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African Journal of Reproductive Health
Women's Health and Action Research Centre
ISSN: 1118-4841
Vol. 14, Num. 1, 2010, pp. 71-81

African Journal of Reproductive Health, Vol. 14, No. 1, March, 2010, pp. 71-81

ORIGINAL RESEARCH ARTICLE

“Not a Boy, Not a Child”: A Qualitative Study on Young People’s Views on Childbearing in Uganda

« Pas un garçon, pas un enfant » : etude qualitative sur les impressions des jeunes gens sur la procreation en Ouganda.

Jolly Beyeza-Kashesya1,2*, Stella Neema3, Anna Mia Ekstrom2, Frank Kaharuza1, Florence Mirembe1 and Asli Kulane2

1Department of Obstetrics & Gynaecology, College of Health Sciences, Makerere University, Kampala, Uganda; 2Division of Global Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; 3Makerere University Institute of Social Research, Kampala Uganda

*For correspondence: Email: jbeyeza@yahoo.com

ABSTRACT

To understand reasons for persistent high fertility rate, we explored perceptions and influences of fertility motivation among young people from Uganda. Qualitative inquiry was used, data were organised using NVivo 2 package and latent content analysis performed. Major themes that emerged on factors that entrench high fertility included “Sustenance of ‘men’s blood’ through the male child”; “poverty, joblessness and child bearing”, and “other socio-cultural issues: religion, kin, elders and child bearing”. Factors that reduce fertility included “perception on women emancipation, job security and couple fertility communication”. Young peoples’ views on motivation for childbearing in Uganda are embedded in cultural norms and linked strongly to patriarchy, social respectability and women’s sustenance. Innovative cultural practices and programs that increase women’s social respectability such as emphasis that a girl can be heir and inherit her father’s property are needed to reduce sonpreference and fertility rates in the younger generation (Afr J Reprod Health 2010; 14[1]:71-81).

RĖSUMĖ

Pour comprendre les raisons pour lesquelles le taux de fécondité demeuré élevé, nous avons exploré les perceptions et les influences de la motivation de la fécondité chez les jeunes gens en Ouganda. Nous avons fait une enquête qualitative et les données ont été organisées à l’aide d’un programme de NVivo 2 et nous avons fait une analyse du contenu latent. Parmi les thèmes importants que nous avons découverts concernant les facteurs qui retranchent la stérilité élevée il y avait la « préservation du sang des ‘hommes a travers un garçon » ; « la pauvreté, le chômage et la procréation », et « d’autres problèmes socio-culturels : la religion, les parents, et la procréation ». Les facteurs qui diminuent la fécondité comprennent la perception sur l’émancipation de la femme, la sécurité de l’emploi et la communication de la fécondité du couple ». Les impressions des jeunes gens sur la motivation pour la procréation en Ouganda sont gravées dans les normes culturelles et fortement liées au patriarcat, la respectabilité sociale et les moyens de subsistance de la femme. Des pratiques culturelles innovatrices et les programmes qui avancent la respectabilité sociale de la femme tel que l’accent mis sur le fait qu’une fille peut être héritière et peut hériter la propriété de son père, sont nécessaires pour réduire la préférence pour un fils et des taux de fécondité chez la jeune génération (Afr J Reprod Health 2010; 14[1]:71-81).

KEYWORDS: Fertility, young people, childbearing, male child, high fertility rates

Introduction

High fertility rates in Africa are influenced by many social cultural factors including the economic value of children, insurance for old age, lineage, posterity, and expecting relatives to assist in children’s upbringing 1. A strong relationship exists between sexual decision-making and fertility decision-making. Proximate factors include lower age at marriage and high rates of adolescent pregnancies, low female literacy rates, and young age at first sexual intercourse 2-6. Since 1950, most countries in Sub-Saharan Africa, except Uganda, have seen moderate to high declines in fertility rates 7. Comparing Uganda and its near neighbour, Kenya, earlier demographic surveys show distinct differences in their fertility rate levels; a declining trend for Kenya where the total fertility rate (TFR) fell from 7.5 in 1950 to 4.8 in 2007 compared to a negligible change for Uganda -TFR 6.9 in 1950 to 6.3 in 2007 8. Moreover, Ugandan women desire to have more children (5.3 in 2000/2001) than do their Kenyan counterparts (3.6 in 2003).

