Uganda hosts 1.4 million refugees and conflict-affected people. Widely regarded as the best place in Africa to be a refugee, Uganda’s policies encourage self-sufficiency and local integration. However, abortion is legally restricted and recent studies suggest that displaced women and girls have persistent unmet sexual and reproductive health needs. In 2017, we conducted a multi-methods study to assess the reproductive health needs of displaced Congolese women in camp- and urban-based settings in Uganda. Our project focused on maternal health and delivery care, contraception, and abortion/post-abortion services and the intersection of these issues with sexual and gender-based violence. We interviewed 11 key informants, facilitated 4 focus group discussions with refugee women, and conducted 21 in-depth interviews with Congolese women of reproductive age to understand better knowledge, attitudes, practices, and services. Using both inductive and deductive techniques, we employed a multi-phased analytic plan to identify content and themes and triangulate and interpret findings. Our results suggest that Congolese refugees in Uganda are unable to navigate the legal restrictions on abortion and are engaging in unsafe abortion practices. This appears to be the case for those living in both camps and urban areas. The legal restrictions on induced abortion pose a barrier to the provision of post-abortion care. Efforts to ensure access to comprehensive abortion care should be prioritised and providing information and support to women in need of post-abortion care is imperative.
In the summer of 2017, we undertook a multi-methods reproductive health needs assessment with Congolese refugees living in Kampala and the Nakivale Refugee Settlement.33 Modelled after other needs assessments conducted in refugee and displacement settings,12–14 our study consisted of four components: (1) a review of the published literature as well as internal reports, statistics, and documents from institutions working with refugees in Uganda; (2) interviews with well-positioned key informants; (3) focus group discussions (FGDs) with Congolese women; and (4) in-depth interviews with Congolese refugee women of reproductive age. Interviews with key informants aimed to explore a range of perspectives from individuals and agency representatives working with refugees and/or in the SRH field. Our semi-structured interviews focused on the availability of, accessibility of, and avenues for improving reproductive health services to Congolese refugees in particular. Our key informants included policy makers, health service providers, and non-governmental organisation (NGO) representatives. We purposively recruited interviews by utilising publicly available information, study team contacts, and early participant referrals. For both our FGDs and our in-depth interviews, we recruited Congolese women of reproductive age (15 to 49 inclusive) who resided either in Kampala or the Nakivale Refugee Settlement. We worked with two refugee-focused organisations to recruit these women and supplemented this strategy with flyers, word-of-mouth campaigns, and early participant referral. Focus group discussions with women focused on maternal health and delivery care, contraception, and abortion/post-abortion care, and explored community knowledge, access to and utilisation of SRH services, facilitators and barriers to access, and priorities for improvement. In the FGDs we aimed to solicit community norms as well as identify outliers. In-person interviews with women focused on individual-level experiences with SRH services, including abortion and post-abortion care, in both the pre-displacement and displacement periods. We also asked women to reflect on the ways in which services could be improved. RN, a tri-lingual Congolese-Canadian master’s student at the University of Ottawa (Canada) led all components of data collection after being trained by her thesis supervisor, AMF, a medical anthropologist and medical doctor with SRH expertise. RN conducted all of the interviews with key informants, which lasted 60–90 minutes, in English and later transcribed the interviews herself. AB, a Ugandan university student, acted as a local research assistant and helped coordinate these interviews. Focus group discussions lasted an average of one hour and were conducted in French, Lingala, or Swahili; RN led the discussions with the help of a local research assistant who was able to interpret from Swahili to English. These discussions were translated into English by translators hired from the two refugee-focused organisations and transcribed verbatim. RN also led all of the in-depth interviews, which she conducted in French, Lingala, and Swahili (with assistance). These interviews lasted 30–60 minutes and were later translated and transcribed by local research assistants. We offered both the FGD and in-depth interview participants a small honorarium to reimburse them for their transportation costs and cover any childcare-related expenses. RN took extensive notes during each interaction, debriefed with local research assistants immediately after each FGD or interview, and debriefed with AMF regularly. RN also formally memoed after each interaction, a process that allowed for reflections on emergent themes and concepts as well as the participant-researcher-interpreter interaction. The memoing process also allowed RN to establish thematic saturation for the in-depth interviews34; once we suspected we had reached thematic saturation, we did several additional interviews for confirmation and then closed this portion of the study. With the permission of the participants, we audio-recorded all but one of the interviews and all discussions. We used NVivo 11.4.3 to manage our data, which included transcripts, notes, and memos and we analysed these data for content and themes.34–35 We employed an iterative analytic approach and began data analysis during the data collection phase. We developed an initial codebook containing a priori codes based on the study aims and research questions; as we familiarised ourselves with the data, we added emergent codes and categories. RN coded the data and then worked to identify themes; AMF reviewed the codebook and a subset of transcripts and provided input on emergent codes and categories. We initially worked with each component of the study separately; in the final analytic phase we reviewed all components and explored areas of agreement and disagreement. Regular meetings between RN and AMF guided this process and the overall interpretation of the findings. Presentation of these results at several international meetings and global webinars yielded valuable feedback that shaped our final recommendations. This project received ethics approval from the Social Sciences and Humanities Research Ethics Board at the University of Ottawa, Canada (File #: 04-17-15), the School of Medicine Research Ethics Committee at Makerere University, Uganda (File #: 2017-073), and the Uganda National Council of Science and Technology (File #: SS-4321). Additionally, given the nature of this project and the participants, we also obtained clearance from the Office of the Prime Minister in Uganda to conduct our study at the Nakivale Refugee Settlement. In this paper, we focus specifically on the findings related to abortion and post-abortion care. We use illustrative quotes to showcase themes and ideas. To provide thick description and a more robust picture of women’s experiences with abortion and post-abortion care, we also present several narrative vignettes. These vignettes summarise the experiences of individual women who shared their stories with us, based on our close review of in-depth interview transcripts. We have removed and/or masked all personally identifying information and used pseudonyms throughout.
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DIMA AI Care
