Long acting reversible contraceptive (LARCs); Rural women; Indigenous men; Qualitative research in reproductive health; Unintended pregnancies

Unintended pregnancies constitute a major public health concern worldwide, affecting approximately 74 million women annually in low-resource countries, with Africa accounting for approximately one-quarter of these cases [1]. Factors contributing to this issue include insufficient support from male partners, limited access to contraception, lower levels of maternal education, and economic constraints [2]. Although not all unintended pregnancies are unwanted, they can result in various health complications for both mothers and children, including illness, malnutrition, abuse, neglect, and increased risks of maternal and infant mortality [3].

Moreover, unintended pregnancies often result in high fertility rates, increased school dropout rates, and limited job opportunities, perpetuating the cycle of poverty [4]. A considerable portion of unintended pregnancies end in unsafe abortions, which are a leading cause of maternal morbidity and mortality, especially in LMICs, accounting for approximately 61% of cases [5]. These consequences can have intergenerational effects, with a significant percentage attributed to the lack of modern contraceptive use, particularly in these regions, which is estimated at 86.8% [6,7].

Estimates suggest that without modern contraceptive methods, unintended pregnancies could result in approximately 25 million unsafe abortions and approximately forty-seven thousand maternal deaths annually [8]. Shockingly, the global maternal mortality rate remains high, with a substantial number of deaths occurring in sub-Saharan Africa, including Uganda, accounting for approximately 70% of maternal deaths [9]. Moreover, complications from pregnancy and childbirth, such as severe bleeding, infections, and unsafe abortions, contribute significantly to maternal mortality rates, accounting for approximately 75% of cases [9].

1.1. The situation in Uganda

In Uganda, nearly half of pregnancies are unintended, with a significant portion occurring among teenagers, estimated at approximately 60% [10]. Unsafe abortions, often stemming from unintended pregnancies, account for a significant burden of maternal mortality, accounting for approximately 60% of this burden [11]. Districts such as Rubanda in southwestern Uganda experience alarmingly high maternal mortality ratios, emphasizing the urgent need to prevent unintended pregnancies as a crucial strategy for reducing maternal deaths, with a maternal mortality ratio of approximately 541 deaths per 100,000 live births [12]. This involves addressing the unfulfilled demand for family planning by enhancing access to modern contraceptive methods, including long acting reversible contraceptives (LARCs), such as implants, and intrauterine devices (IUDs), which are highly effective options [13].

Despite their cost effectiveness, the utilization of long acting reversible contraceptives (LARCs) remains limited. Implants constitute only 17.3% of the contraceptive methods used, whereas IUDs account for a mere 4.1% within the family planning spectrum [14]. In regions such as Rubanda district, specifically the Nyamweru subcounty, which is characterized by high maternal mortality ratios, complications from pregnancy and childbirth, including hemorrhage and hypertensive disorders, contribute significantly to mortality rates [15]. Encouraging the use of contraceptives, especially LARCs, could mitigate these complications, thereby reducing mortality ratios and total fertility rates [5]. However, despite their potential benefits, methods of contraception, such as LARCs, are underutilized compared with the national average [5]. In Rubanda, LARC uptake stands at 14%, with a rural total fertility rate of 4.8 [14,15,16].

Owing to their perceptions and beliefs, the limited acceptance of LARCs, particularly among indigenous men in the Nyamweru subcounty in Rubanda district, contributes to their low uptake [17,18,19]. This resistance mirrors trends observed globally [20,21,22].

Consequently, this study aims to understand the attitudes and beliefs of rural indigenous Ugandan men in Rubanda district, Nyamweru subcounty, regarding LARC usage, particularly with respect to how it affects relationship stability and fears of infidelity, to develop strategies for enhancing utilization.

This qualitative study provides a comprehensive understanding of the viewpoints of rural indigenous men residing in the Nyamweru subcounty of Rubanda district regarding the utilization of LARCs by their female partners.

2.1. Study design

The study employed a constructive phenomenological qualitative data collection method, which aims to capture individuals' life experiences and the significance they attribute to those experiences [23].

2.2. Study setting

The study was conducted in Nyamweru subcounty, which is located in Rubanda district within the Kigezi region of southwestern Uganda. This selection was made because of the secluded rural environment, where the use of LARCs is limited and there are higher rates of both fertility and maternal mortality. Notably, the adoption of contraceptives, particularly more affordable LARCs, is considerably lower in Rubanda district than the national average of 21.4% [14,24].

2.3. Study population

The participants included rural indigenous men residing in the Nyamweru subcounty of Rubanda, defined as individuals born and living in the study area.

