We want birth control: Reproductive health findings in northern Uganda
The Women's Commission for Refugee Women and Children (Women's Commission) and the United Nations Population Fund (UNFPA) conducted a reproductive health (RH) assessment among the conflict-affected populations of northern Uganda in February 2007. Northern Uganda has been embroiled in a civil war for almost 20 years, resulting in the displacement of approximately 1.5 million people. The assessment team visited the districts of Kitgum and Pader and also visited a youth center and clinic in Gulu. In general, the findings revealed that although some basic services were in place, many were sorely lacking.
Although the World Health Organization (WHO) leads the health cluster in the cluster approach aimed to enhance coordination and accountability at the field level, and works collaboratively with UNFPA and the UN Children's Fund (UNICEF), there is a lack of adequate overall coordinationfor RH. Specifically, RH coordination meetings are not in place at the national level and RH is reportedly buried in health coordination meetings that primarily address infectious disease control. However, RH coordination meetings were established in Gulu district approximately one year ago though the meetings reportedly lack vigorous activities and some direction for them would be helpful. In addition, in Pader district a sub-sector working group was established for child and reproductive health though no information about the group was obtained. The overall environment for RH programming is made worse by a significant gap in the coverage of health facilities and a dearth of qualified health care workers resulting in fair to poor RH services in the settings visited. In addition, although Ministry of Health (MoH) protocols for the delivery of comprehensive RH services are developed and were observed at WHO, they are not used at the facility level.
Overall antenatal care coverage was good, although supply gaps were found. Most deliveries take place at home with traditional birth attendants (TBAs). Although UN agencies and nongovernmental organizations (NGOs) had undertaken some training of health workers in life-saving emergency obstetric care for women suffering from complications of pregnancy and delivery, essential materials and supplies were not available in some cases and there were gaps intraining follow-up. In addition, most health workers did not have access to telephones or transportation options to facilitate timely referrals to higher level facilities and hospitals.
Gaps in health workers' knowledge and practice of universal precautions to prevent transmission of infections were significant. Although sexually transmitted infections (STIs) were reportedly common, standardized protocols for syndromic treatment were unavailable.
Many focus group participants appeared to have knowledge about HIV/AIDS and generally good access to HIV/AIDS prevention, treatment and care, perhaps reflecting the success of political will and funding. However, female condoms were not available and some men wanted to use male condoms but did not know how to use them. In addition, there were stock-outs of nevirapine to prevent mother-to-child transmission (PMTCT), post-exposure prophylaxis (PEP) for women and girls surviving rape and a shortage of anti-retroviral treatment drugs in government centers.
Family planning services were very weak and women were desperate to access birth control. Yet many men wanted large families and did not recognize the benefits of birth control; others suspected that their wives were planning affairs if they accessed birth control, resulting in significant discord and some domestic violence. Further, although some family planning supplies were available, women often did not know how to access them.
Sexual abuse and exploitation were reportedly very widespread and appeared to be accepted as a distressing outcome of the poverty associated with war. Rape and domestic violence were also pervasive. Practices relating to gender-based violence (GBV) such as marrying girls to perpetrators, encouraging girls to engage in sexual relationships with men in a position of economic and other power and domestic violence are entrenched in cultural norms and exacerbated by conflict. Services for youth were generally lacking, although a particularly good initiative that combined recreational and educational programs with high quality service delivery was identified in Gulu district.