Scientific Papers

Perceptions of indigenous ugandan men on the use of long acting reversible contraceptives (LARCs) by rural women | Contraception and Reproductive Medicine


Table 1 Summary of the theme, categories and sub-categories emerging from both focus group and individual interviews for Rubanda and Kiboga Districts

In this part, the following abbreviations below are used.

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.

Perception of LARCs

The study findings revealed that all participants had negative perceptions that were a barrier to the utilisation of LARCs by their rural women. These perceptions included:

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 nonstop. 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 have heard that women who use capsules bleed nonstop, making them very weak and unable to work at home and in the garden. Therefore, to avoid my wife getting such problems, I cannot allow her to use an implant (I RM 9).

“A woman using a family planning method does not see the monthly periods; when they finally come, she will bleed for all the months she missed. This kind of bleeding can kill her; therefore, I cannot allow my wife to use a LARC method (I K15)”.

“Family planning users can bleed profusely and become weak over a long period, and as a man, you find you are starved” (FGD-KD 9).

Low libido

The findings from the districts of Rubanda and Kiboga confirmed that men perceive LARCs as a method that reduces sexual strength in both men and women. Participants indicated that LARCs reduce women’s sexual desires, resulting in less frequent sexual activity with their spouses. In other instances, the libido of certain males is diminished. Most participants from both districts refused to embrace the use of LARCs by their women due to the perceived loss of libido. The following quotations represent 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).

“I have heard from other men’s experiences that when a woman uses family planning, their husband’s libido decreases also. I also experienced the same when my wife used a family planning method as she lost interest in sex which made me also to lose sexual urge. Therefore, for this reason, I cannot allow my wife to use any family planning method” (I-R 14).

Effect on the body organs

Under this sub-category, it became apparent that several men hold that LARCs affect both women’s and their own organs. The participants reported that the use of LARCs reduces the size of women’s reproductive organs to the point where they are unable to penetrate during sexual encounters. In addition, they indicated that LARCs cause their genitalia to become smaller, weakened, and unable to please their women.

When my wife used a coil in the arm, her womanhood became very small, and I could not enter even after taking a long time trying to stimulate her” (I RM11).

The participants in this study also believed that when a woman uses implants or IUDs, the methods can disappear into the stomach and heart, which could lead to additional health issues such as malignancies, “pressure” (hypertension), and other complications in the body. The following are excerpts 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).

“Family planning makes women who use it very weak and yet they have a lot of work to do at home. It also makes women become regularly sick“(FGD-RM 7).

Infertility of women

Infertility is the inability to conceive and produce a child and can affect men or women. A majority of men in this study believe that LARC use results in a delayed return to fertility or lifelong infertility. Therefore, the majority of men favoured short-term or natural methods of contraception over LARCs. Listed below are some of the submissions made by men within this sub-category.

“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).

Domestic violence, separation of couples and single mothers

Participants thought the LARCs might lead couples to separate due to domestic violence, particularly when the woman used the method without her husband’s consent. 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 have sex by force, a fight erupts, and the woman ends up separating from the husband to become a single mother” (I-K 13).

Some participants believed using LARCs contributes to reduced libido in women, and when men seek sex, they decline. As a result, the men may leave those women and seek solace with other women, leaving them as single mothers. The following quotation 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).

Participants stated that they would prefer their women use short-term and natural contraceptive methods over LARCs to avoid such a situation.

Some participants thought that when women use LARCs, they have very few children, and if they disagree with their spouses, they leave the relationship. This is because they are still attractive to other men. After all, they have not had many children, allowing them to remarry quickly. Participants were against their spouses using LARCs for this reason. This assertion was expressed in Kiboga District but not in Rubanda District.

“Women who use long-acting family planning may leave marriages because they don’t have many children and are still attractive to other men” (FGD K4).

“A woman easily leaves the marriage if they don’t have many children with the man. Therefore, if I allow my wife to use family planning, we will only have a few children, and in case of any misunderstanding, she can easily run away from me. In order to protect my marriage, I cannot allow my wife to use a long-acting family planning method” (FGD K5).

Challenges with removal or management of side effects

Some participants expressed concern about their wives using LARCs because they are inserted for free at health facilities. Still, when the time for removal comes, or their wives get challenges with this method, 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 (organisations) that inserted them. This is also true for women who want to remove the LARCs. As a result, men indicated spending a lot of money to get their women managed for side effects and removal of the devices. 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).