During the 1994 International Conference on Population and Development (ICPD) in Cairo, many thought that advancing gender equality and women’s empowerment and autonomy would improve maternal and infant mortality, which in turn would have an impact on population growth rate 9. However, Uganda’s TFR has remained stable and high over the last three decades, and the contraceptive prevalence has remained very low10 . Although adolescent pregnancies have reduced significantly from 45% in the 1990s to 25% in 2006, this has not translated into any reduction in fertility rates among the youth 10 . While Uganda has been implementing family planning within the health system, and it appears that, this investment has helped little to reduce unwanted fertility. At the same time, it has had little effect on reducing the desired family size. There are suggestions that improved socioeconomic conditions have been associated with a decline in fertility desires, which could be due to reductions in unwanted fertility 11 . In the recent past, Uganda has made strides in improving its socio-economic status, but almost one third (31%) of its people still leave below the poverty line 10. This is a reduction (from 56% in 1991) has not influenced the fertility rate.

Theoretical models of fertility motivation predominantly focus on describing the interaction between biological, psychological and sociocultural factors that translate a person’s subconscious and conscious desires and intentions into fertility behaviour at an individual level and later to couple level behaviour that will promote or prevent childbearing 12 . Cultural socialization strongly influences how both boys and girls perceive and experience sexual and reproductive health and rights. Individual behaviours and choices are nurtured and influenced by the socio-cultural contexts which are incorporated in cultural identity, relationships and expectations that define the roles of persons in a family and community 13 14. Young people usually emulate the traditions, values and practices of communities. They do not, however, share their elders’ experiences and memories. They instead develop unique ways of perceiving, appreciating, classifying and distinguishing issues, create new ideas, and mediate between cultural tradition and cultural change15 .

This unique attribute could be a critical strength as we focus on the youth to bring about the desired fertility decline in high fertility settings. The paper presents views, current perceptions and values that the Ugandan youth have on factors that have entrenched high fertility in Uganda. In addition, we examine what factors young people perceived to increase couple communication and negotiation for lower fertility. Understanding the implications of these results could inform policies and support the design of culturally appropriate programs to facilitate informed reproductive choices, reduce fertility and contribute to reducing the incidence of maternal morbidity, mortality and HIV infection among young people.

Methods

From June to December 2007, we conducted qualitative interviews in communities and with individuals residing in Wakiso and Kampala districts. Kampala is also the capital city of Uganda and is predominantly urban with an estimated population of 1.2 million multi-cultural, multi-ethnic and socio-economically diverse residents. Wakiso is predominantly a rural district with about one million residents mainly from one ethnic group (77% Baganda) 16. We purposefully selected Kampala and Wakiso districts from Uganda’s 80 districts based on residence (rural urban) and HIV prevalence. The prevalence of HIV in the 15-24 years age group in Kampala is ten times higher in females than in males (6.3% in females and 0.6% in males) and three times higher in females than males (4.8% in females and 1.7% in males) in Wakiso. HIV infected youths were recruited from The AIDS Support Organization (TASO), Mulago branch. TASO is a non-governmental organization founded in 1987 to provide care and support for HIV/AIDS infected and affected people in Uganda. We selected multi-cultural, multi-ethnic communities because fertility is heavily culturally responsive. Young people assimilate and develop a culture mirrored on what they see around them. In addition, we selected rural communities with predominantly one ethnic group for comparison. We used multistage sampling technique to select a parish to work in. At each stage [Stage 1 to select a county, stage 2 to select a sub-county, and stage 3 to select a parish] we used simple random sampling.

