Which circumstances shape contraceptive use in Uganda’s secondary cities?

Urban residents are often assumed to have better access to health services. Yet city-wide averages can conceal substantial differences between neighbourhoods and between women living in apparently similar circumstances.

A study published in BMJ Public Health examined modern family-planning use among women in Jinja City and Iganga Municipality in eastern Uganda. The researchers asked a deeper question than whether women were using contraception: how much of the inequality in use could be connected to circumstances outside women’s control?

What the researchers found

Modern family-planning prevalence was 45.6%. Among women using a modern method, 63% were using a long-acting reversible contraceptive method.

The statistical model explained 37.8% of the observed variation in predicted modern family-planning use. Within this explained portion, approximately 90% was attributed to circumstances classified by the inequality-of-opportunity framework as unfair or outside women’s control.

These circumstances included age, number of children, employment, religion, household decision-making authority, place of residence, wealth, education and marital status.

The hidden groups inside the urban average

The findings showed that the effects of education, employment, wealth and residence were interconnected.

Poorer women did not necessarily gain better access simply because they were employed, educated or living outside a slum area. Women from the poorest households who lived in non-slum areas had particularly low predicted use of modern family planning.

This is important because many urban health programmes concentrate resources in recognised informal settlements. Economically disadvantaged women living elsewhere may be less visible to programmes designed around conventional definitions of urban vulnerability.

The findings therefore challenge the idea that education, employment or urban residence provides the same advantage to every woman. The conditions surrounding those characteristics still matter, including income security, available time, service location, affordability and household decision-making power.

What researchers can learn from this study

Important limitations

• The cross-sectional design cannot establish causation.
• Family-planning use and other sensitive information were self-reported.
• A substantial proportion of inequality remained unexplained.
• Findings from Jinja and Iganga may not apply directly to larger cities.
• The classification of circumstances and effort reflects the assumptions of the inequality-of-opportunity framework.

Why the findings matter

Programmes addressing urban family-planning inequalities need to recognise the diversity that exists within cities. This includes women living in informal settlements, economically disadvantaged women in non-slum areas, informal workers and women whose employment or household responsibilities limit when and where they can seek services.

The study recommends integrating family-planning information and services into routine health-system contacts, community health-worker activities and other platforms women already use. Workplace, digital and out-of-hours approaches may also help reach women who have limited contact with conventional services.

Better routine data are also needed to identify inequalities within cities. Broad categories such as “urban,” “employed” or “educated” can conceal groups facing overlapping disadvantages.