2.4. Sampling and participant selection

Purposive sampling was employed to select the participants. Ten participants engaged in focus group discussions, and five took part in in-depth individual interviews. The participants who were reluctant to take part in focus group discussions were given the option to participate in face-to-face interviews. The sample size was determined by data saturation, meaning that no new information emerged from additional participants [24,25,26].

2.5. Selection criteria

To participate in the study, men needed to meet the following criteria: they had to be aged 20 – 49 years, indigenous to Nyamweru subcounty in Rubanda District, and have lived there for at least two years. They also had to be either married or in a relationship with a woman of reproductive age. This age range was selected on the basis of data from the 2016 Uganda Demographic Health Survey, which indicated that most indigenous men in this age group are likely to be sexually active, married, or have female partners of reproductive age, making their female partners suitable candidates for LARCs. The participants were required to consent to being recorded during interviews and to be in a stable mental state.

In contrast, men who did not meet these criteria were excluded. The two-year residency requirement ensured that the participants had enough local experience to provide relevant insights into the community’s views on LARCs. Furthermore, men who lacked basic knowledge about LARCs or were unable to communicate effectively in the local language were also excluded to ensure that the study gathered meaningful and informed perspectives.

2.6. Data collection method

This study employed phenomenological data collection techniques, including focus group discussions and in-depth interviews. The researcher, assisted by a trained research assistant, conducted the interviews. Research assistants were trained to ensure that ethical research guidelines were followed. Prior to the main study, pilot testing of the interview tool was performed to refine the questions and approach. The interviews followed distinct guidelines in line with ethics committee specifications but included similar questions. Both formats were utilized to accommodate participants uncomfortable with sharing views in group settings. All interviews were recorded with prior permission from the participants. The interviews were conducted in open yet isolated areas to ensure privacy and were translated into Rukiga, the local language. One session of focus group discussions involved 10 men and lasted approximately 68 minutes. It was conducted in an open yet private setting to ensure participant comfort and confidentiality. Additionally, five men participated in individual in-depth interviews and were selected to provide more detailed personal insights. Each interview lasted between 45 and 53 minutes.

2.7. Development of data collection tools

Prior to data collection, several tools were created, including open-ended interview guides for focus groups and in-depth interviews, as well as consent information sheets and informed consent forms. These tools were designed to promote participants' free expression and comprehension and were translated into Rukiga to enhance understanding. Ethical approval for these tools was obtained from the University of South Africa Ethics Committee (Registration Number: UNISA Rec-240816-052), the AIDS Support Organization (TASO) Ethics Committee in Uganda (Registration Number: TASO-2021-56), and final clearance was granted by the Uganda National Council for Science and Technology (UNCST) (Reference Number: HS2152ES).

Data collection employed qualitative methods, including focus group discussions and in-depth interviews. Focus groups provided a broad understanding of community attitudes and beliefs about long-acting reversible contraceptives (LARCs), whereas in-depth interviews offered detailed insights into individual experiences and concerns. This approach ensured a comprehensive and nuanced exploration of participants' perspectives on LARCs.

2.8. Approval for data collection

Permission to collect data was obtained from various authorities, including the Uganda National Council for Science and Technology, the President’s Office, and local leaders at the district and village levels. Local leaders facilitated participant identification on the basis of the inclusion criteria, ensuring objectivity in the selection process.

2.9. Data analysis

The researcher transcribed all the interviews meticulously by carefully listening to recorded conversations in a quiet environment to maintain accuracy. Comprehensive notes on data insights were made by memoing techniques, aiding in code and theme development. The data were manually coded by the researcher, ensuring the validation of themes, concepts, and categories before labeling similar text segments [27,28,29]. Additionally, an independent researcher served as a cocoder, and together, consensus was reached on the study themes, categories, and subcategories. Rigorous methods were employed to ensure the trustworthiness of the study.

Table 1 above summarizes the themes and subthemes regarding the perceptions and belief systems of rural indigenous Bakiga men that guide the comparative analysis described below.

3.1. Women's attractiveness, domestic violence and couple separation

The participants in the Nyamweru subcounty, Rubanda district, expressed concerns that LARCs could lead to marital discord, mainly instances of domestic violence, particularly when women took up these methods without spousal consent. One participant highlighted this, stating:

A woman using family planning (LARCs) becomes less inclined toward sexual intimacy with her husband. When coercion is attempted, conflicts arise, often resulting in the woman leaving her husband to become a single mother.

Few of the participants noted that women who use LARCs tend to have fewer children, which can make them more desirable to other men. If disagreements arise with their husbands, these women may be more inclined to leave and form new partnerships with whom they can have more children. This perception arises from the belief that women with fewer children appear more physically attractive to other men, thus making remarriage easier. As a result, participants expressed hesitation or resistance toward their wives' use of LARCs. This sentiment seemed particularly pronounced and was possibly influenced by cultural norms regarding marriage and divorce.

