Decision-making dynamics in the use of female sterilisation among women living with HIV/ AIDS in Uganda

Abstract

Family planning programmes have shifted focus from controlling population growth by increasing contraceptive use to providing rights-based family planning services. However, the power dynamics that facilitate inequity in contraceptive decision-making persist. This study explored the power dynamics in decision-making regarding the use of female sterilisation as a method of contraception among women living with HIV in Uganda. The study utilised a multiple case study and phenomenology research designs and a qualitative approach to explore the contraception decision-making experiences of women living with HIV. Data were collected using in-depth interviews with 23 women (14 sterilised and 9 using long-term methods) and key informant interviews with 12 healthcare providers. Informal conversations (with 5 out of the 23 women and 6 out of the 12 key informants) and document analysis methods were also used to supplement the data collected from the interviews. Concepts under each level of the social-ecological framework and the intersectionality theory were used to conceptualise the interactions and interdependence between individual-level, micro, and broader macrostructural contexts that influence the contraception decision-making process. The study suggests that contraception decision-making is a complex process influenced by multiple actors and intersecting structural forces operating at various levels of society. Variations in contraception decision-making autonomy and agency seem to have been affected by an intersection between individual-level factors, such as having comprehensive knowledge about all the available contraceptive methods and health status, which interacted with hierarchical and gendered structures of privilege and discrimination at multiple levels of society. These included social and gender norms influenced by reference groups such as peers and family members and macro-level structural factors such as the family planning policy and ethical guidelines. The study recommends that family planning programmes should focus on providing comprehensive information and counselling about the benefits and side effects of all methods of contraception. In addition, the Ministry of Health should collaborate with social networks that reinforce harmful social norms and practices that negatively influence sterilisation use by providing outreach services, recruiting and training Village Health Team members, and utilising peer counsellors to provide information about all methods. Lastly, family planning programmes that aim to deliver rights-based and justice-oriented services for people with diverse needs and experiences should incorporate measures that examine the gendered power dynamics affecting individual and group agency in contraception decision-making at all policy and programme design, implementation, monitoring, and evaluation stages.