Participants and data collection

The research team conducted a pre-visit to the selected parishes to establish contact with local leaders and the “gate keepers” of the villages. Local Council leaders appraised the objectives of the study, characteristics and qualities of respondents needed and collaborated with the principal investigator (PI) to select informationrich participants. At TASO, the counsellor identified by the clinic in-charge assisted the PI. The PI assessed and selected the information-rich youths by asking them questions about fertility, sexuality and condom use; and obtained informed consent for their study participation.

We conducted twelve FGDs comprising of 126 participants (62 males and 64 females), 13 IDI and 10 KI interviews. We did four FGDs each in Wakiso, Kampala and TASO Mulago, grouped by age (15-19, and 20-24 years) and gender. Interview venues were approved by the LCI chairpersons, counsellor and participants. All FGDs were tape recorded after getting group consent. IDIs were conducted with two LC youth representatives, one Catholic, Protestant, and Moslem faiths’ youth leaders and eight HIV infected youths. Key informants included adults who handled the youth in their daily activities at community level: the LC chairperson, woman representative on local council, female and male teachers responsible for the students’ social welfare, a school nurse, four HIV counsellors, and a village shopkeeper where the youth bought condoms. Information on childbearing practices, the key factors that influence fertility decisionmaking, negotiation for pregnancy, contraception; gender and power relations, socio-cultural context of high fertility and the influence of HIV infection was obtained using pretested interview guides 17 .

Quality control

Research assistants were trained to ensure that they fully understood the study and the meaning of each question. Translation of the interview guides into the local language (Luganda) and back translation to English was done before data collection 18 . The interview guides were pretested with one FGD and IDI and adjusted for clarity. To increase the validity of the information collected, purposive sampling using maximum variation sampling technique was adopted to gather different views 19 . We used two methods of data collection, to complement each other, and for triangulation. The PI and two research assistants moderated all the FGDs, conducted all IDIs, and kept daily field notes and a field dairy. Immediately after the FGD or interview, the moderator and note-taker held debriefing sessions to expand the notes when the memory was still fresh; discussed any issues that could have arisen from the discussion groups and planned for the next activity. This helped us to focus our next interview by more probing for unclear questions but also allowed us to detect that no new information was forth coming.

Data Management and Analysis

The research assistants fluent in Luganda listened to and transcribed verbatim tape-recorded data (interviews, and FGDs). Research assistants who participated in interviews were involved in data transcription and translation. The PI and a social research expert from Makerere Institute of Social Research (SN) independently coded a portion of the transcribed data. We compared the two coding for consistency of coding and consensus on data interpretation. All coded data was organized into categories and themes using NVivo 2.0 20. Latent content analysis technique that refers to what the text talks about with relationship aspects and indepth interpretation of underlying meanings was used 21 . Lastly, we reviewed the text to identify quotes to illuminate the themes.

The College of Health Sciences Research and Ethics Committee, and Uganda National Council of Science and Technology (UNCST) approved the study. Informed consent was handled according to the national guidelines 22 23. Emancipated minors provided informed consent. Research assistants were age-appropriate and trained to handle and discuss sensitive topics such as sexuality and HIV with the minors.

Results

Of the 139 FGD and IDI participants 22% were under 18 years, about two thirds had more than eight years of formal education, and 44% were still single. Only six percent had skilled employment and one-third (34%) were not employed. Others had small businesses and wage jobs such as brick lying. Only 19% were in school.

The major pro-fertility themes that emerged from the interviews and focus group discussions (on motivating factors for childbearing) were similar in all the focus groups and interviews from both the young people from the community and those from HIV/AIDS care units. These included 1) perceptions of how patriarchy and succession can only be attained by sustenance of ‘men’s blood’ through the male child, 2) How poverty, joblessness affects child bearing, and 3) other socio-cultural issues such as religion, kin, elders could influence child bearing. On the other hand, factors that were perceived to reduce fertility rates included “perception on women emancipation, job security and couple fertility communication”.

