Christine Lamwaka and her husband gathered their six children and fled. It was April 2017 and their town in South Sudan had just been attacked. They walked for two days from Eastern Equatoria before crossing the border into Uganda.
“It was hard to flee with the young children. We struggled to run. I thought we couldn’t make it alive,” says Lamwaka, who was 22 at the time of the attack.
“We suffered a lot. I had given birth just a few months before and was breastfeeding. The children were crying. We are lucky to be alive.”
As well as ensuring her children were safe and the family had food and shelter, Lamwaka wanted to make sure she didn’t have any more children. But she was unable to access family planning services.
“Looking after these many children is very hard. We don’t have money for treating them, feeding and providing basic necessities,” says Lamwaka, from the safety of Palabek refugee settlement in Lamwo, northern Uganda. “We couldn’t afford to add more children.”
Research conducted by the Liverpool School of Tropical Medicine last year found that more than 40% of women in refugee settlements in northern Uganda who wanted to use contraceptives were unable to obtain them.
“Many health facilities in refugee camps are out or under-stocked,” said Simon Richard Mugenyi, advocacy and communications manager at Reproductive Health Uganda (RHU). Those seeking services often have to wait for organisations such as RHU to provide them.
Last year, however, Lamwaka enrolled in a pilot programme for a single-use, self-injectable contraceptive, Sayana Press. The contraceptive is being rolled out by the NGO Path Uganda, with support from the UN population fund (UNFPA), to promote increased uptake of family planning among refugees.”
In South Sudan, deep-rooted socio-cultural factors discourage family planning. The inevitable upshot is larger families. On average, women in South Sudan have 4.6 children. Among women aged 15 to 49 who are married or in a relationship, only 10% use any form of contraception. According to the UNFPA, this is the lowest rate in east and southern Africa, and many women have their first child while in their teens.
“I started giving birth while still a teenager. I was giving birth almost every year. There was no time to rest or for child spacing,” says Lamwaka.
“They need you to produce more children. Women are looked at as factories for babies. Men expect women to be producing a child every year.
“Women are not allowed to decide the number, timing and spacing of children.”
Uganda now hosts more than 1.3 million refugees, more than 850,000 of whom are from South Sudan.
About 75% of the more than 50,000 South Sudanese refugees at Palabek are women and children.
Lamwaka was pleased when she found out about the self-injectable contraception, which is taken every three months. It means she won’t have to seek out a health worker when she needs it, which is not always straightforward in a refugee camp.
She and her husband, Solomon Olum, decided she should enrol in the programme. “We are struggling to raise these children. I don’t have a job. I am a farmer. But I don’t have enough land to farm here. I have to burn charcoal and do hard labour to get money to support the family,” says Olum.
More than 9,000 women began taking Sayana Press, a variation on the established contraceptive Depo-Provera, between April and November last year.
Edson Twesigye, a programme officer for Sayana Press, says the pilot scheme resulted in 43% more women accessing contraceptive services.
“This is a big achievement,” he says. “These are refugee women who had never used any family planning method in their lives because of cultural beliefs, lack of access, or other reasons. Reaching 43% is a great milestone.”
Julitta Onabanjo, the UNFPA regional director for east and south Africa, says: “This is something we can take as a lesson learned as we look how to introduce it into [our] programmes in other countries.”
There were social stigmas to overcome before the rollout of the new contraceptive, says Twesigye. His team had conversations with community and religious leaders, to position family planning “not as a way of stopping having children, as they thought, but as a way of planning how many children you want, when to have them and when to stop,” he explains.
He adds that men in village health teams in the area were also talking to other men to help them better understand family planning.
“Many women in these settings have a desire to plan their families and don’t have any method that suits them. Therefore being able to give them any option of [family planning] method is very important,” says Onabanjo.
Mugenyi says the Ugandan government must spend more on contraceptives, starting with the allocation of the $5m (£3.8m) it committed to provide each year at the family planning summit held in 2017.
“If the government honoured this commitment, this would help to stock family planning commodities in public facilities, including those in refugee camps,” he says.