“I sneak from home”: how health system constraints undermine covert contraceptive use among women facing partner opposition in public health facilities in Uganda

Abstract

Covert contraceptive use — the use of family planning without a male partner’s knowledge — is well documented in sub-Saharan Africa and is typically studied as an individual response to partner opposition. Population estimates suggest it describes a substantial minority of contraceptive users in Uganda. Much less is known about how the routine performance of public-sector family planning (FP) and post-abortion care (PAC) services affects whether concealment can be sustained. We examined the experiences of women navigating partner opposition, and of the providers serving them, at public health facilities supported by the ACTUATE project in Uganda. This paper reports the qualitative component of the ACTUATE end-line evaluation; the structured client exit interview survey conducted as part of the same evaluation is reported separately. Between 25 March and 7 April 2025 we conducted seven focus group discussions with 70 women clients (ten per group) and 18 key informant interviews with facility in-charges, medical officers, doctors and midwives, at ten facilities from Health Centre III to General Hospital level across nine districts and four regions of Uganda. Three structured field observation reports provided a third data source. Focus group participants were women aged 18 years and above who had received PAC or FP services at the facility. Data were analysed thematically using a hybrid inductive–deductive approach. Reporting follows the Consolidated Criteria for Reporting Qualitative Research (COREQ). Partner opposition arose spontaneously in six of the seven focus groups and was described by providers in 10 of the 18 interviews. Women reported selecting methods for concealability rather than for duration or side-effect profile, with injectables strongly preferred because they leave no trace a partner can detect, and reported treating each clinic visit as a time-bounded operation that had to be completed before a partner noticed an absence. Three health system features determined whether that strategy succeeded. Stockouts of injectables removed the one method that could be hidden, leaving women to accept a visible substitute, leave without a method, or return another day. Waiting times extending through most of the working day, compounded by single-day outreach scheduling, closed the interval within which a concealed visit had to be completed. Procedures performed in shared or open space exposed women to recognition by people who knew them or their partners. Providers described the same three constraints accurately and within the sphere in which they could act, as problems of supply, workload and infrastructure; the consequences for concealment accumulate outside the consultation and were largely invisible from within it. Stockouts, waiting time, outreach scheduling and procedure privacy are long-standing priorities of family planning programmes, and sustained work on them has produced measurable gains. What these data add is an account of what these constraints cost women whose access depends on concealment, for whom a visit that overruns or a method that is unavailable can compromise autonomy rather than merely cause inconvenience. Attending to concealment within existing quality-of-care measurement — recording the distribution of visit durations rather than the mean, the proportion of procedures conducted in enclosed space, and the temporal distribution of service days — would make this group of clients visible in routine data. In Uganda, many women want to use modern family planning but face opposition from their husbands or partners. Some respond by using family planning in secret. National survey data suggest that around one in five women using a method that can be hidden say their partner does not know about it. Most research on secret use has looked at women’s own circumstances and decisions. Less is known about whether the health service itself makes secret use easier or harder. We spoke with women and with the nurses and doctors who serve them at ten public health facilities supported by the ACTUATE project in nine districts and four regions of Uganda. We held seven group discussions with 70 women, ten in each group, and 18 interviews with health workers and facility managers. Researchers also observed how three of the clinics ran during full working days. Women told us that three things about the service made secret use harder. When the injection they had come for was out of stock, the alternative offered was a method their partner would notice. When the queue lasted most of the day, they could not get home before questions were asked. When procedures were done in open spaces, neighbours and relatives could see them. Women repeatedly asked for an injection that lasts longer than three months, because the injection is the method partners cannot see. Family planning programmes have worked on supplies, waiting times and privacy for many years, and there has been real progress. What our study adds is what these problems cost women who depend on secrecy. Changes such as spreading family planning clinics across more days, and separating the room where procedures are done from the room where women wait, are mostly matters of organisation rather than money.