Sustenance of ‘men’s blood’ through the male child

Uganda is a patrilineal society and succession is through the male children. In all the discussions, young people elaborated that the boy child was valued more than the girl child. Discussants concurred that girls are mainly valued as income because they bring in bride price or dowry; which the boys will use to get wives. In most groups, discussants agreed that considering one's lineage and posterity was very important when deciding on the number of children to have.

“Men would always want to produce a boy first. ...Everyone has their own reasons but men usually think of their blood. For example, when a man leaves a boy, then he is sure of the continuity of his blood since he leaves an heir behind”. [Male, LC youth representative, IDI]

Another important consideration that leads to producing many children was the process of getting the heir. Young men reported that there was no hard and fast rule to choosing who will be the heir as long as it was a boy. Their view was to get as many boys as possible so that one has many boys with a variety of talents to choose from even if it means getting them from different women, as illustrated below:

“Others say that when you produce many children, so you do not get a loss at once. That is, one night become stupid, even another one but the other one becomes bright and he helps you in a way. ..That is why you see some producing with many different wives. In the first one, you can get those ones then the next one you also get others knowing that their characters will not be the same. There are some characters that will be desirable and others will not be desirable, some will be dull and others will be bright”. [Males, 20-24 years, FGD Kampala]

Most discussants concurred that one will want to get at least one boy. A girl was not considered a child because she cannot succeed her father. In addition, when girls get married, they move away and produce children for another clan; therefore, one cannot rely on them to expand their parents’ lineage. Therefore, couples without boys go to any length to produce a boy. Young people noted that the importance of boy children was enshrined in the patrilineal nature of their society. They explained that children belong to the man because even when the girl gets pregnant out of wedlock; her family still looks for the father of the baby to take responsibility of his child. They take the child to its father’s family.

“There is no woman who does not want to get a son. So, they always struggle to see that they get a son to please their husbands… If a woman produces only one sex of children, then they have to continue producing until the other sex appears [is born]. This is especially so in women who have produced girls. Such a woman has to continue producing until she gets a boy, the heir.” [Males, 15-19 years, FGD Kampala]

“Even if you give birth to a baby girl or girls only..., they start saying that ‘what did she produce?’ So giving birth without a boy also tends to pressurize women to continue producing to get at least a boy for the man.” [HIV positive females, 2024 years, FGD]

Not having a male child destabilizes homes. Most discussants agreed that a home without a male child was like the home of an infertile couple, where there is a lot of misery and quarrels. A focus group of 15 to 19 years old males’ concurred that “A woman who has not produced any boy is referred to by the society as someone who has no children.” The result is a man getting another wife and sometimes they (man and wife) both may end up practicing high-risk sex to get the desired sex of the children. Therefore, to avoid an empty home, whether now or in old age [after the girls have got married], the man goes outside marriage to produce boys when he fails to get boys from his wife. The discourse below illustrates the struggles the man may go through to get a boy.

Respondent 4 -There I get a solution if I had decided to have two girls and two boys and I have only one woman, and I am having four girls, then I might try another way round. I look for another lady because I am looking for the boy child.
Moderator -Is this common?
All-Yes [in unison from the whole group]
Respondent 8-I also consider that if you fail to give me a boy, I think maybe I try my luck elsewhere; to see if I find there a boy.
Moderator-What if you find a girl?
Respondent 4-[laughter from many] I don’t give up of course. I keep that one but ...
Moderator-Even the other woman gets a girl, what happens and what do you do?
Respondent 5-I just give up [others interject, others laugh]
Respondent 4-I just go ahead; if I am financially stable, I make an increment in ladies and they become three. [–laughter] I try that one.
Moderator-You try the third lady?
Respondent 4-Yes
Moderator-And she gets a girl?
Respondent 4 -I make an increment, [-Laughter prolonged.] If my target is a boy and I don’t get him then I am to blame.
Moderator-While you are there getting the fourth woman the first woman gets the tenth child who is a boy what do you do?
Respondent 4-I relax...I declare [the battle is won]. [Males, 15-19 years, FGD Kampala]