“I cannot accept that my wife uses a capsule in the arm because when the time for removing them comes, the health workers at the health centre cannot help as they want money” (I-RM 4).

“Usually, women who get family planning services get them for free from Marie Stopes, but when they get problems and want to remove them, they cannot be helped by the nearby health facility workers at the public health centres. We spend a lot to remove them from private clinics” (FGD-RM 5).

LARCs use leads to adultery

Men believe that if their spouses use LARCs, they are unlikely to be impregnated as a result of extramarital sexual relations, and this will encourage them into such relationships, according to the findings of this study. Therefore, participants from the Rubanda and Kiboga districts believed that LARCs could result in infidelity among women. The same assertion holds for men who believe that, once their partners begin using LARCs, their diminished libido will cause them to seek satisfaction from other attractive women. According to the participants, this has led both men and women to contract sexually transmitted diseases, such as 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 using a long-acting family planning method tend to be cheaters because they are not worried about being impregnated by other men. So, family planning encourages cheating, and I do not support it to save my marriage” (FGD RM 8).

“A woman who is using a family planning method, especially those that take long, will go out for other men because she knows she will not get pregnant since she is protected” (FGD-KD 1).

“A woman 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. For this reason, I can never allow my wife to use such family planning methods. Natural ones are better for her” (I-K14).

Fear of losing their land to other tribes

Some participants in Kiboga District thought the Ugandan government was encouraging the Baganda to use LARCs so that they would have fewer children. In contrast, other ethnic groups in the same district continued producing without restrictions, according to the same participants. They were concerned that non-Baganda tribes, particularly those from the West (Banyakore, Bakiga, and Banyarwanda), would seize their land and wealth if their tribe had a small population. Some participants reported that numerous organisations were promoting family planning in central Uganda, where Kiboga is located, and they believed there were evil schemes to reduce the Baganda population in Uganda. Therefore, some Baganda in Kiboga District oppose the use of LARCs so that they can maintain a large population. 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 possible. They will take our land as many non-Baganda already own a huge 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 family planning methods” (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. As a true Muganda, I must produce as many children as possible since our culture allows and encourages it” (I-K15).

LARC use leads to producing children with disability

According to the findings from both the Rubanda and Kiboga districts, participants perceived that LARC use could cause their spouses to give birth to children with disabilities. They claimed that some women who use LARCs have abnormal and disabled children. Consequently, they stated they could not support using LARCs because they want healthy children in their families and communities.

“As a man, I cannot allow my wife to use long-term family planning because when she is to produce again, she may end up producing a disabled child” (FGD-RM 16).

“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).

Complications in subsequent deliveries

The Rubanda and Kiboga Districts participants indicated they feared that when their wives use long-acting contraceptives, they could lead to complications in the subsequent deliveries. Participants suggested that pregnancy complications 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 women who use LARCs, it becomes hard to push a baby, usually through the vagina, explaining the many caesarian sections where men indicated spending much money to have the operation done. Below are some sentiments from selected participants in the Rubanda and Kiboga Districts.

“I have heard that family planning causes women to bleed a lot, which means there will be complications to subsequent pregnancies. Therefore, my wife cannot use those methods to avoid feature complications in her other pregnancies” (FGD-K4).

“The capsules and coils can lead to complications in the succeeding pregnancies, producing weak babies who eventually die. So, allowing my wife to use such contraceptives is out as a way of preventing feature problems of producing” (FGD-RM 9).

“My friend told me that women who use long-acting family planning end up getting complications in the next pregnancies and end up being operated on; they become weak and can never function normally at home” (FGD-RM 15).

“My wife used a family planning method and ended up getting problems during labour after stopping the method. She ended up getting operated on where I spent a lot of money” (I-KD 15).

Discussion of the study findings

The study found that indigenous Ugandan men have negative perceptions that retard support for using LARCs by their rural women. These perceptions include Low libido, effects on the body’s organs, infertility, fear of partner separation leading to single mothers, adultery, and worry that other non-Baganda tribes might seize their land are just a few of these perceptions and fear of producing children with disabilities after using the LARCs.

In this section, the discussions for the study findings are presented in the following paragraphs.

