A qualitative study on fertility preferences and barriers to fertility autonomy in rural Uganda among women with an unmet need for family planning

Women's autonomy in fertility decision-making is essential for improved health and social outcomes. Guided by the social-ecological model, this investigation explores multilevel influences on the fertility autonomy of women with an unmet need for family planning in rural Uganda. We conducted four focus groups with men and women (<i>n</i> = 26), and 15 key informant interviews with community leaders and individuals involved in the provision of family planning. The data were analyzed thematically. The results highlight how community-level norms reinforce gender inequalities in decision-making and underpin beliefs to not limit men's number of children. Religious norms and polygamy practices were shown to influence attitudes towards family size and family planning, as well as shape relationship dynamics related to fertility. Concerns about poverty were identified as a driver of shifting preferences and increasing acceptance of family planning. Results showcase how health system weaknesses limit women's access to family planning services, contribute to mistrust of health systems and drive misinformation about contraceptives, especially among men. This study underscores the need for multifaceted gender transformative interventions to increase women's fertility autonomy. This study also highlights health system strengthening, religious leader endorsement and male engagement as approaches to increase women's autonomous use of family planning.