Reality check: 'I can't afford the big family I had desired'

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 FAMILY MATTERS 

Grace Nyafamba had once heard that "life begins at 40", but never had she thought part of that would mean her being in the mood for more babies in her 40s. Until now.

Already with two adult children — whom she had with her late partner — and an eight-year-old with her current lover, the 43-year-old hairdresser desires to have at least one more child to come close to fulfilling her reproductive goal.

Problem is, her live-in partner does not. 

He has told her he is already financially burdened by two children from his past relationship. Having a fourth would be a step too far.

But Nyafamba, a resident of Kiteezi in Uganda's central district of Wakiso and owner of a modest beauty salon in the same area, is not one to give up easily.

"I told him: 'Okay how about this: Let's have a second child together and I will take full financial responsibility for the child'.

"I could sense he was not comfortable with the idea, but that's how far I was willing to go to get another baby. He reluctantly agreed."

However, a year on and with her salon business not doing so well now amid stiff competition, Nyafamba senses the inevitable.

"Yes, I may have desired four or five children, but the way things are now, financially speaking, plus with my partner not so enthusiastic about expanding our family size, I see myself eventually abandoning the idea," she says.

Nyafamba — one of nine children raised by a widowed mother — lives in a country whose fertility levels, despite declining within the last decade, have remained relatively high.

Official statistics show that today, a woman in Uganda is expected to give birth to an average of four children by the end of her reproductive period. By comparison, that number stagnated at seven children between 1970 and early 2000s, before declining in subsequent years.

Just like Nyafamba, millions of people around the world are not able to create the ideal families they want. While some have more children than they believe ideal, others have fewer offspring than they desire. For various reasons.

"We see it everywhere we look," says Dr Natalia Kanem (pictured below), the executive director of UNFPA, the UN's sexual and reproductive health agency.

That is the "crisis in reproductive agency" that Kanem and fellow campaigners of sexual and reproductive health and rights (SRHR) are seeing happening across the world now.

Reproductive agency here means individuals being able to make their own free and informed choices about everything from having sex to using contraception to starting a family.

Advocates say this fundamental human right is being undermined.

They argue that amid fertility declines globally, some governments are coming up with "drastic measures" to encourage especially young people to make fertility decisions primarily in line with national targets.

World over, people have reportedly had to revise their intended family sizes — either to accommodate fewer children or more.

A study conducted jointly by UNFPA and YouGov, whose report was released this month (June), revealed that the most common number of children desired was two.

And of all the reasons participants of this online survey gave for not having the family sizes they desired, financial limitations — unsurprisingly — topped the list. The second most commonly reported factor was, relatedly, unemployment or job insecurity and the third was housing concerns, such as lack of space or high cost.

In all this, individuals and couples have also been found to experience difficulty preventing unintended pregnancy as well as becoming pregnant at the timing they desire.

In Uganda, for instance, teenage pregnancy and motherhood remains a health and social concern among youths and adolescents. For one, it is associated with high morbidity and mortality for both mother and child.

"One of the biggest challenges we have is that our children give birth early," says Dr Betty Kyadondo, the director of family health at the National Population Council.

"Teenage pregnancy is high. So they [pregnant teens] drop out of school, they don't even think about their future, they continue living with their parents-in-law and there is no future to look to," she adds.

Dr Kyadondo says Uganda is focusing on the quality of the population

Pregnant adolescent girls are also likely to face health problems during delivery because their bodies may not be physically ready compared to older women.

Nyafamba of Kiteezi, who was 16 when she found out she was pregnant with her first child, is among the lucky few teens who did not experience age-related prenatal complications.

With her mother unable to afford to send her and her eight siblings to school, long idle hours spent at their home in Mulago in the capital Kampala inevitably lured an adolescent Nyafamba into covert sexual encounters with a male student.

The teenage boy's family accepted responsibility and provided support to the young couple. They later had a second child, before the young man tragically died after a brief illness in 2014, condemning Nyafamba to single motherhood.

It took a couple of years for her to find a new partner.

Looking back now, the bashful but resolute mother firmly believes that if she had gone to school, she would have delayed having sex long enough to make better and informed decisions about her reproductive choices — and at a more convenient time.

"That's why I was determined to send my children to school. My girl, the eldest, completed Senior Six without getting pregnant. She is now old enough to decide whether or not to have children, when to have them and with whom," she says.

Community pressure

It is a different story for many other people.

Gloria Chelangat, 29, is an anti-FGM campaigner and a member of Youth Action Movement-Uganda, an initiative that empowers young people to make informed and better choices in their lives.

In her native Sebei sub-region in Uganda's east, where the fertility rate of five children per woman is above the national average of four, most women feel socially pressured to produce as many children as they possibly can.

"They never have a say as to how many children they wish to have, especially in the more remote communities," says Kapchorwa-born Chelangat.

"The majority of people we have interacted with in different communities say that 'children are a blessing from God, so we have to keep producing more'.

"Men dictate decisions on family size. For them, children have to be born until the woman reaches her reproductive limit."

