The first time Sunday returned to the village of her birth, she was frightened. She wanted to go home, of course, to be with her parents at long last. But it was there, on her family’s farm, that she was abducted at the age of 10.
For seven years, she endured the horrors of life with the Lord’s Resistance Army (LRA), the Ugandan rebel group led by Joseph Kony. She witnessed her brother’s murder and was forced to watch the mutilation of other abductees, to loot villages, and to “marry” a rebel.
“I had no voice to refuse,” she says.
Today, Sunday is 32 and living a life split between her village and Gulu, the city at the center of northern Uganda’s rebel movement. The LRA left the country after a truce was signed in 2006, but the emotional and physical scars remain. “I can’t forget what happened,” she says.
Sunday is a serious and soft-spoken woman. And when she unleashes her big smile and full-body laugh, her resilience and fortitude shine through.
She is bitter that she wasn’t able to finish school. Her response: make sure her children have the opportunities she didn’t. Her two homes, along with family planning, hold the key to their future.
The children go to school in Gulu while Sunday spends much of her time on her farm, despite a long bus ride and the terrible memories that linger there. The money she raises from growing rice and groundnuts goes toward school fees and the rent on the two tiny huts that she, her husband, and seven children and stepchildren share in Gulu.
If she had another child, she wouldn’t be able to “care for the children well,” Sunday says. So she does one more thing to ensure her children’s future: she uses family planning.
Specifically, she self-injects the new contraceptive Sayana® Press as part of a study supported by PATH and Uganda’s Ministry of Health.
PATH first worked with Uganda’s Ministry of Health to introduce Sayana Press through community health workers, known as village health teams (VHTs) in Uganda. We also talked with Ministry officials early on about the potential for self-injection.
The Ministry realized right away that putting a contraceptive in women’s hands would help them overcome many of the hurdles women face accessing family planning—from the time and money it takes to get to distant health centers to the lack of privacy. It would also reduce the number of visitors at overburdened, understaffed health clinics.
Starting in mid-2015, PATH and the Ministries of health in Senegal and Uganda launched a series of studies on self-injection to determine if women liked the option and could inject themselves successfully, remember their reinjection dates, and safely store and dispose of the device. A second set of studies are assessing whether women who self-inject continue using injectable contraceptives longer than women who receive intramuscular contraceptive injections from providers.
Sunday is one of the more than 900 women who have participated in one of the self-injection studies in Uganda. She’d gone to Gulu Central Hospital to receive a contraceptive injection from a nurse. But when she heard about the opportunity to self-inject, she signed up for the study instead.
Self-injection, Sunday says, solves her biggest problem—making sure she can prevent a pregnancy whether she’s in Gulu or her village. “I can inject myself at the farm because I travel with the contraceptive,” she says. That means no more waiting for hours at the hospital to be given an injection, and no worrying she’ll miss her scheduled injection when she’s away.
She missed her injection date once before—and became pregnant. She doesn’t want to miss another. “Indeed, it is very important!” she says with a laugh.
Justine Tumusiime, PATH’s research officer for the self-injection studies in Uganda, describes the initial feasibility study: “It was the first to look at self-injection of contraceptives in Africa, so we had many questions: whether women were able to do self-injection, were they willing, and is it even possible in our Ugandan setting?”
Justine and her fellow researchers also wanted to be sure that women could safely store a device for months at a time, sometimes in secret. “This is very important in our context, where we have domestic violence associated with family planning use,” explains Justine.
Sunday and the other study participants practiced on a model (a condom filled with salt) until they were comfortable, then did their first self-injection under the supervision of a study nurse. They were given a calendar, a booklet depicting the injection steps, and one Sayana Press to take home for unsupervised self-injection. Shortly after their next injection date, the study nurse visited to see how they’d done on their own.
“I’m happy to report that nearly 90 percent of women were able to inject themselves correctly, and 95 percent were able to remember when their next injection will be,” says Justine. “We were surprised and happy that 98 percent of women who participated in the study wanted to continue self-injecting.”
In addition, PATH partnered with the Ugandan Ministry of Health on a separate study to understand how adolescents would respond to Sayana Press. Around 60 percent of households in the Gulu area are headed by children under 18 as a result of the LRA rebellion. Some of these teenagers have children of their own already, victims of early “marriages” with rebels; others are raising their orphaned siblings.
Study researchers described Sayana Press to the young women and explained how it could potentially be given by a health provider or via self-injection.
“Most of the adolescents really felt Sayana Press could be a game changer for their lives,” Justine says. “They are really excited because it could overcome barriers for them, like the stigma around adolescents coming to the health center for family planning. They can hardly afford food, so they cannot invest in travel to come to the hospital. And the secrecy that is associated with self-injection blew their minds.”
In her previous work as a hospital nurse, Justine often had to turn women away who came for family planning because the hospital was out of syringes, or she had too many other patients with urgent medical problems.
“It’s so exciting to see women in charge.”
“Most of these women are poor and needed to be working,” Justine says. “They would come in the morning and they were the last to be seen. It would break my heart. It’s so exciting to see women in charge. Now they can do it themselves.”
For Sunday, this new way of planning her family represents autonomy and control. “I love Sayana Press,” she says.
Innovations in birth control have had a profound impact: A half century ago, the pill revolutionized the lives of women in the wealthy countries where it was first made available. It allowed them to control their fertility independent of their partners. It gave them the freedom to work, and it increased their wealth and well-being—and that of their families and communities.
For many African women who are struggling to plan their families, self-injection could have a similar effect.
Building on the positive results of the feasibility study, Uganda’s Ministry of Health, with PATH support, is beginning to offer Sayana Press self-injection, starting in one district in southern Uganda. Hopefully, it will be available in Gulu by the time the study Sunday is enrolled in concludes in 2017.
Because this is what it means to put family planning in women’s hands: a woman who lost all control over her childhood is able to take control of her life as a mother, and in the process give her children the possibilities she never had.
—Written by Lesley Reed