• [Image: Dr. Moses Muwonge]

    Dr. Moses Muwonge

    Uganda

    SAMASHA Medical

    “SRHR issues are real, and as a doctor I saw them on a daily basis. What shocked me was the stress girls would have, coming in with many questions but very few answers.”


    “One girl came after she had a good experience, but the condom broke and she didn’t know if she was pregnant. You can do a pregnancy test but it doesn’t always work, so this girl needed emergency contraception. To me that was the most disturbing aspect of the young people: they fear HIV and AIDS more than pregnancy, and they think about the pregnancy once they are pregnant. The other thing that struck me most was that because abortion is illegal, you can’t get one at health facilities, but if you walk in and you are bleeding the doctors will finish the abortion. So many girls go to unqualified doctors and poke with anything they can find, and then the girl bleeds and goes to a real doctor. Some bleed more than others, and often this is the source of women dying from unsafe abortion. Some doctors pierce any part of the cervix, and some women lose a lot of blood. Most often I saw young women coming in after unsafe abortions — women between the ages of 18 and 25. This was partly because I was in a university hospital, but even in the national hospital I was seeing younger people more often than older people. There’s a common trend in terms of abortions. Young people are having problems with abortions and have found a way to get around the law.”


    “The other experience I had was up country, in the north, at Gulu Hospital. This was with stock-outs of contraceptives: condoms, injectibles (which is the most common method) and implants. We only hade pills, so the method mix wasn’t there, and it became difficult, because if a woman is on injectibles and we only have pills, the woman just leaves with no protection. Though there is a wide belief in some circles that pills are convenient, in Ghana this is not always the case. It’s difficult to disguise if you have to take a pill every day, but if you walk the distance to get injections only every three months, your husband doesn’t know.”


    “In 1995 and1996 I was working in a conflict area, and the women would come in the evening and then return home in the morning, as most families would sleep on the streets in the cities where it was safer than the villages. You can imagine such a situation, women want family planning but couldn’t get it. The stock-out was at country level, yet other medicines were coming through despite the conflict.”


    “Often, the national medical storage does not have a choice of contraceptives for the public sector. There is a supplier for the private sector, but it is faith-based, which limits choice.”


    “Choice of method is very, very important. If a young person is not regularly having sex, and has a sexual contact, she does not need daily pills. She may need emergency contraception, but then she goes back to her normal life. If I’m a woman and I have eight kids, and I want to limit this, I need a different method than that young person. Women present to you with different needs. Some are medical, such as being unable to take certain pills. Some just want to limit births, and you can’t tell them to go on pills for three years. We have to help a woman make the right choice for her. Some will say “give me pills,” others say “I just want to have something that I can use once and come back in three years.” Some women react badly, for example, to injectibles, so they need another method. Other women cannot use hormonal methods at all, so they need an IUD. For doctors like myself, it is not right to say we have no other methods. We should be aware that women react differently to different contraceptives. If you don’t offer choice you are not doing a service to the women.”


    “One reason why knowledge about family planning is nearly universal is because you have many civil society organizations (CSOs) working on this, and you have things like radio stations that reach many people. But the reach of the messages is not as good as the reach of the family planning and public health facilities. If someone is 20 kilometres within a village, they know about family planning. CSOs have meetings in the villages. The question is, once I have the knowledge, where can I access the services? That is for the public sector. The more remote areas are most likely to have faith-based health units, for example, the Catholic organizations usually go deeper into villages, but they don’t provide contraceptives. They do talk about family planning and natural methods, and they say if you want modern methods, we can’t provide them here. To me the issue of knowledge and access are not matching up. We need an alternative method so that women can also access services, not just knowledge.”


    “Most social marketing entities and projects do outreach, maybe one outreach in an area in a year. So if anyone misses that, they’ve missed their chance. To me, we have a mis-match between giving out the message and actually providing the services.”




    Other quotes


    “There are social marketing organizations working in Uganda, funded by donor money. However, I don’t think they’re reaching the majority of people because of the fees they charge. However much they talk about cost-recovery, it’s still not reaching the people who need it. Social marketing is good for dissemination of information, letting people know the products are there. That’s when they talk about family planning as a whole, not just one method. Most just promote one, and if you can’t afford you can go to local clinic to get it.”