Domtila Aguti, from Olwelai village in Katine, recently suffered a miscarriage. It would have been her 14th child, a remarkable feat even by Ugandan national standards, where on average a woman gives birth to seven children in her lifetime.

When Aguti, 39, had her last child nearly two years ago, doctors warned that having more children could endanger her life. She had earlier used an injectable form of contraception and was considering resuming this method when she realised she was pregnant again. She and her husband, Stanislas Olupot, don't want to take any more chances, which is why they are among the 60 women and men seated on benches under a mango tree at Tiriri health centre one Monday listening to officials from the reproductive health NGO Marie Stopes. They want tubal ligation – female sterilisation – which means Aguti will not have any more children.

Katine resident Domtila Aguti. Photograph: Richard M Kavuma

"We were told by village health team (VHTs) members that there was this permanent method of contraception and we agreed, with my husband, that we should get it," says Aguti, a farmer who also makes some money by selling doughnuts on market days.

Family planning is a divisive issue in Uganda. The Catholic church to which about 42% of the population belong, preaches against artificial or modern contraception. Like many African men who pride themselves in having many children, Ugandan president Yoweri Museveni wants the country's population of 30 million to grow, even as experts warn that the annual population growth rate of 3.2% could wipe out any gains from economic growth. According to the Uganda Bureau of Statistics, only 18% of married Ugandan women use modern contraceptives, while 6% use other methods of family planning. Another 41% of women would like to use contraceptives but can't access services, or are unable to afford them.

According to the Amref project officer for health, Joseph Otim, properly planned families are seen as one way of reducing infant and maternal mortality.

The idea of family planning is being gradually introduced into Katine and this slow approach appears to be paying off.

Otim says Amref first engaged district health officials and staff at Tiriri health centre on family planning. Then it trained VHTs about the advantages of family planning, the various methods available and how to promote the idea in the community and refer women to health centres. VHTs are also helping distribute condoms in their villages. Meanwhile, traditional birth attendants, with whom Amref meets monthly, are being encouraged to refer expectant mothers to health centres for more information on family planning services.

Amref and Tiriri health centre have now linked up with Marie Stopes to provide a range of services to villagers, including implants and tubal ligation, which were otherwise not available in Katine. On their first visit to Katine in May, Marie Stopes officials performed 16 tubal ligation procedures alone.

Last month when officials returned to the sub-county the turnout was even higher. But so was the level of disappointment because the Marie Stopes doctor responsible for carrying out procedures fell ill and did not travel with the team. Two support officers, however, were available to answer questions. Villages were advised to return on September 16.

"I am disappointed because I wanted to get this done today, but I am satisfied with the explanation," Aguti said.

Explaining the side effects

Aguti and her husband know the advantages of family planning. After the birth of their ninth child Aguti started using an injectable contraceptive, Injectaplan, until the couple decided to have more children. She says spacing children gives a mother time to rest while raising the younger ones.

"It is also difficult to educate and feed very many children. For instance with the current food shortages, we are struggling to buy enough food for the family," she says.

Despite this knowledge, many families have far more children than they can adequately provide for. The problem, Aguti says, has been lack of information at the community level. Waiting to advise expectant mothers who visit health centres has not got the message across. By training VHTs to spread the word in their villages, Amref seems to have overcome that problem in Katine.

But another hurdle to overcome is the side effects and myths associated with family planning. Olupot says that health workers need to explain to people from the start that contraceptives can cause bleeding and headaches and other problems. When Aguti first used Injectaplan, she developed heavy bleeding, but the couple persevered.

"I just went back to Soroti hospital and they gave us some treatment and the problems eventually disappeared," says Olupot. "But when our first child after stopping Injectaplan died of malaria at eight months of age, a rumour went around that he died because of it. Indeed we had three other children after that and they are all healthy."