Pregnancy among adolescent women in Nepal: a mixed methods investigation of a complex persistent phenomenon
2017-02-24T00:21:50Z (GMT) by
Background: Pregnancy related morbidity and mortality is much more prevalent among adolescents than adults. Adolescent pregnancy is therefore a significant public health problem. Most births to adolescents (95%) occur in resource-constrained countries. However, little is known about the risk factors for adolescent pregnancy in these settings. Objectives: The first objective of this study was to describe the prevalence and determinants of pregnancy among adolescents in Nepal using the Nepal Demographic and Health Surveys (NDHS). The second was to ascertain the views and perspective of young married and unmarried women in rural Nepal about pregnancy among adolescents. The third was to understand from the perspectives of key informants from relevant policy and programme sectors why adolescent pregnancies persist in Nepal and what efforts have been made to date to reduce them. Methods: Mixed methods were used consisting of quantitative and qualitative methods. Secondary analyses were conducted on data from NDHS from 2001, 2006 and 2011. In-depth interviews were conducted with young women (married and unmarried) aged 15-24 years from the rural area of Lalitpur district of Nepal. Semi-structured interviews were conducted with key informants representing government and non-governmental organizations with experience working in adolescent health programmes. The data were collected from August to October 2013. Results: Prevalence of pregnancy and birth among married adolescent women in Nepal (56%) is still high, and did not decrease significantly between 2001 and 2011. Risk factors for adolescent pregnancy identified in the NDHS data included living in the less well-resourced Eastern development region, low socioeconomic status, partner's age and early sexual debut. Some risk factors identified by young women were similar to these: early marriage, lack of access to education and the family being of low socioeconomic status. Others were different: cultural traditions about early arranged marriage, size of dowry payments in relation to the woman's age, lack of access to income-generating work and avoidance of contraception because it was either unavailable to unmarried or childless women, or believed to cause infertility. Key informants described further relevant factors: slow and ineffective implementation of adolescent sexual and reproductive health strategies and programmes; poorly trained teachers and health workers, a focus on health services rather than prevention, and a belief that the internet and other social media were making young people prematurely sexually interested and active. Some risk factors are similar to those identified in high-income countries, but there are structural, community, family and individual factors that are unique to Nepal, but possibly also to other low-income settings in South Asia. Discussion: The risk factors for adolescent pregnancy identified in this study can be understood within the World Health Organisation Social Determinants of Health Conceptual Framework. At a structural level it is clear that the overall development of a region has impacts on families and individuals, including their access to essential resources and to the social benefits of modernisation. At the family and community level, young women still face gender-based discrimination about their rights to complete primary and secondary education, to self-determination in terms of an income-generating occupation, the choice of a marriage partner and when and how many children they want to have. At an individual level young women have no awareness of their reproductive or other rights, and nor are they empowered to realise these. The persistent high prevalence of adolescent pregnancy suggests that Nepal's adolescent sexual and reproductive health strategy has not been effective. These factors are interlinked and indicate that strategies with a single focus are unlikely to be effective and that multi-stranded and multi-level approaches are required. Increasing access to adolescent friendly reproductive health services is worthwhile, but has negligible impact on preventing pregnancies occurring. Conclusion: These data provide evidence that adolescent pregnancy is determined by interlinked structural, family and community, and individual factors. Comprehensive programmes addressing risk factors such as poverty, lack of local infrastructure, the low social position occupied by women, lack of access to education, gendered restrictions on opportunities and sociocultural traditions need to be addressed at structural, family and individual levels, which are likely to be more effective than single strategies in preventing adolescent pregnancy and promoting choice for healthy reproduction. The findings from this study provide public health professionals with a comprehensive framework for the development of intervention programmes to target recognised and unrecognised risks for pregnancy among adolescents in low- and middle-income countries. It is unlikely that strategies to reduce pregnancy among women aged less than twenty years will be effective unless these are addressed directly.