Barriers to family planning through structural health vulnerabilities: findings from case studies from rural Uganda

The burden of maternal mortality in sub-Saharan Africa is the highest in the world. As high fertility rates present an increased risk to women's health, programmes and services have been put in place to increase access to family planning. Several studies have identified sociocultural factors as limiting access to family planning, including male resistance and women's low decision-making power. However, these studies have often used a behavioural approach that anchors barriers to access in women's attitudes or motivations. In 2019, a qualitative evaluation of a family planning programme using a behavioural approach was conducted in rural Uganda, focusing on women's attitudes and unmet needs. With hindsight, we realised that our evaluation was insufficient to adequately capture barriers that extend beyond women's motivations. This paper shares three case studies that we analysed using a structural health vulnerabilities approach. Our analysis highlights political, economic, social and cultural structures that can impede access to family planning. Using a structural health vulnerabilities approach, we identify structural barriers which have their roots in the local realities women face and propose context-specific structural recommendations. Finally, we contrast our initial results with findings the case studies presented to highlight the relevance of taking structural vulnerabilities into account in future family planning programme evaluation and women's sexual and reproductive health studies.