Master of Public Health - MPH / The problem of the unmet need for contraception continues to affect contraceptive uptake particularly the use of long-acting reversible contraceptives. Globally, Sub-Saharan Africa is reported to have the highest unmet contraceptive need. For example, nearly 50 % of married women of reproductive age, wanting to avoid pregnancy or plan when to have children, are reportedly not using contraception. More specifically, the prevalence of contraceptive use, in the Midlands Province of Zimbabwe where the Gweru District is situated, is estimated to be only 11%. This study examined the uptake of and reasons for use of different types of modern contraceptives; the factors influencing contraceptive use; discontinuation of use and non-use and reasons thereof for contraception and for long-acting reversible contraception in particular, amongst women in the Gweru district attending contraceptive services.

Background It is estimated that 6.1 million people have HIV in South Africa, which makes it the country with the highest number of people living with HIV in the world. Adolescents are a severely affected and exposed group, since they tend to have several risk factors and a risky sexual behaviour. However, sexual education is implemented in school and there are special prevention programmes for adolescents in the country. Aim The aim of this study was to examine the HIV prevention work for adolescents in South Africa. Method The study was accomplished with a qualitative method and a semistructured interview design. The respondents were reached through purposive sampling and snowballing. In total six interviews were accomplished with people active within school, healthcare and different organisations. Results South Africa is a diverse country with many different cultures, beliefs and languages. Due to all the differences in the country, the widespread poverty and the previous political situation the challenges are many when it comes to prevention work. The key findings of the thesis are the importance of education and gender empowerment for adolescents to prevent the further spread. Conclusion HIV prevention for adolescents is important to reduce the HIV epidemic in South Africa. However, further education and gender empowerment is needed. Stigmatization and poor adherence to ART is also issues that need to be addressed in order to make progress in the prevention work. A mutual goal has appeared in the field of HIV prevention; to have zero new infections.

A prospective study of two combined oral contraceptives was conducted in the Sudan. No pregnancies occurred. Overall incidence of side effects was low. Headache was most frequently reported. Elevations were observed for weight, systolic and diastolic blood pressures, and SGOT and SGPT values while a decrease was seen for hemoglobin levels. Menstrual irregularities were not a problem for the users. Total 6-month use discontinuation rates were low for both pill groups.

Gender equality and ensuring the equal rights of women and girls is the fifth United Nations Sustainable Development Goal set for 2030. Access to quality reproductive healthcare and information is a critical aspect of gender equality, including access to information about family planning and contraceptives. However, there are many barriers that impact a woman’s access to contraception in rural sub-Saharan Africa, such as financial constraints, supply shortages, stigma, and misconceptions. Through and African Feminist lens, this study examines how these perceived barriers intersect with each other, and how they negatively impact women’s access to family planning and their perceived value of contraceptives in Luweero, Uganda. This qualitative study analyzed data collected from healthcare workers at one private clinic and one public clinic that offer family planning services in four focus group discussions in Luweero, Central Region, Uganda. Two focus group discussions were held in each clinic. Coded transcripts were analyzed using a reflexive methodology through an African Feminist lens. Most of the responses indicated that financial constraints experienced either by the clinic or the women significantly impact access family planning. Healthcare workers and Village Health Teams (VHTs) reported that funding constraints impact their ability to reach the clients with the resources they need in the rural areas, and clients in rural areas are often not able to afford the cost of family planning methods, especially when considered with the hidden costs of contraception. Social barriers were also discussed, and the participants explained that barriers such as stigma, misconceptions, lack of knowledge, religiosity and cultural values impact women’s motivation or ability to access contraceptive methods. Side effects also have a significant role to play in women’s ability or motivation to navigate through these perceived social barriers. Participants determined that increased funding for transportation for VHTs, consistent funding for free contraception, and expanded sensitization efforts that particularly target men would be some of the most impactful methods they can adapt to address some of these barriers. This study demonstrates that increasing women’ access to contraception in rural Uganda requires increased state funding for sensitization efforts and subsidized contraceptive methods. Social barriers can be more deeply understood and addressed by the international development community through an African Feminist lens, which explores modern contraceptives in the Ugandan context in a more culturally, socially and historically conscientious way.

This thesis draws on a political economy of fertility framework and the concept of biocitizenship to analyze changing family size and family planning among women and men in northern Ghana. I draw on a variety of ethnographic sources from eight months of fieldwork conducted under the umbrella of the Navrongo Health Research Centre in 2013 and 2014 in two rural communities in Kassena-Nanakana (K-N) West District in the Upper East region. The primary questions behind this thesis are: 1. How has the desire for smaller families emerged and to what is this transformation linked? 2. What role have family planning programs played in the reduction in family size? Have they been the most important driver of the transition to smaller families? 3. What are the current ideas about family planning and contraceptives in K-N West? Are they gendered? How have they changed over time? 4. Are local views about family planning and contraceptives in K-N West in keeping with those of public health practitioners? These questions are addressed in this sandwich thesis in three papers, which have been submitted or accepted for publication. A major contribution of this thesis is its call for health programmes to pay greater attention to the social context of both women’s and men’s lives where family planning takes place. Contrary to existing public health studies, I argue that while health programming has affected fertility decline, larger social and economic shifts have been some of the most important drivers of women’s and men’s changing practices of family formation and views of contraceptives. In Kassena-Nakana West, the desire for smaller families is linked to processes such as decreasing levels of child mortality and agricultural productivity, as well as parents’ increasing focus on educating their children. In addition, the emerging concepts of responsible manhood and companionate marriage, combined with the decline of polygamy, have helped improve communication between husbands and wives about family planning. Narratives of changing family formation from Kassena-Nankana West expand understandings of biocitizenship by illustrating the important role intergenerational relationships play in the construction of “political economies of hope”. When young people adopt family planning, they not only consider the well-being of their own children and the larger community, but make the decision in the context of their aspirations for a more successful life than their parents experienced. Due to larger political-economic shifts, the majority of Kassena women and men today think family planning is beneficial; however, worries about the side effects of contraceptives remain. Women’s ongoing concerns about infertility and the stability of their marriages and men’s conditional acceptance of family planning also reveal that gender inequality persists. I argue that typical policy recommendations, which focus primarily on educating and sensitizing communities to increase the use of contraceptives are problematic in that they often focus on decreasing fertility and are not articulated within a broader, multi-sectoral agenda. Greater attention to local biologies and expanding reproductive rights and freedoms would improve existing family planning programs. / Dissertation / Doctor of Philosophy (PhD)

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