Prolonged vaginal bleeding

These findings are consistent with a study in China by Luo et al. [38, 39], which found irregular vaginal bleeding as a solid barrier to LARCs uptake as men thought it would leave them 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 use the LARCs. About 20% of implant users experience amenorrhea, while up to 50% experience intermittent, regular, or protracted vaginal bleeding [40]. According to available literature, users of Implanon, one of the contraceptive implants (LARC), are more likely to experience infrequent or no menstrual bleeding than experience irregular bleeding, centrally to the perception that participants hold [41]. Although prolonged vaginal bleeding is a known side effect of some LARCs, it can be well managed by service providers if the women experiencing it visit health facilities [39, 42]. 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 in this study.

Low libido

Loss of libido in women is linked to the use of Depot medroxyprogesterone acetate (DMPA) implants and vaginal rings, but not hormonal Intrauterine Devices (IUDs) [43]. The men’s concern over libido loss aligns with a Swedish study by Omar et al. [44], who expressed concern that contemporary contraceptives could affect future fertility. Due to these adverse effects, male companions find it undesirable for their women to use all LARCs, even if not all women experience this effect. There is, however, no evidence that men whose spouses use LARCs experience a loss of libido. Men may hold this perception due to their limited knowledge of LARCs [45]. Caruso et al. [46] discovered in their study that implant users had an increased desire to have sex, disproving the belief among participants that LARCs cause reduced libido in women. This is also corroborated by Guida et al. [47] in a study which revealed an enhancement in sexual activity among LARC users.

Effect on the body organs

According to this study’s findings, indigenous Ugandan men indicated that implants, or IUDs, can disappear into the stomach and heart, leading to additional health issues such as malignancies, “pressure” (hypertension), and other complications in the body. However, this assertion is not supported by any available published literature. This finding could be due to the perception that men have that makes them not support the use of LARCs by their rural women. However, the finding agrees with the results from a study by Boivin, Carrier, Zulu, and Edwards [48], even though there is no published evidence that implants and IUDs, when used, can disappear in the body and cause more problems. The findings in the Rubanda and Kiboga districts are consistent with those done in Ethiopia [49], which found that participants feared using LARCs for a variety of reasons, including the disappearance of implants in the body and the perception that IUDs cause cancer and harm to the genitalia. Some participants feared that LARCs could destroy the “eggs” of women, rendering them incapable of feature reproduction. This finding is consistent with a study by Boivin et al [48], which found that men have similar concerns about contraceptives scorching the embryo. However, this assertion by men is a perception, as no literature supports the claim. The men’s reluctance to support their wives’ use of LARCs is due to the incorrect information they possess about those methods [48,49,50].

Infertility of women

Similar to research conducted in Malawi [51] that confirmed the fear of side effects as an impediment to the adoption of Implants and IUDs, the current study demonstrated that fear of side effects is a barrier to the adoption of Implants and IUDs. Fear of infertility and delayed conception is consistent with the findings of a study conducted in Ethiopia [52] that discovered the husband’s support for contraception was closely related to the belief that they cause infertility, as well as the findings of a study conducted in Uganda [50] that found men were concerned about infertility caused by IUDs.

As reversible contraceptives, implants and IUDs do not cause infertility or delay the return to fertility after cessation of use, according to the available literature [41]. Since many men seem not to understand the reversibility of LARCs, this could explain why they are against their wives utilising the same methods of contraception. This is validated by two studies [53] and [38], which found that the non-use of LARCs by women was due to fear of decreasing future fertility and damaging the body through the same method.

The present study’s findings concur with [54], a Ugandan study that confirmed that contraceptive use was lower among women who believed the methods affected future fertility. Similar conclusions were reached in studies conducted in California and Kenya [55]; [39], which confirmed that participants’ concerns about infertility are significant barriers to their use. Similarly, a study conducted in China [56] discovered that the fear of future infertility was a significant barrier to IUDs adoption. However, studies have shown that some hormonal LARCs may lead to a delay in return to fertility up to one year, which can be misinterpreted by the population as infertility [57, 58].

Domestic violence, separation of couples and single mothers

This finding is consistent with one study conducted in Ethiopia [52], which found that women feared using contraceptives because they believed that if they became infertile, their spouses would leave them. This contrasts the current study’s findings, which indicate that men fear their spouses will abandon them for other men. Similarly, a study conducted in Nigeria found that some males force contraceptive-using women to leave their residences, resulting in separation [42]. Separation was also detected in a second Kenyan study [39] that identified the same concerns among men.