Poverty, joblessness and child bearing

Poverty and idleness provides an enabling environment for producing many children. Majority of young people reported that considering the resources (how he earns) one has before deciding on the number of children to have, was very important. One would decide whether they could afford to look after this number of children. However, they observed that most poor families had many children and the rich had few. Some explanation offered were that poor people see children as a source of income (especially dowry from girls), a source of labour and old age insurance. In addition, young people explained that those men who do not work get time to produce many children because they are not occupied; indicating that they use sex as a pastime. Others were reported to use sex in times of grief as a consolation, and in times of joy as a celebration. Both men and women groups reported this as illustrated below:

“.. because people don't have what to do. They [men] don't have jobs. Now you find a man wakes up at 9.00 am, let me say that the wife is a bit wise she tries and fries some cassava and gives him to eat and by 10.00 am, he has gone to the field and comes back at 6.00pm, tired and he rests and by 9.00 pm he is already in bed.” [Males, 20-24 years, FGD Kampala]

“The poor, when he gets money, they don't plan for it. They just go to the bedroom and when trouble encompasses them, they still go to the bedroom and what comes out are the many children. They say that they take their troubles to the bedroom and even their joy. …. he goes and when he gets money, he will buy for her a cloth, “oh!! Sweetheart, thank you”. Then to the bedroom and they produce children.” [Females, 20-24 years, FGD Kampala]

Other socio-cultural issues: Religion, Kin, Elders and Childbearing

While the poor rely on having many children for their future survival, young people alluded to many other factors such as one’s religion to strongly influence childbearing. The majority of the respondents reported that it was not easy to separate cultural norms from religious practices since Catholics and Muslims are very different religions, yet they both believe that their religions direct them to produce all the children as God wants. This meant that God would decide for the number of children to have.

“.. Also, a friend of mine said he wants 10 children. That, as Catholics, we should not limit God; that we should get as many children as He prepared for us.” [Female, 24 years, IDI Kampala]

Looking at catholic and Muslims from other countries, especially that they have fewer children, it is possible that other factors in addition to religion are at play. Another important influence reported by discussants was that African societies, the kin and elders prefer bigger families. One man narrated how his senga (paternal aunt) told him to marry many women and produce many children to expand the clan, though he did not seem to agree with her, as shown below.

Moderator-You said that your senga [aunt] told you something different from what you believed. How many [children] did she tell you to produce?
Respondent-She didn’t tell me the number but said that if possible, I should marry many women and produce many children. At least each woman produces like four; this is because we are few and so must produce and expand the clan.
Moderator-Isn’t there a secret she told you which we could share?
Respondent-It’s not there but when she told me that, then I knew that was her mind as an old woman. She said that you should never allow a woman to beat you, and if she does then divorce her and marry another one.... But all she said, I see it from another angle. [LC II –Youth representative, Wakiso]

Sometimes, the woman wants more children and the husband wants less. Discussants agreed that it would be problematic since women have no say in “anything at home” meaning the man is the decision-maker in everything. Such disagreements were thought to bring violence in homes. However, males agreed that it was difficult to force the woman to stop child bearing if they wanted more children. Their suggestion was to sit with the woman and negotiate for a smaller family, because it would be useless for the man to appeal to the elders for redress because the elders would support the person who wants more children.

