Second of three parts
SIRAKANO, Uganda — At age 45, after giving birth to 13 children in her village of thatch roofs and bare feet, Beatrice Adongo made a discovery that startled her: birth control.
"I delivered all these children because I didn't know there was another way," said Adongo, who started on a free quarterly contraceptive injection last year. Surrounded by her weary-faced brood, her 21-month-old boy clutching at her faded blue dress, she added glumly: "I fear we are already too many in this family."
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On a continent where fewer than one in five married women use modern contraception, an explosion of unplanned pregnancies is threatening to bury Adongo's family and a generation of Africans under a mountain of poverty.
Promoting birth control in Africa faces a host of obstacles — patriarchal customs, religious taboos, ill-equipped public health systems — but experts also blame a powerful, more distant force: the U.S. government.
Under President George W. Bush, the United States withdrew from its decadeslong role as a global leader in supporting family planning, driven by a conservative ideology that favored abstinence and shied away from providing contraceptives in developing countries, even to married women.
Bush's global anti-AIDS initiative, the President's Emergency Plan for AIDS Relief, poured billions of dollars into Africa but prohibited groups from spending any on family-planning services or counseling programs, whose budgets flatlined.
The restrictions flew in the face of research by international aid agencies, the U.N. World Health Organization and the U.S. government's experts, all of whom touted contraception as a crucial method of preventing births of babies being infected with the human immunodeficiency virus, which causes AIDS.
The Bush program is widely hailed as a success, having supplied anti-retroviral drugs to more than 2 million HIV patients worldwide.
However, researchers, Africa experts and veteran U.S. health officials now think that Bush's program also contributed to Africa's population growth by undermining efforts to help women in some of the world's poorest countries exercise greater control over their fertility.
"It was a huge missed opportunity to integrate HIV-AIDS and reproductive health in ways that made sense," said Jotham Musinguzi, a Ugandan physician who heads the Africa office of Partners in Population and Development, an intergovernmental group that promotes sexual health in developing countries.
In some countries that received substantial Bush program funding, such as Uganda and Kenya, health surveys have found that fertility rates remained constant or even rose slightly over the past decade. In Uganda, where many men want large families and abortion is illegal except to save a woman's life, the average woman bears 6.7 children, one of the highest rates in the world.
A woman has to be strong to have a small family in Uganda.
The high-fertility cues start from the top: The longtime president, Yoweri Museveni, often has said that a large population could turn his landlocked nation into an economic power. His wife, Janet Museveni, is a born-again Christian who's urged women not to use birth control because it goes "against God's clear plan for your life." Opposition to birth control also comes from the Roman Catholic Church, the country's largest, and from husbands who consider big families badges of masculine accomplishment, health workers say.
When Congress reauthorized Bush's program in July 2008, to the tune of $48 billion over five years, religious groups such as the U.S. Conference of Catholic Bishops fought to keep the family-planning restrictions.
Conservatives equated birth control with abortion, U.S. officials said, even though aid agencies are prohibited from spending federal money on abortions, and the procedure is illegal in much of Africa.
President Barack Obama has begun to roll back some of the restrictions. In a sharp turnaround, the administration has called family planning "an important component of the preventive-care package of services" for HIV patients.
In March, Congress raised global family-planning funding by 18 percent, to $545 million, the first substantial increase after more than a decade of stagnation. The Obama administration has called for an additional 9 percent increase in 2010 and issued guidelines encouraging agencies funded by the Bush program for the first time to link the anti-AIDS effort with family-planning services.
Ugandan officials said that with additional support, they could educate more men and women about the need to keep their families to manageable sizes.
THURSDAY: Pressured to marry, African girl fights for her education.