A Qualitative Study on Fertility Preferences and Barriers to Fertility Autonomy in Rural Uganda

Women’s autonomy in fertility decision-making is essential for improved health and social outcomes, especially in high fertility regions and countries like Uganda. This qualitative study explores factors influencing women’s fertility autonomy in central Uganda focusing on interpersonal, community, and healthcare system influences. Guided by the social-ecological model, we explore different levels of influence on women’s autonomy in their fertility decisions, such the interpersonal, community and health care system levels. We conducted focus groups with men and women (n=26), and key-informant interviews (n=15) with community stakeholders in a rural district in central Uganda and conducted thematic analysis. We identified five themes:1) Community level gender norms were found to reinforce inequalities in decision making, giving men greater authority in fertility preferences and limiting women’s autonomy; 2) Gender norms underpin community beliefs to not limit men’s number of children and contribute to men’s disapproval of family planning; 3) Religious norms and polygamy practices influence attitudes towards family size and family planning, and shape relationship dynamics related to fertility; 4) Family income is a driver of fertility preferences, and concerns about poverty and the rising cost of living is increasing family planning acceptance; and 5) Health system weaknesses limit women’s access to family planning services, and contribute to mistrust of the health systems and community misinformation about contraceptives, especially among men. These results delineate multilevel influences on women’s fertility autonomy in rural Uganda. Community-level gender and religious norms shape spousal relationships (e.g., quality, equity, polygamy practices) and men’s approval/disapproval of family planning, together influencing women’s fertility preferences and autonomy. This project points to the need for multifaceted interventions that challenge norms counter to women’s fertility autonomy, such as gender transformative interventions. Strengthening health systems, religious leader endorsement, and promoting the economic benefits of family planning could be ways to engage both men and women.