Challenges with removal or management of side effects

As a result of the lack of removal services and management of side effects for LARCs, 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. This finding is related to a study by Adeagbo et al. [58] in South Africa, which found that nurses lacked experience with Implanon NXT removals, leading to low uptake of the same method. The lack of LARCs removal services was also verified by women in a study done in Kenya [59]. This, therefore, could mean that men’s fears are 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 healthcare providers at the health facilities are well-trained in the recommended method.

LARCs use leads to adultery

This study’s findings regarding men’s fear of adultery are consistent with Kenya’s studies [61], in which participants were afraid to use contraceptives because they believed their partners would suspect them of infidelity. In the same study, women feared that using contraceptives would encourage their male companions to engage in extramarital relations. In his research, Mwaisaka et al. [39] also identified fear of adultery as a concern for the use of contraceptives.

Therefore, participants in the current study hesitated to permit their wives to use LARCs to prevent infidelity in their households. In addition to findings from the Rubanda and Kiboga Districts, a study [61] found that permitting women to use contraceptives would make them healthier, more appealing, and more desirable to men. Due to this conviction, men in the districts of Rubanda and Kiboga cannot permit their spouses to use LARCs.

Fear of losing their land to other tribes

No literature from Ugandan or international studies supports this finding in the Kiboga district. This fear might be a widespread myth from tribal distrust and prejudice and the experiences of land acquisition by people from other tribes in the district.

LARC use leads to producing children with disability

The fear of having children with disabilities due to the use of LARCs is supported by research conducted in Tanzania [62]. Similarly, the findings of the study conducted in Kenya [39] corroborated the notion that contraceptives may cause birth defects in children.

Complications in subsequent deliveries

The available literature shows that it is not true that women who use LARCs get complications in their subsequent pregnancies [12]. This finding from the current study concurs with a study in Uganda by [49] in which men were concerned 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 using IUDs complicated deliveries among their partners [39]. The conclusions of the current research in Rubanda and Kiboga Districts confirm those from another study done in Uganda [63], where participants indicated that contraceptive use could cause the many caesarian sections in their region. However, no literature shows that contraceptive use leads to complications. This perception could be related to the limited information the men have regarding LARCs. When men have misinformation and little details on LARCs, they are more likely to oppose their use by their female partners [44].

Study recommendations

The study recommends strengthening social and behavioural change communication through re-orientation and deployment of village health teams and community and religious leaders to sensitise the communities on the benefits of LARCs and address the negative perceptions of men on LARCs. The district health management teams of Rubanda and Kiboga, working with the health facility staff and supported by the implementing partners, should identify, train, and deploy male LARCs satisfied users as champions to disseminate positive and correct information about LARCs. By the champions sharing their positive experiences regarding LARC use in the communities, they could increase the knowledge and understanding of LARCs among men, changing their negative perceptions. The district health management teams of Rubanda and Kiboga, working with the implementing partners, should strengthen service provision, monitoring and evaluation systems for LARCs to address the gaps, such as managing side effects and removal services. Additionally, policymakers should provide a conducive environment for LARCs services where all services, including insertion, removals, and management of side effects, are effectively offered in all health facilities.

Limitations of the study

Despite the study’s empiric findings on the perceptions of Ugandan men regarding the use of LARCs by their rural women, the study has some limitations. The study had a limited sample size and was conducted in a specific geographical area. However, the researcher overcame this limitation by having a more representative sample of 61 participants. Moreover, conducting the study in two distant districts and sub-counties in each district adds improved validity to the study that could be applied to similar contexts. The qualitative nature of this research is subjective and cannot measure how the perceptions influence men’s opposition to LARC use among rural women. This limitation was overcome by recommending more quantitative studies to determine how the perceptions of men influence their opposition to LARCs use. The qualitative research design meant that the study documented the experiences of a relatively small number of participants, which has negative consequences for the generalizability of the study’s findings to other contexts. Due to the context-specific nature of the qualitative study, the analysis and interpretation of the research data were heavily reliant on the researcher’s decisions; however, the same data could have been interpreted differently by another researcher, which could have led to different conclusions.

Despite the limitations above, the results are reliable, valid, and trustworthy. This is especially true because the emic methods used to collect and analyse the data were thorough and were checked by an expert in qualitative research at every step of the data collection, analysis, and reporting process. Even though there are limitations, the results show strong evidence that indigenous Ugandan men have negative perceptions about using LARCs. As a result, the men dissuade the rural women from using those contraceptive methods, justifying the need to mobilise their support for LARC use, which this study addresses.



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