SIRAKANO, Uganda — At age 45, after giving birth to 13 children in her village of thatch roofs and bare feet, Beatrice Adongo made a discovery that startled her: birth control.
“I delivered all these children because I didn’t know there was another way,” said Adongo, who started on a free quarterly contraceptive injection last year. Surrounded by her weary-faced brood, her 21-month-old boy clutching at her faded blue dress, she added glumly: “I fear we are already too many in this family.”
On a continent where fewer than one in five married women use modern contraception, an explosion of unplanned pregnancies is threatening to bury Adongo’s family and a generation of Africans under a mountain of poverty.
Promoting birth control in Africa faces a host of obstacles — patriarchal customs, religious taboos, ill-equipped public health systems — but experts also blame a powerful, more distant force: the U.S. government.
Under President George W. Bush, the United States withdrew from its decades-long role as a global leader in supporting family planning, driven by a conservative ideology that favored abstinence and shied away from providing contraceptive devices in developing countries, even to married women.
Bush’s mammoth global anti-AIDS initiative, the President’s Emergency Plan for AIDS Relief, poured billions of dollars into Africa but prohibited groups from spending any of it on family-planning services or counseling programs, whose budgets flatlined.
The restrictions flew in the face of research by international aid agencies, the U.N. World Health Organization and the U.S. government’s own experts, all of whom touted contraception as a crucial method of preventing births of babies being infected with HIV, the virus that causes AIDS.
The Bush program is widely hailed as a success, having supplied lifesaving anti-retroviral drugs to more than 2 million HIV patients worldwide.
However, researchers, Africa experts and veteran U.S. health officials now think that PEPFAR also contributed to Africa’s epidemic population growth by undermining efforts to help women in some of the world’s poorest countries exercise greater control over their fertility.
A woman has to be strong to have a small family in Uganda.
The high-fertility cues start from the top: The longtime president, Yoweri Museveni, has often said that a large population could turn his landlocked nation into an economic power. His wife, Janet Museveni, is a born-again Christian who’s urged women not to use birth control because it goes “against God’s clear plan for your life.”
Opposition to birth control also comes from the Roman Catholic Church, the country’s largest, and from husbands who consider big families badges of masculine accomplishment, health workers say.
In national surveys, 41 percent of married women say they want to practice family planning but aren’t. Every year, some 775,000 Ugandan women get pregnant without intending to, according to the Guttmacher Institute, a New York-based reproductive-health advocacy group.
With these domestic challenges, “PEPFAR was like a death blow,” said Angela Akol, the Uganda director for Family Health International, a reproductive-health aid agency.
While global U.S. family planning funding flatlined at roughly $430 million a year, PEPFAR’s 2003 authorization of $15 billion for five years created “a giant sucking sound” as governments and relief agencies rushed to grab chunks of the new AIDS funds, in the words of a former U.S. health official, who like several current and former U.S. officials requested anonymity in order to speak more candidly about the Bush policies.
PEPFAR pumped $285 million into Uganda this year, a flood of money in an extremely poor nation, which eventually helped pay for some nine out of 10 AIDS projects. By contrast, Ugandan health officials said they spent $7 million this year on family-planning supplies such as injections and pills.
In three-quarters of the country’s health clinics, at any given time, at least one type of birth control device is out of stock, officials said. During one six-month period two years ago, the national medical warehouse had no supplies of Depo-Provera, a quarterly injection that’s become the most popular form of female contraception in Uganda because it’s simple, infrequent and discreet.
“The U.S. had been a major funder of family planning in the past. Their absence meant that a lot of programs suffered,” said Musinguzi, the physician. “They don’t get adequate supplies; training of health workers doesn’t take place; the skills aren’t there. The impact is great.”
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