Women's experiences negotiating barriers and asserting agency on family planning in urban east-central Uganda: A photovoice study

Abstract

Many women in Uganda face barriers to using family planning in ways that are safe and responsive to their needs. This study explored the experiences of women in urban east-central Uganda to understand how they access, use, and navigate family planning services to identify opportunities for service improvement. Ten women participated in a three-month photovoice process combining photography with bi-monthly group discussions. Data were analysed using reflexive thematic analysis. Five themes were generated: (1) Services that do not serve: a disconnect between the promise of free, accessible care and the reality of stockouts, hidden costs, poor provider attitudes, and poor infrastructure; (2) Disputed and constrained decision-making power: reproductive choices were restricted by male partners, providers, and age-based stigma; (3) Living with side effects in exchange for protection: women reported several physical and psychological effects, often self-managed with little healthcare system support; (4) Community Health Workers (CHWs) as trusted and flexible providers: CHWs filled gaps left by formal healthcare services through accessible, discreet, and personalised care; and (5) Quiet acts of reproductive agency: despite the barriers, women maintained control over their fertility through covert use or reliance on unevidenced alternatives when modern methods were inaccessible or perceived unsafe. These findings offer distinct visual and narrative evidence of a disconnect between policy commitments and women’s realities. To strengthen family planning programs, approaches must shift from a narrow focus on uptake to prioritising women’s agency and well-being. This requires user-centred strategies that address structural, interpersonal, and method-related barriers while strengthening community-based service provision. • Family planning services, while available, often failed to meet women’s needs. • Partners, providers, and stigma constrained women’s reproductive decision-making. • Women endured side effects in exchange for protection, with little clinical support. • Community health workers bridged service gaps with discreet, flexible, trusted care. • When faced with barriers, women asserted agency through covert use or alternatives.