“No, they will support their daughter. Besides that, they usually go to the elders of the African traditional society-the old people. They feel like you can produce, produce and produce. That stuff of stopping does not exist.” [Males, 15-19 years, FGD Wakiso]
Participant-“Because I tell you and explain but you fail to see that we are in a “muziigo” and rent is 10000/=, children’s fees let’s say 2 is 30000/= and we all depend on my income. Now if I earn less and I tell you to stop or to reduce and add when we get more money and you refuse and you refuse by saying that you want like for the neighbour then what I do is to help myself or else she will break you yet you can get a solution.”
Moderator-“What can happen if you do that to help the two of you and she takes it differently?”
Participant-“...But if she fails to understand then we can go to the parents on both sides and we explain to them and they give us a solution to that.” [Catholic and business man, Wakiso]

Perception on women emancipation, job security and couple fertility communication

Young people perceived an emancipated woman as one who is educated, has a job and is able to stand up to the husband. In almost all discussions, young people concurred that education and income give women a voice -to talk, to communicate, or even to stand up and challenge the husband’s decisions if she feels the demands are not favourable or realistic. Uganda still has fewer educated women and negotiation for childbearing was less reported. Young people could reminisce what they would do if they had a job or income to support themselves as illustrated below.

“If I am a woman who is emancipated and I have a job, I have where I get income from, out of my money, [I say to you] I love you but these are the things I want, let's just talk about them. Communication is the key to some things you will want.” [Females, 15-19 years, FGD Kampala]

In addition to lack of couple communication for fertility, negotiating for when and how many children to have may be very difficult for women who fully depend on their husbands. Such women resort to guessing that the man wants more children which may lead to large families. Young people reported that often women keep silent for fear of violence or the husband’s threats to send her away to fend for herself. Young people alluded to the dilemma faced by orphans of HIV infection. They face challenges of starting and sustaining families. Being in unstable families makes them vulnerable to unplanned marriages and cannot negotiate fertility as illustrated below.

“They chase us because mum and dad, who were paying the rent, died; [and now] the landlord wants his house. I have nowhere to go with the property. Maybe I sell all of it. Then, when I get someone proposing for marriage, I just go. In my view, I see that [my] seventeen years are many. The guy can't tell me [to marry him] and I refuse because am going to be in my own home. …since I don't have where to be. My uncle can't accept me [in his home] for he thinks that I also have HIV because my parents died of it. So when I get a guy and he tells me, "I love you; let's get married”, I also go.” [Females, 20-24 years FGD, Kampala]
“.. last month, many women came when they were pregnant-last year it was worse, everywhere you go. They were about 15 at our place…I don’t know how many they are now. Our ancient grand fathers said that you produce and fill the world. How will you tell the man that I won’t give birth because I am HIV positive? His intention is expanding the family. If they have been 10, he wants to add on 8, if they have been 30, he wants to add on 15. So then, [you ask] how will you produce with this disease? Isn’t he going to add on another wife?” [HIV positive females, 20-24 years, FGD]

Discussion

While young people emulate the traditions, values and practices of communities, they may not share their elders’ experiences and memories. This would imply that young people could learn from the experiences of their kin but with guidance, shape or improve their situations. We asked young people’s views, current perceptions and values on fertility in Uganda and their perception on factors that increase couple communication and negotiation for fertility. This could inform policy planning and support the design of culturally appropriate programs to facilitate informed reproductive choices, among young people, that reduce fertility. Our study findings show that several childbearing-related influences and practices of young people in Uganda entrench high fertility. These included Sustenance of “men’s blood” through the male child, poverty, joblessness and other socio-cultural issues like religion, kin, and elders. In addition, young people had the understanding that women empowerment or emancipation and having a secure job would increase the ability of women to participate in couple dialogue for fertility and negotiate for lower fertility.

