Balancing pragmatism, norms and power relations: a qualitative study among post-abortion intrauterine device users in central Uganda

While almost half of all pregnancies in Uganda are unintended, the use of post-abortion intrauterine devices (IUDs) remains low. In this study, we explored how women in Uganda with current or recent post-abortion IUD use navigated socio-cultural factors, norms and power relations, and overcame challenges that often hinder contraceptive use in this context. Between January and August 2023, we conducted a qualitative study at four health facilities in central Uganda. The study included 24 in-depth interviews with women aged 19 years and above who had used an IUD following treatment for incomplete abortion (spontaneous or induced). The data were transcribed and coded in NVivo and analysed using reflexive thematic analysis. Respondents justified their IUD use through a combination of pragmatic reasoning, personal autonomy and economic considerations. The right to bodily integrity, alongside practical reflections on financial constraints, gender roles and societal expectations, emerged as important considerations. Compassionate post-abortion contraceptive counselling enhanced confidence in their decision and dispelled myths and misconceptions. Concealed IUD use enabled participants to pursue their reproductive goals, while evading influence from partners, peers, or social norms that discourage use. Our findings highlight the potential of post-abortion contraceptive counselling in supporting women's choices, and the role of concealed IUD use in realising reproductive goals. Integrating arguments around bodily autonomy in post-abortion contraceptive counselling and advocacy and supporting overt and covert use may be important strategies to strengthen sexual and reproductive health and rights in this setting.