Women utilizing long-acting family planning methods may opt to leave marriages with few children, as they still look nice and get married to other men (FGD K4).

3.2. Extramarital affairs concerns

The study revealed that men believed that LARC usage by their wives provided a sense of security against pregnancy from extramarital affairs, potentially leading to adultery. Some quotes from the participants are as follows:

Knowing that she will not conceive from extramarital encounters owing to long-term family planning encourages infidelity.

Another participant said that:

Women on long-acting family planning are prone to infidelity, feeling protected from pregnancy.

3.3. Perceived reduced respect for husbands

The participants in the Nyamweru subcounty, Rubanda district, indicated a decrease with respect to husbands by women using family planning, including LARCs. Some participants expressed feelings of their wives being less attentive or caring toward them when using family planning, including LARCs. One participant shared:

When my wife started using those contraceptives, it felt like she was not as interested in what I had to say anymore. It is like she had lost respect for me (FGD-R1).

Another participant echoed this sentiment, stating:

I noticed that my wife became more distant when she started using those methods. It made me feel like she did not value our relationship as much (I-K11).

3.4. Diminished sexual responsiveness

In Nyamweru subcounty, situated within Rubanda district, there is a perception among men regarding LARCs and their purported impact on libido for both genders. Concerns are raised about LARCs diminishing women's sexual desire, thereby leading to a reduction in sexual activity between spouses. Additionally, some men express experiencing a decrease in their own libido when their partners opt for LARCs. Consequently, many individuals are hesitant to endorse LARCs for their partners because of the perceived adverse effects on libido. This discrepancy suggests that the lack of understanding of LARCs among men might contribute to these apprehensions. This underscores the importance of educating both men and women about the advantages and potential drawbacks of LARCs to increase their acceptance and utilization. The representative quotes from the participants include the following:

The utilization of LARCs renders our women impotent and unresponsive during intimate moments (FGD-R1).

Another participant stated:

My friends told me that women using LARCs exhibit decreased interest in sexual intercourse, appearing disengaged and unresponsive in bed" (I-K11).

This study explored the perceptions of indigenous Bakiga men in the Nyamweru subcounty, Rubanda District, regarding long-acting reversible contraceptives (LARCs) and their implications for relationship dynamics. By examining the intricate interplay between contraceptive use and factors such as women's attractiveness, domestic violence, couple separation, concerns about extramarital affairs, perceived respect for husbands, and diminished sexual responsiveness, this research highlights critical issues affecting reproductive health and marital relationships. The findings resonate with literature from various African contexts, illustrating the shared challenges and misconceptions surrounding contraceptive use. This discussion aims to contextualize these findings within the broader scope of reproductive health and relationship stability, shedding light on the unique cultural dynamics that influence attitudes toward contraceptives and their impact on familial and romantic relationships.

4.1. Women's attractiveness, domestic violence and couple separation

This finding aligns with research conducted in Ethiopia [30], which highlighted women's fears of contraceptive use leading to infertility and subsequent abandonment by husbands. However, in the current study, men expressed apprehensions regarding their wives leaving them for other partners. Similarly, research conducted in Nigeria revealed instances where men expelled women employing contraceptives from their households, resulting in marital dissolution [31]. Additionally, another study in Kenya [32] highlighted similar concerns among men, leading to separation.

The findings from the study in Nyamweru underscore the significant impact of contraceptive practices on marital relationships, drawing upon evidence from various studies conducted across different regions, including Ethiopia, Nigeria, and Kenya. These studies consistently reveal concerns regarding the consequences of contraceptive use, such as fears of infertility, abandonment, and marital dissolution, voiced by both men and women. By synthesizing this body of evidence, this study highlights the broader implications of contraceptive methods for marital dynamics, reaffirming the importance of our findings in this context.

4.2. Extramarital affairs concerns

The apprehension of adultery by men in this study echoes findings from research in Kenya by Obare et al. [33], wherein participants feared that contraceptives might provoke suspicions of infidelity. Similar concerns were raised by women, who feared that using contraceptives might lead their partners to seek extramarital affairs. Mwaisaka et al. also noted this fear in their studies regarding infidelity [29]. Our study participants harbored reservations about their wives' LARC usage to prevent adultery and family conflicts, which aligns with findings suggesting that contraceptive use could increase women's attractiveness to other men.