The enthusiasm with which young people discussed the value society attaches to the gender of the children shows how the values of the youth contribute to Uganda’s continued high fertility. Male children were reported important because only they can sustain the family name and expand the clan. A family without a male child will not have anyone to bear the family name 24. This puts the male child in a special position (on a pedestal) and places the girl child in second position. Since the man must get a son to preserve his lineage, men will do whatever it takes to get a son. Young people in this study reported that men would seek concurrent partners outside marriage or marry other wives to give them boys. Other studies of masculinity report that a man’s virility is measured by being able to produce a child, especially a son 25. In such a high fertility society, it is taboo to talk about infertility in men and “infertile men” hardly exist 26 . If infertile men are believed not to exist, then society puts pressure on women to produce children first but more important, to give the husband an heir. There was an animated discussion about the search for a boy. All youth believed that the woman must produce more children until at least one boy is born, lest the man goes out to look for a boy elsewhere. Young people reported occasions where even the women with no sons may secretly go outside marriage to look for a boy.

Respondents in this study reported that a woman without boys is like one without children. In addition, an infertile couple was described as having no peace, unfulfilled and socially incomplete 25 26. In bargaining with patriarchy, Kandiyoti explains that older women have power through their sons and rule over their daughters-in-law 27 . Therefore, the woman in such communities would hope to attain status and power only when they have sons. Besides having an heir to inherit her husband’s property, her own security, and being called the mother of the clan all compel her to have as many boys as possible without being forced or coerced. Therefore, low contraceptive use may not indicate a lack of contraceptives but a lack of cultural evolution and a failure to attain cultural equality for both boys and girls. The Uganda’s Constitution of 1995, articles 21, 31, 32 and 33 protects women’s inheritance rights and prohibits discrimination on the ground of sex and the application of customary law that discriminates against women28 . However, section 154 of the Penal Code sections 2(n) (i) and (ii) of the Succession Act prefers a male heir to a female heir. Moreover, the law provides for inheritance of a man’s property but there is no such arrangement for inheriting the property of a deceased woman. In addition, until recently, widowers had the right to 100 percent of deceased wives' property but widows only 15 percent 29 . Though this was overruled in court in 2007, succession laws to effect changes have not been formulated leaving women to continue to suffer under the customary laws.

In societies that have no sex preference, women make family planning and childbearing decisions because, men regard these issues as women’s business. This has significantly contributed to the fertility reduction in Indonesia 30. However, in countries with strong son preference, reports of sex selection, infanticide and male dominance are rampant and women do whatever it takes to have sons 31 .

Young people were unable to separate the influence of religion from the influence of the cultural norms because both promote high fertility. Cultural and religious upbringing strongly influences how both boys and girls experience sexual and reproductive health and rights. In Uganda, boys are brought up to become heads of households and girls to be submissive. The youth believed that the woman making decisions in a home is a foreign phenomenon, threatens male identity and brings confusion, strife and punitive sanctions, including domestic violence. Therefore, women must do what the husband approves of. As in Kenya, women are more likely to use contraception if the husband approves of family planning 32. However, young people pointed out that a man with many wives cannot fully take control of all families. They gave an example of Moslems who have four wives (this is normal in Islam) or traditionalists who are polygamous. Women in such relationships may start competing for the man’s love by producing many children especially boys hoping the man will choose one of her boys as the heir. Moreover, Islam does not accept modern methods of contraception. Conversely, though the Catholic faith promotes monogamy, it does not encourage contraceptive use and this leads to high fertility rates. However, fertility rates among people of other faiths are still very high which implies that the cause of high fertility in Uganda is more cultural than is due to religion.

