Kampala — When Martin Owor, a father of six, told his wife he was considering having a vasectomy, she told him it was out of the question. How would they live as husband and wife after his surgical sterilisation?
But after a long conversation about growing up poor, the Ugandan man went ahead with a procedure that remains widely unpopular in sub-Saharan Africa, where misunderstandings are high.
To spur development, this East African country that has been a regional leader in tackling health challenges like AIDS now hopes to lower population growth.
The issue is widespread in Africa, which faces a population boom even as other parts of the world see dropping birth rates. Over half of the global population growth between now and 2050 will take place in Africa, the United Nations says.
Sub-Saharan Africa, with some of the world's most impoverished nations, will continue to be plagued by poverty unless governments reduce high fertility rates, development experts say.
Uganda has started recruiting "champion men" to speak publicly on television and elsewhere about vasectomies as a method of family planning. It has proven difficult.
Many men fear it leads to impotence. Some worry about being stigmatised. Others ask what might happen if, after a vasectomy, they lose all their children in some catastrophe.
"Many people think that when a man goes for a vasectomy he is not going to continue being a normal man," said Owor, who runs a grocery store in eastern Uganda. "But there is no problem. My wife is very happy."
Owor said he was compelled to have a vasectomy because he did not want his children to grow up hopelessly poor.
"My father had 12 children, so we never had a chance of having a quality education," Owor said. "I needed a number that I would try to manage."
Uganda's population has ballooned from 17 million in 1990 to more than 41 million in 2016. It one of nine African countries in the world's top 10 fastest-growing populations, according to U.N. figures.
Only 35 percent of married women in Uganda use modern methods of contraception, according to government statistics. Abortion is illegal in Uganda, except to save the mother's life.
Although Uganda's fertility rate dropped from 6.9 births per woman in 2001 to 5.4 today, officials say a desirable rate is four births per woman.
As "champion men" speak out, the government is working to increase male involvement in family planning as a way to meet that goal.
"We can't coerce them, because family planning is voluntary and is supposed to be based on human rights, and we want to keep on engaging them," said Placid Mihayo, an assistant government commissioner in charge of sexual and reproductive health.
Uganda's openness recalls its public campaigns against the AIDS epidemic in the 1990s, when many African countries, including Kenya and South Africa, did not fully acknowledge the crisis.
"Uganda has done extremely well," said Alain Sibenaler, the U.N. Population Fund representative in Uganda, whose office has been working closely with the government on family planning options. "The total fertility rate has dropped in a very short time."
Uganda remains one of the world's poorest countries, with a per capita income of $615 (about R8000), according to World Bank data. The situation is dire in rural areas, where health facilities often lack basic medicines and many children drop out of school.
Some warn that the country won't come close to meeting its ambitious development targets — achieving lower-middle-income status by 2040 — without wider use of birth control.
"If you produce 100 children and create only two jobs in that period, so where are the other 98 going to get jobs?" asked Sam Mwandara, project coordinator for Reproductive Health Uganda, a U.N.-supported group. "The population is expanding so fast in relation to land, jobs, education and health. So it's alarming."
Vasectomies are still a small part of Uganda's effort. Each month two or three of the procedures are performed at a clinic run by Reproductive Health Uganda in the capital, Kampala, said Dr. Kenneth Buyinza, an expert on reproductive health. The vasectomy costs about $13 (about R170), which Buyinza said is affordable to most Ugandans. The price is $50 (about R650) or more at some private facilities.
The organisation also distributes millions of free condoms each year in a country where their use has become widespread.
"When it comes to the permanent methods of family planning we are still on the low side," Buyinza said of vasectomies, though the organisation tries to spread the word that of all the modern family planning methods the procedure has the fewest side effects, if any.
"The uptake of vasectomy, much as it offers the best option in terms of lifetime birth control, it is still not yet easy to sell."