Chelangat (2nd from left) says many women in Sebei have limited control over reproductive decisions

Despite the availability of family planning services in parts of Sebei, there is a general aversion to the approach — reportedly mostly by the men.

"When a woman says she wants to start family planning, it becomes a big issue because her partner will firmly tell her: 'You can't block my children'," says Chelangat, who together with other like-minded young people, routinely engage the local communities on SRHR matters.

She admits it is not easy to shift mindsets in communities deeply-rooted in culture like Sebei's.

"Even though someone had wanted to have only one child, at the end of the day they are forced to have more because of pressure from community members.

"Every time, people will keep reminding you: 'When are you having another child? What is happening? Why are you delaying?'," says Chelangat.

Data published by UNFPA in the last five years shows that about one in ten women are unable to decide whether to use contraception. 

Additionally, an estimated one quarter of women are unable to make decisions about their own healthcare. And roughly one quarter of women are unable to say no to sex.

A view of hilly terrain in Kapchorwa, one of the districts in Sebei sub-region

In her household, Chelangat and her husband have convergent views on the sort of family they want.

"I desire to have only the number of children that I can be able to provide for and give the necessary support. My husband, too, wants a number of children we both are able to sustain together. I am glad we think alike," she says.

Theirs is the sort of picture campaigners want to see more of: individuals having caring, supportive partners with whom to share the load of childbearing equitably. They are pushing for "urgent action" to deal with the pervasive fertility crisis — but with interventions different from those currently being implemented.

"Solutions that do not place reproductive choice at the centre have been proven, time and time again, to fail," say the authors of the UNFPA report on fertility.

Adding: "Our goal should not be to engineer fertility rates, but to provide individuals with the information and the means to decide freely and responsibly on the number, spacing and timing of their children.

"A healthy society means ensuring that mothers and children can obtain affordable, accessible and quality healthcare."

Promoters of reproductive agency also say that when planning for their families, people must feel secure in their economic situation and trust that they can find an affordable place to live for themselves and their families.

That includes trusting their political system to prioritize future investments.

But the UN says these conditions "are still out of reach for far too many people".

Among other things, the organization recommends global investments in advancing reproductive autonomy, irrespective of a country’s fertility rate. 

'Quality of population'

Uganda's population size is edging towards the 50 million mark

For Uganda's fertility context, population experts say local attention is on the quality of the people.

"We have not forced or coerced anyone on when individuals or couples should have their children. We have told them to make decisions about their reproductive lives. That's what we have always preached," says Dr Kyadondo of the National Population Council.

"When we talk about fertility, we want to address it from the quality of the population." 

The senior medical doctor says an uneducated and unskilled population means poverty levels remain high.

She speaks of the importance of managing fertility at the family level — so that families are able to take their children to school and the learners gain skills that would in turn open them up to jobs or entrepreneurship opportunities.

And in the broader context, an actively working population means more savings, which by extension contributes to the economic growth of the country.

▪️ 'We need to reconfigure our social protection systems'

At the time the 2024 population census was conducted a little over a year ago, Uganda's literate population was 23.1 million and 25.1 million made up the working age group.

The census also revealed that 1.3 million people were unemployed in a country where nearly half of the population is under 18.

We also learnt that only a little over half of the around 11 million households in Uganda are food-secure. That means millions of other people are not certain about their next meal. Factor in children and that would mean individuals or couples having to think really hard about family size.

With a Ugandan expected to live up to around 68 years, Wakiso-based 29-year-old carpenter Fenekas Mulwana (pictured below) says while he is never certain what the future holds, his focus now is to work hard so that his two young daughters at least attain an education.

He trusts that when they get educated, they will navigate through life more easily.

Mulwana was himself already done with school and 23 when he impregnated a Senior Three student, who dropped out of school as a result. He admits it was reckless of him at the time.

The hostility he says he faced from the girl's family — including threats to have him arrested — and the teenage mother later abandoning the child with him, gave Mulwana a hard life lesson. After failing to trace the mother of his daughter, he decided to play the challenging double parenting role.

"I swore never to mess around with underage girls again. I could have easily ended up in jail. I was very lucky that the girl's parents were forgiving," he recalls. 

Now running his own nascent carpentry business in Wakiso district, Mulwana is settled with a wife he got through the formal traditional means and with whom they now have a daughter — his second child.

The couple, like many young people out there, have thought hard about what sort of world their children would — and should — live in.

"Initially, I had wanted to have six children. But after discussing with my wife, we have since settled for potentially one more because we don't earn that much collectively," he says.

"We don't want to produce many children and they end up suffering."

'I thank God he left me'

While individuals and couples have the right to decide the number, timing and spacing of their children, there is also another common reality that can interrupt these essential human rights: infertility.

As a result of this condition, some families have failed to get complete. Others have fallen apart.

The sperm proteomic analysis measures the levels of different proteins in sperm and can be used to identify potential causes of male infertility

"So many relationships have been broken. People are struggling from one marriage to the next trying to find children and others just totally giving up," says Dr Paul Kibenge, a Ugandan clinical embryologist.

"The sad reality is that we are moving from fertility to infertility."