Our study participants reported that people do consider family income before deciding on the number of children to have. Nonetheless, the majority acknowledged that in Uganda, the rich and the educated have fewer children. They suggested that the poor people, in fact, do not plan for childbearing. Others, their idleness contributes to producing many children because sex is used as recreation, celebrating achievements and a consolation in time of grief and trouble, but without protection. Notestein, 1953, said that high fertility in poor countries is because of high child mortality. People produce many children to ensure population survival, old age insurance, and to ensure there is an heir 33 11 24. In this aspect, the poor do not make a connection between having few children and greater financial capability due to savings on health care, education and welfare. This gap in understanding may occur because the perception of wealth is subjective and extends beyond actual income and investments. It includes ideas of self worth and feelings of capability. Studies on child quality-quantity trade-offs confirm the association between larger family sizes and poorer outcomes for children 34 , which happens because of the dilution of household and parental resources devoted to each child. Some families, however, feel they are less poor if they have more children and will continue to have them in spite of the negative economic consequences this has on investments for children 35 . If wealth will lie in the number of children produced, then sentiments of “leaving behind own blood to propagate the lineage”, as this study says, may also overshadow the need to consider the children’s support and care as one tries to leave as many patches of blood [boys] as possible.

Our study, like other studies, shows that income and education empower women to negotiate for fertility. When women have this opportunity, they often negotiate for a lower family size 32 36. Young people were of the view that women stay in marriages for security purposes. Though they may have other views, they need someone to fend for them therefore; they will not dare question the husband’s decisions. Phrases like “If not working, she must stick with what the man says”, or “women who have got a chance of going to school can also speak out” imply that the woman’s voice needs enabling in order to be heard. Other studies have shown that urbanization and both male and female education are associated with reduced fertility 36 37. The effect is stronger if the partners communicate and make joint decisions on fertility 32 36 38.

In discussions on lack of empowerment, young people voiced fears that the need for care and security makes women dependent on men. They gave an example of young people orphaned by HIV/AIDS who have no one to care for them. They felt that HIV infection has created a generation of vulnerable youngsters, who are not empowered to negotiate for sexuality let alone negotiating for marriage and childbearing. They need love and security; therefore, they accept anyone who proposes to marry them. Studies show an increase in fertility rates among the 15-19 year-old HIV positive adolescents 39 40. When we assume that this group represents newer HIV infections that may not have affected fecundity, this could indicate a failure to negotiate for fertility in this age group.

In conclusion, views of young people on childbearing in Uganda are still embedded and strongly influenced by the patriarchal cultural and religious norms. These youth have already formed values and attitudes that they assimilated from the elders before they reach adolescence. It could also imply the rooting of culture, mores and tradition more than experiential learning. The male gender continues to enjoy a superior position in Ugandan society and compels women to desire to have many boys for their security. Therefore, women empowerment alone may not suffice to reduce fertility rates if the society continues to look at the male child as having more value than the female child has. Young people need innovative cultural practices and programs that increase women’s social respectability such as emphasis on respect for girl children, sensitize communities that a girl can be heir, and inherit her father’s property. In addition, we could start the gender and power re-learning process earlier in the pre-adolescent period. Focusing on fertility choices, sexual communication, and promotion of small families and the value of the girl child is critical to reducing son-preference and fertility in the younger generation.

There is paucity of information on how HIV affected young people are negotiating sexuality and fertility, with the stigma of their parents dying of HIV and to some, stigma of their own status. This lack of negotiating power has a potential to increase both fertility and HIV infection rates among the youth if they also must look for boys. In-depth understanding of the influence HIV infection has on young people’s fertility and sexuality is critical for programming for their sexual and reproductive health needs. Finally, introducing adult education and income generating activities in poor communities may reduce idleness, raise socio-economic situation, which is empowering and reduces fertility.

Acknowledgements

We acknowledge SIDA-SAREC through Makerere University-University-Karolinska Institute Research Collaboration for funding this study. In addition, TASO Mulago branch, Kampala and Wakiso districts for the support and accepting to utilize their premises; the youth, youth leaders and Key informants who accepted to participate in the study. We acknowledge Dr. Tom Barton for reading and editing this manuscript. Finally, Mr. Joseph Rujumba, Ms. Atwine Patience, Ms Mercy Agasha and Mr. Asaph Turyamureeba, who participated in data collection for their commitment.

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