of producing disabled children arising from the use of LARCs is verified in findings from a study done in Tanzania [67]. Similarly, the findings of the study done in Kenya [46] confirmed the perception that contraceptives could cause disabilities in children born after their use. However, there is no literature that supports the assertion that indeed contraceptives can cause disability in children.
Complications in subsequent deliveries
The participants from both Rubanda and Kiboga Districts indicated that they feared that when their wives use long-acting contraceptives, they could lead to complications in the subsequent deliveries. Participants indicated that the pregnancy complications arising from LARC use often lead to women getting operated on during delivery or even other complications like excessive bleeding before or after delivery. Participants thought that for those women who use LARCs, it becomes hard to push a baby normally through the vagina hence explaining the many caesarian sections where men indicated spending much money to have the operation done. Below are some of the sentiments from selected participants in both Rubanda and Kiboga Districts.
“Since family planning causes women to bleed a lot, it means there will be complications to subsequent pregnancies” (FGD-K4).
“When women use long-acting Family planning, they end up getting complications in the next pregnancies and end up being operated, they become weak and can never function normally at home. For this reason, I cannot allow my wife to use those methods” (FGD-RM 15).
“There are difficulties during labour which lead to operations while giving birth” (I-KD 15).
When men have misinformation and limited information about LARCs, they are more likely to oppose their use by their female partners [52]. However, the available literature shows that it is not true that women who use LARCs end up getting complications in subsequent pregnancies [48]. This finding from the current study concurs with a study in Uganda [42] in which men showed a concern that IUDs could cause future complications in subsequent pregnancies and birth. This also relates to the findings of a study done in Kenya which verified that men feared that the use of IUDs complicated deliveries among their partners [46]. The findings from the current study in Rubanda and Kiboga Districts confirm those from another study done in Uganda [68] where participants indicated that contraceptive use could be the cause for the many caesarian sections happening in their region. There is however no literature to show that contraceptive use leads to complications.
Getting desired number of children
Every family desire to have a particular number of children and this was expressed by participants from both Rubanda and Kiboga Districts. Men expressed the unwillingness to allow their women to use LARCs if they still have few children than those they desire to have. Some participants mentioned that when some women use family planning, they become comfortable because they are free from disturbances that come along with childcare. When men want to have more children to their desired numbers, those women who are already comfortable using LARCs will not accept having more children. Participants also indicated that such women who are comfortable with LARCs end up cheating with other men. Men also indicated that it is because the women know they are free from the risk of getting pregnant by those side lovers. The purported cheating by women and not giving the men more children might lead to gender-based violence according to participants. So, some men thought it is better for them not to allow their women to use LARCs in order to keep their families free from gender-based violence.
“When women use long-acting family planning, they get used to it and become comfortable such that when a man wants more children, they refuse because they have taken long without producing” (FGD RM 48).
“You see some women of these days think that if they produce more children, they grow old very quickly and do not look attractive, so they want to use family planning yet as a husband you feel you still need more children” (I R12).
“As a man, I cannot allow my wife to use a long-acting family planning method except when we have finished producing” (FGD K6).
Several studies conducted in different countries indicate the need to attain a family size before using LARCs was a priority as expressed in different studies [69, 70, 40] in which both women and men alluded to having a modest family before using a contraceptive method. The need for desired children is also supported by studies [71, 52] which found that socio-cultural expectations require a woman to produce both boys and girls. As a consequence, therefore, the use of LARCs is not supported by men especially those who believe they have not produced the desired number of children or the other gender opposite to what they have.
Belief in natural methods
According to participants in both Rubanda and Kiboga Districts, men do not encourage their partners to use family planning and LARCs because their ancestors never used the same methods. The participants claimed that their fore parents used natural contraceptives which worked very well without bothering their women with adverse effects of contraceptives and all the undesirable complications that come with the use of LARCs. The participants, therefore, believed that natural contraceptive methods are better, and work well compared to LARCs.
Similarly, some participants stated that they would rather encourage their partners to use the indigenous natural methods of family planning such as withdrawal, abstinence, herbs tied around the waist area and drinking concoctions to prevent pregnancies. The participants also believed that their female partners should get permission to use contraceptive methods. According to this belief, men participants agreed that women should first seek permission from their husbands before using any contraceptive methods other than natural ones. This also confirmed the patriarchal control that the men have over women.
“Our ancestors never used these long-acting methods that are currently in the system instead they depended on nature which still worked for them without getting any problems” (I KD12)
“We need family planning methods that can keep the woman in her normal state when they use them and therefore natural methods are better” (I K14).