Infertility is a condition where a woman cannot (or a man fails to make her) pregnant after one year of trying to conceive; without protection.

In its secondary form, at least one prior pregnancy has been achieved.

Although both women and men can experience infertility, often times it is women that are perceived to suffer from the condition — regardless of whether they are infertile or not.

▪️  Fertility practitioners want proposed law fast-tracked

For a long time, Margaret Namatovu had feared that the problem was with her.

After three years of trying to get a child with the man he had formally introduced to her family, with no success, he acrimoniously left her for good thinking she was infertile. The couple, banking on patience, had never sought medical advice.

After being dumped by a man she had loved, what followed were months of emotional stress and the constant feeling of low self-esteem for Namatovu. Thankfully, she was lifted by her family's encouragement to give it another shot. Hesitantly, she obliged.

Now 33 years old, the resident of Mulago in Kampala eventually found a new partner and interestingly, at the first time of trying, she got pregnant.

"When I look back now, I think my previous partner was infertile and we just didn't know. Although I was hurt that he left me, I thank God that he did because it helped me discover I was not the problem," says that mother of two, who is a produce seller at Kalerwe Market in Uganda's capital.

There are many other people like Namatovu — both females and males.

Dr Kibenge, who is also the academic registrar at Sali International School of Fertility Medicine in Bukoto, says infertility breeds stigma for sufferers, including those mistakenly perceived to be infertile.

"In many cultures, in Africa and beyond, infertility is blamed on women. But the issue is, there is more to infertility in both sexes than blaming one sex. There is a lot of stigma around women. Some get depressed as a result," he says.

"Stop stigmatizing women thinking they are infertile. This is a blame that takes both sides."

Estimates suggest that approximately one in every six people of reproductive age worldwide experience infertility in their lifetime, with the developing world having the highest prevalence.

In Uganda, infertility affects approximately 10-15% of couples.

With all this in mind, education and awareness-raising interventions are reported to be essential in helping save families and individuals' reproductive rights and choices.

Common causes of infertility in males, according to the World Health Organization (WHO), include problems in the ejection of semen, absence or low levels of sperm, or abnormal shape and movement of the sperm are the common.

In females, the causes could include abnormalities of the ovaries, uterus, fallopian tubes, and the endocrine system.

Fertilization occurs when a sperm penetrates an ovum, generally in the uterine (fallopian) tube

Generally, eating disorders, excessive alcohol consumption, environmental toxins, smoking, substance abuse, using tobacco products, radiotherapy or chemotherapy, chronic diseases and even over-exercising can also cause infertility.

Treatment includes anywhere from medication to surgery or Assisted Reproductive Technology (ART) and lifestyle changes.

For now, campaigners argue that when reproductive rights and fertility desires are fulfilled, the impact would be seen in the health and wellbeing of people and their families.

They also say there would be significant gains for communities and countries through:

▪️ reducing the economic costs associated with unintended pregnancy 
▪️ minimizing the significant health-system costs of unsafe abortion
▪️ realizing the labour-force participation of future generations born in secure socioeconomic conditions supportive of their families

Back in the village of Kiteezi, after considering other factors, Nyafamba sees herself ultimately dropping the idea of having a fourth child.

She lives not far from where a massive landfill collapsed last August, killing dozens of residents, displacing hundreds others and sparking concerns about the hazards of living near garbage dumps.

While her household was not directly affected, it gave Namatovu plenty to think about.

"Yes, we built our house here. We never thought anything like this [landfill collapse] could happen. But then it happened. Am I feeling safe living here? Is this a place I would wish to raise another child?" 

After a brief pause...

"Definitely not," she says.
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💬   HAVING THEIR SAY 

Farha Shamim, 20, nurse 💬
📍 Based in Wakiso district

❝I will not have children before I have got the right partner. To me, that ideal partner will have to be one who loves children and is ready to commit to stay for the long haul as we build our family together. Some men are only interested in fathering a child or children with you then they abandon you. 

Timing is also important for me. I want to have children after I have achieved some of my aspirations like furthering my studies and having my business for financial stability — because in case the unexpected ever happens, I would still be able to support my children without having to go around begging for help.

For the number of children, I desire to have two or three. In case my future partner wants more, I will not accept. Since I intend to date a fellow Muslim, polygyny is accepted in Islam. I would, therefore, ask him to get the additional children from his other wives.

Maryam Hairat, 22, nurse 💬
📍 Based in Wakiso district

❝Ideally, I wish to have three children. However, achieving that — or not — will depend on my finances. I believe in the power of independence. I want to be able to take care of my children without having to bother their father or family members. I also fear to be disappointed by an unserious man, in case the father of my children ends up urning into one.

In case I am not ready to have a child, I will delay to do so. I will not allow my family or peers to pressure me into having babies. Some of my former schoolmates got pregnant at a very early age and I have seen how some of them are struggling. I am not a teen anymore, but I don't want to lead a similar path.

Before deciding on having more children, I will observe how my partner behaves around the child/children we would already have. That will inform my decision. He may say he wants four children yet he has failed to take care of even one. There are men who have money but are not responsible. I don't want one like that.