4.3. Perceived reduced respect for husbands

This study in Rubanda is supported by a study performed by Boozalis et al. [30], who reported similar results, suggesting that certain contraceptives could indeed affect relationship dynamics, including shifts in respect. Additionally, a study in Ethiopia [34,35] reported similar perceptions among men in other cultural contexts, indicating a broader concern about the impact of contraceptives on relationship quality. This highlighted the importance of comprehensive discussions and education about the broader effects of contraceptives on both physical health and relationship quality.

4.4. Diminished sexual responsiveness

Research indicates that certain LARCs, such as the DMPA, implants, and vaginal rings, are linked with low libido in women, whereas no such association is observed with hormonal or nonhormonal IUDs [34]. The concerns voiced by men about diminished libido align with findings from studies conducted in Sweden among Somali men, hinting at a broader cultural perception [31]. However, the scarcity of literature corroborating reduced libido in men whose partners use LARCs suggests a possible psychological belief stemming from inadequate knowledge [35]. While some studies indicate an improvement in sexual life among LARC users [35,36], conflicting evidence exists regarding the effects of LARCs on libido. Therefore, it becomes imperative to educate individuals about LARCs comprehensively, addressing misconceptions and facilitating informed decision-making while managing potential side effects.

The study revealed significant concerns among indigenous Bakiga men regarding the use of long-acting reversible contraceptives (LARCs) and their impact on marital dynamics. Men expressed fears related to women's attractiveness, believing that contraceptive use could lead to infidelity and marital separation, mirroring findings from studies conducted in Ethiopia, Nigeria, and Kenya. These anxieties reflect broader cultural perceptions that contraceptives might undermine relationship stability. Furthermore, participants voiced apprehensions about diminished respect for husbands and potential impacts on sexual responsiveness linked to certain LARC methods. Despite varying evidence on the effects of LARCs on libido, these concerns highlight a gap in knowledge and understanding among men. Overall, the findings underscore the necessity of targeted education and communication strategies to address misconceptions about LARCs, ultimately fostering better support for women's reproductive health choices within the community.

The study involved only fifteen participants, which did not adequately represent the broader population of men in Uganda, thereby limiting the generalizability of the findings. Additionally, the focus on indigenous Bakiga men in the Nyamweru subcounty restricted the applicability of the results to other ethnic groups or regions in Uganda or Africa. As a qualitative study, the findings were based on subjective perspectives and could have been influenced by individual biases, making the results difficult to quantify or replicate. Furthermore, the study primarily examined men's views on long-acting reversible contraceptives (LARCs) without considering women's experiences and opinions, which are crucial for understanding the dynamics of contraceptive use.

Actively engaging men in health education and discussions about LARCs is crucial. This engagement should involve providing comprehensive information about LARCs, including their benefits, potential side effects, and how they work. Men should be encouraged to participate in family planning decisions and discussions with their partners, promoting shared responsibility for contraceptive choices. Additionally, targeted educational campaigns specifically tailored to men can help dispel misconceptions and address concerns surrounding LARCs. By actively involving men in the conversation and providing them with accurate information, the community can work toward promoting informed decision-making and acceptance of LARCs as a viable family planning option in Rubanda District.

The study conducted in Nyamweru subcounty, Rubanda District, revealed significant concerns surrounding LARCs among men. The participants expressed apprehensions about the potential impact of LARCs on marital relationships, including decreased sexual intimacy, attractiveness to other men, and diminished respect for husbands. These findings underscore the need for targeted interventions to address misconceptions and concerns surrounding LARCs within the community. Tailored behavior change communication and comprehensive community engagement initiatives are essential to ensure informed decision-making and promote the acceptance of LARCs as safe and effective family planning options in Rubanda District.

Conceptualization, DDM, and RAK; methodology, DDM, and RAK; software, RAK; validation, DDM; formal analysis, RAK; investigation, RAK; resources, DDM, and RAK; data curation, RAK; writing—original draft preparation, RAK; writing—review and editing, DDM; visualization, RAK; supervision, DDM; project administration, RAK. All authors have read and agreed to the published version of the manuscript.

This research received no specific grant from the public, commercial, or not-for-profit funding agencies.

Ethical approval was obtained from the University of South Africa Ethics Committee (UNISA Rec-240816-052), the AIDS Support Organization (TASO) Ethics Committee in Uganda (TASO-2021-56), and the Uganda National Council for Science and Technology (UNCST) (HS2152ES).

Not applicable.

The data supporting this study's findings are available from the corresponding author, Ronald Arineitwe Kibonire, upon reasonable request.

None.

The authors declare no conflicts of interest.

© 2024 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) Li­cense. The use, distribution, or re­production in other forums is per­mitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or re­production is permitted which does not comply with these terms.