“Our parents and grandparents tell us that they never used family planning and they were able to take good care of all their children. Why should we give long-acting family planning methods that can expose our women to diseases?” (FGD RM 38)
The findings above relate to those of studies done in a Tanzanian study, Kassim and Ndumbaro[67] which found that women preferred using herbs because they had fewer side effects than contemporary contraceptive methods, including LARCs. Additionally, this study underscores the findings from a study done in Nigeria and Ethiopia, which confirmed that men preferred natural methods to modern contraceptives because they believed that they were free from side effects [40]. In consideration of the failure rate of Natural methods, which is very high compared to LARCs, more women should be opting for LARCs other than natural methods, which is not the case. As shown by the findings of this study, men could be deciding for women to take up less effective contraceptive natural methods instead of encouraging them to take up more effective LARCs methods. The failure rates of natural methods that men are expressing to support are as follows: fertility awareness method has a failure rate of two to five percent for ideal users and 12 to 24% for typical users; lactational amenorrhea has 2% failure rate, and coitus interruptus has a failure rate of about 22% effective [72]. For LARCs, Intrauterine devices (IUDs), and contraceptive implants, they are very effective methods with a failure rate of 0.1% for hormonal IUDs, 0.8% for Copper T IUD (ParaGard), and 0.4% for implants [73].
Source of labour for the family
The participants expressed that the more children they have, the more labour they provide to the family for food production if the family has enough land. Therefore, some participants indicated that they are not in support of their wives using LARCs because they take many years and are not sure if their women will produce again. They also indicated that this might reduce their chances of having as many children as possible to provide labour for food production for generating cash in the homes. Some of the quotations from participants are stated below.
“If a family has many children and they go to cultivate, they dig a very big area for food production, and you will find such a family had enough food and money from selling excess food” (FGD R2).
“I am a coffee farmer and I need labor to help in this venture, I need many children who will help me to plant and manage the coffee and for this reason, I only support my wife to use short-term family planning methods and not LARCs” (FGD K 5).
Families in Africa consider many children as a source of labour as supported by a study done in Nigeria [40] which states that families preferred to have many children to provide labour. This finding is also consolidated in another study done in Ethiopia where many children were preferred as a source of labour for the family [56]. However, it is not a must that having many children translates to direct labour for the family. Instead, many children especially in many parts of Uganda where there is already a problem of limited land can be a danger to the family and the community. In some cases, the many children can end up being engaged in unlawful activities like abusing drugs, rape, theft and dropping out of schools or not even attending any school at all. Therefore, the issue of having many children for family labour should not be reason enough for families not to use LARCs.
Expanding and strengthening the clan
In this sub-category, participants expressed the need to expand and strengthen their clans as the reason why men do not support the use of LARCs by their women. In the Kiboga District in addition to expanding the clan, men stated that they also need to expand the Kiganda tribe to counter the non-Baganda who are producing many children in their districts. Some participants from Rubanda mentioned that a man is viewed as being great by the family size he has in terms of children and wives while participants from Kiboga District expressed that a true Muganda is required to produce many children as required by the Buganda culture. The quotations below highlight the views of men from both the Rubanda and Kiboga Districts.
“I am from the Bahimba clan and in this area, we are only one family so men and my brothers need to produce many children to expand our clan so that when [we] are at the bar we are not overlooked and beaten. Therefore, we cannot allow our women to use long-acting family planning” (I R11)
“I also have to be seen as contributing to expanding my clan and therefore it is not in order for my wife to use long-acting family planning. I will be considered a man when I have many boys to enlarge our clan” (FGD RM 22).
These submissions from both Rubanda and Kiboga Districts are supported by a study done in Ethiopia by [64] which found that cultural leaders were against the use of family planning in preference for big family size to cope with inter and intra-clan competition and other dynamics. Expanding the clan becomes a principal motive for not allowing their wives to use LARCs. This is also supported in studies conducted in Tanzania and South Africa where women submitted that men do not want them to use contraceptives because they feel they have a responsibility of enlarging their clan by producing many children [67, 52].
Preference for boys for wealth inheritance
Wealth was raised by participants as a reason for not allowing their women to use LARCs. They expressed that they needed many children, especially boys, to inherit the riches in their families and therefore if their partners use the LARC, this becomes impossible. Participants said this was because LARCs take a long time and they cannot guarantee that their partners would have children again after using them. This notion is held by men who thought they have enough assets such as land, domestic animals and other properties that generate income for the families.
“That if a man has not produced a boy, he is not considered a man and won’t have a say in public gatherings thus keep producing in order to have boys to inherit property” (FGD RM 22).
“According to our culture and clan, they advise men to produce many children and to have boys that will look after our wealth as heir” (FGD R7)
“As a man, you have to have a boy that will inherit your property and therefore if I do not have boys among my children, I cannot allow my wife to use a long-acting family planning. She must continue producing until when we have boys” (I R15).
“Culture says every child comes with their own blessing so everyone should produce what they can… both boys and girls” (I K12).
