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."
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 decades-long role as a global leader in supporting family planning, driven by a conservative ideology that favored abstinence and shied away from providing contraceptive devices in developing countries, even to married women.
Bush's mammoth global anti-AIDS initiative, the President's Emergency Plan for AIDS Relief, poured billions of dollars into Africa but prohibited groups from spending any of it on family planning services or counseling programs, whose budgets flat-lined.
The restrictions flew in the face of research by international aid agencies, the U.N. World Health Organization and the U.S. government's own experts, all of whom touted contraception as a crucial method of preventing births of babies being infected with HIV, the virus that causes AIDS.
The Bush program is widely hailed as a success, having supplied lifesaving anti-retroviral drugs to more than 2 million HIV patients worldwide.
However, researchers, Africa experts and veteran U.S. health officials now think that PEPFAR also contributed to Africa's epidemic 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 PEPFAR 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.
This small nation of rolling hills and banana trees is at the epicenter of Africa's demographic boom. Uganda is roughly the size of Nebraska, but in 40 years its population is projected to triple to 96 million, surpassing Japan, according to the Population Reference Bureau, a Washington research center.
Stanching that tidal wave will require a dramatic increase in contraceptive use, currently practiced by only 18 percent of married women.
"There hasn't been a country in the world where the birth rate came down without it," said Carl Haub, a senior demographer with the population bureau.
AN UPHILL BATTLE
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, has often 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.
In national surveys, 41 percent of married women say they want to practice family planning but aren't. Every year, some 775,000 Ugandan women get pregnant without intending to, according to the Guttmacher Institute, a New York-based reproductive-health advocacy group.
With these domestic challenges, "PEPFAR was like a death blow," said Angela Akol, the Uganda director for Family Health International, a reproductive-health aid agency.
While global U.S. family planning funding flat-lined at roughly $430 million a year, PEPFAR's 2003 authorization of $15 billion for five years created "a giant sucking sound" as governments and relief agencies rushed to grab chunks of the new AIDS funds, in the words of a former U.S. health official, who like several current and former U.S. officials requested anonymity in order to speak more candidly about the Bush policies.
PEPFAR pumped $285 million into Uganda this year, a flood of money in an extremely poor nation, which eventually helped pay for some nine out of 10 AIDS projects. By contrast, Ugandan health officials said they spent $7 million this year on family planning supplies such as injections and pills.
In three-quarters of the country's health clinics, at any given time, at least one type of birth-control device is out of stock, officials said. During one six-month period two years ago, the national medical warehouse had no supplies of Depo-Provera, a quarterly injection that's become the most popular form of female contraception in Uganda because it's simple, infrequent and discreet.
"The U.S. had been a major funder of family planning in the past. Their absence meant that a lot of programs suffered," said Musinguzi, the physician. "They don't get adequate supplies; training of health workers doesn't take place; the skills aren't there. The impact is great."
Last year in Kampala, the capital, one PEPFAR-funded agency conducted a series of counseling sessions with HIV-positive teenagers. Several of the girls turned up pregnant, and when they asked about birth control the counselors were stumped; they hadn't received any training on the subject.
Akol sighed: "We have a whole generation of counselors and project managers who know about HIV but not how it's linked to family planning."
'ADDING POVERTY TO POVERTY'
At a hospital in Busia, a sleepy town in the green hills of eastern Uganda, Agnes Lojjo, a matronly health worker, sat with a handful of pregnant women one recent morning and asked how many were practicing family planning.
Fewer than half the hands went up. One woman in her 30s, wearing a man's oxford shirt and a colorful wrap around her head, said that a mother who used birth control would bear a deformed child.
Lojjo cocked her head and shot the woman a disapproving look.
"Everyone just has children without thinking," she said afterward. "It's adding poverty to poverty."
In the nearby village of Sirakano, as roosters clucked and the acrid smoke of a charcoal cooking fire wafted from a hut, Beatrice Adongo seemed to be staggering under the weight of her family.
Adongo, who has short hair and serious, wide-set eyes, had her first child at 17 and spent the next three decades in a near-constant state of fertility, barely pausing between weaning one baby and conceiving the next.
Now 46, she has 10 children — three didn't survive infancy — and their one and a half acres can't sustain all of them. She and her husband recently began renting part of a neighboring plot, but two of their children were sent home from school recently because they couldn't come up with a few pounds of maize and grains to pay their tuition.
The family gets by thanks to the eldest child, 29-year-old Frederick, who works as a security guard in the capital. His monthly salary, barely $50, also has to help feed his wife and 2-year-old, however, who live on the family plot in Sirakano.
"This one must learn from me and produce fewer (babies)," Adongo said, pointing her chin at her daughter-in-law, who smiled nervously. "We don't have enough land."
Much of Uganda is starting to suffocate. Public school classrooms that were built for about 40 students often burst with 100 or more. Large families are dividing their farmland into smaller and smaller parcels for their children, running afoul of neighbors and triggering a growing number of land disputes in local courts.
"Population growth undermines everything we're trying to do here, all our development efforts as well as political stability," a senior American official in Uganda said. "The economy isn't going to have enough jobs for all the people we're saving through PEPFAR."
'IT'S NOT TOO LATE
When Congress reauthorized PEPFAR 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.
"Nobody is saying we shouldn't be putting money into HIV, but there was little done to mitigate the effects on the other health priorities," said the former U.S. health official, who served in the Bush administration U.S. Agency for International Development, which administers most American foreign aid.
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 another 9 percent hike in 2010 and issued guidelines encouraging PEPFAR-funded agencies for the first time to link family-planning services with the anti-AIDS effort.
Ugandan officials said that with additional support they could educate more men and women about the need to keep their families to manageable sizes.
In 2004, after she delivered her third child in Busia, Catherine Naka began taking contraceptive shots over her husband's objections, calling a local health worker to her home while he was at work. A year ago, though, her husband found her hospital card, with the injection dates ticked off in ink, and ordered her to stop.
On a recent afternoon, with her fourth child nearly due, Naka, 29, sat in a bare concrete room in the Busia hospital, looking fraught. She was worried about feeding her family with her husband struggling for work and their patch of farmland threatened by drought.
"Can you help me?" she pleaded with a health worker.
Akol finds a glimmer of hope in stories such as these. "For many families, it's too late," she said, "but for many others, it's not too late."