“As a man, I should have both boys and girls and if the boys are few, I have to continue producing until when I have a good number of boys. According to our culture, if the man does not have boys to inherit his things, then he is not considered a man” (FGD K7)
‘’A true Buganda family should have a boy in the family who will be heir to his father when he is no more. There, I have only girls and no boy, my wife must continue producing until when God blesses us with boy child’’ (FGD KD4)
According to a study done in Indonesia [74], gender preference by couples reduces the utilisation of contraceptives. The preference for boys is associated with the non-use of family planning methods. A study done in Bangladesh found that women with more boys were more likely to use a contraceptive method compared to those that had more girls [69]. This is also supported by the findings from a study done in Kenya which found that the preference for boys was the reason why families with few boys and many girls avoid using contraceptives. Similarly, low contraceptive utilisation due to a desire for boys over girls was also confirmed in a study done in India [75].
Wealth from Dowries
Another reason given by some participants in the Rubanda District for not allowing their partners to use LARCs was a need for dowry from their daughters. Some participants submitted that when one has many daughters and they all happen to get married, the family amass many cows in the form of dowry and other gifts which improve the wealth of the family. Therefore, allowing women to use LARCs denies the families opportunities of having many girls in the families; hence less dowry in future resulting in limited family wealth.
“When I have many children especially girls and I am lucky they get married, I get cows and that is wealth in the family. So, if I allow my wife to use family planning, you cannot get enough girls and that means few cows” (FGD R9).
“If you produce many girls in the family and they become old, they will get married, and the family will get many cows and goats which are a source of wealth to the family. If the woman uses family planning, she will produce very few children and few cows” (I R 15).
The belief that many girl children are a source of wealth in the form of bride price corroborates the findings from a study done by Harrington et al [71] which found that bride price obligations require women to produce children and use of contraceptives is against the socio-cultural expectations. There is a logic that because a man paid bride-price, some participants in Rubanda District were convinced that women should produce many children both boys and girls for the purpose of recovering the dowry by marrying off the girls in line with a study done in South Africa [52].
Fear of losing a leadership position in the church
In the Rubanda District, some men expressed feared losing leadership positions in the church if they supported LARCs use by their partners. The participants indicated that some of them, as well as their partners, hold powerful leadership positions in the church, and they do not want to be perceived as faltering in their religious convictions. These views were mainly expressed by participants of the Catholic faith and born-again Christian in the two sub-counties of Rubanda District. Below is an aggregate of their sentiments:
“My wife is a leader in the born-again Church and if they know that she is using family planning, they will immediately stop her so for this reason, I cannot encourage her to use a LARC” (FGD RM 31).
“As a Muslim leader, I can only support the use of natural family planning as I will be risking my leadership role in Islam and therefore anything to do with artificial methods is against Islam” (I KD 14)
“As a born-again Christian, if I allow my wife to use a long-term family planning method, I will be bashed for killing the unborn life. I therefore fear that I will be chased. They will chase me away from being a senior member of the church” (I RM 50)
There is no available literature related to the belief of losing leadership positions in Church by participants or their wives if they used LARCs as established in Rubanda District. However, this fear could be directly related to the belief of not wanting to contravene the teachings of their religion. When men or women who are considered religious in the Catholic Church use contraceptive methods including LARCs, the Church would take such men or women as not following the true teachings of the Church and could lose the leadership positions they hold in Church.
Fear of contravening the teachings of the faith
Participants from both Rubanda and Kiboga Districts stated that they do not allow their wives to use contraceptives because it is against the teachings of their faith. This assertion is held by mainly Catholics, Muslims, and born-again Christians but not Anglican participants. They reasoned that using family planning is similar to murdering the unborn baby, yet the Church and Islam encourage their congregants to produce, practice the word and teach against murder. Some participants showed their unwillingness to support their wives’ use of contraceptives including the LARCs except for the use of the natural methods which they believe are God-sent methods. However, in both Rubanda and Kiboga Districts, there were divergent views with some Muslims, Catholics, Anglicans, and born-again Christians stating that the use of LARCs depends on someone’s economic status and not religion. The testimonies below illustrate the diverse views:
“As Catholics, I do not encourage the use of FP by women because it is against the teaching of the bible, and it is tantamount to killing the unborn baby” (GFD-RM 27).
“It is against the teaching of Islam to use modern contraceptives other than natural ones and there I cannot support my wife to use a LARC” (I-KD 15
“As an Anglican, I follow the teaching of the Bible that tell us to produce and fill the world. For that reason, I do not allow the use of long-term Family Planning.” (FGD R10).
“As a Catholic I believe that the use of any family planning even the long-acting one is murder and sin and hence won’t want to commit a big sin by allowing my wife to use a long-acting family planning method” (FGD R4).
These findings from Rubanda, and Kiboga Districts are supported by related studies done in Uganda, East Africa, and globally. According to Mathys [76], religion was one of the key barriers to contraceptive uptake in Uganda, although some religious leaders accepted spacing the children in opposition to the teachings of their religions in private. This is supported by another study done in Uganda [77] which confirmed that religion was one of the predictors of non-use of contraception. In agreement, Kabagenyi et al [78], found that the demand for contraceptives was influenced by religion, with the Catholic having a higher odd of demand for contraceptive services. The current study finding shows how religious and the intensity of religious sentiments continue to significantly influence reproductive behaviours and decision-making in the utilisation of contraceptives including LARCs.