96021 Knowledge Brief Health, Nutrition and Population Global Practice ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH IN NIGER Helene r Barroy, Rafael Cortez and Djibrilla Karamoko April 2015 KEY MESSAGES: May 2014  Poverty affects adolescents in various ways: limited school enrollment, family work, violence, disempowerment and gender inequalities.  The median age for first marriage is 15.7 years for women and 24.2 years for men and sexual debut correlates with age of marriage for girls at 15.9 years.  Education and place of residence have significant impact on whether or not a girl has sex before age 18.  The median age for childbearing is 18.5 years among young women. But a quarter of them already had their first child at the age of 16. Early childbearing is more frequent among the poor and the rural.  There is limited use of Sexual and Reproductive Health services including Family Planning (FP) (7 percent) among adolescents.  There is strong cultural opposition toward use of FP, especially for unmarried girls and at early stage of marriage. INTRODUCTION services. Meeting their SRH needs and rights are therefore important to their health, development, and future  Today’s adolescents and youth face substantial physical, opportunities. social and economic barriers to meeting their Sexual and Reproductive Health (SRH) potential. Implicit to meeting In Africa, Niger presents worrying characteristics for youth these needs are human rights; gender equity and equality; SRH. Niger has the highest fertility rate in the region and and the provision of healthcare. In fact, despite the world, as well as lowest age for marriage and international support for adolescent and youth SRH and childbearing. Early marriage and childbearing have been rights (for example, the 1994 International Conference on identified as key contributors to high fertility and maternal Population in Development), young people consistently mortality in the region (PRB 2011). In Niger, adolescent face high levels of unmet need for contraception, fertility is high affecting not only young women and their unplanned pregnancies, unsafe abortions, sexually children’s health but also their long-term education and transmitted infections (STIs), and maternal mortality and employment prospects (WHO 2011, World Bank 2001). morbidity. For example, at the global level, adolescent • About females 14 years 10 tohalf of age are twice of adolescents as likely reported to die that theyin knewTo understand about SRHR how countries are addressing adolescent childbirth as adult women, and half of all new HIV infections sexual and reproductive health and rights (SRHR), the proportion occur in youngof deliveries people betweenin private 15 and 24 health yearsfacilities increased of age has World Bank ten-fold conducted over the past and a quantitative 18 years. qualitative study (Pathfinder International, 2011). in several countries with a high adolescent’s SRH burden • While the. including Niger. The specific objectives of the study were SRH is a right for everyone, including young people. In fact, to: (i) Investigate adolescent’s socio-economic profile; (ii) adolescents and youth are better able to protect Analyse adolescent’s sexual and reproductive health themselves against STIs, unplanned pregnancies, and status and its determinants from a demand and supply-side take advantage of educational and other opportunities perspective; (iii) Assess effectiveness of existing when they have access to private and confidential SRH adolescent friendly initiatives and programs; and (iv) Recommend a set of policy options to improve access and • Wealthy, urban, and educated women are increasingly relying on the private sector for RH services. Page 1 HNPGP Knowledge Brief  use of services for adolescents in Niger. This Knowledge adolescents is frequent and largely sexual. A 2011 UNFPA brief provides a brief background on adolescent SRH in /OXFAM study showed that 30 percent of the surveyed Niger and summarizes the results of this study adolescents aged 15-18 were victims of sexual violence. Figure 1: Trends in total fertility rate in Niger and the sub-region (1990- Women in Niger are disadvantaged from a young age. 2013) More than 90 percent of female’s experience genital cutting and arranged marriage is common. After marriage, women go to live with their husband’s family, where men have legally recognized authority over them and where mothers- in law have strong intra-familial influence. The female face of poverty also highlights issues of gender inequality. In Niger, this inequality is reflected in per capita consumption which is 45 percent lower in households headed by women (2008), access to credit (17.5 percent of demand met as against 27.4 percent for men in 2008), and employment opportunities (27.4 percent access for 51.1 percent of the workforce). The low level of women’s participation in decision-making at the family, community, administrative Figure 2: Share of married women under 15 and 18 (left); and share of women who gave birth before 18 (right), in Niger and the sub-region and economic levels is a major socio-economic constraint. ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH IN NIGER The median age for first marriage is 15.7 for women and 24.2 for men. About 61 percent of females aged 15 to 19 are already married compared to 2.6 percent of men of the same age group. Early marriage for girls is socially valued. Sexual debut correlates with age of marriage for girls (15.9). Young women become sexually active much earlier than men, since according to 24.5 percent (73.9 percent) of those aged 15 to 24, they had their first sexual encounter SOCIO-ECONOMIC PROFILE OF ADOLESCENTS IN before the age of 15 (18), compared to only 1.1 percent NIGER (10.9 percent) for men of the same age group. A girl’s education and place of residence have significant impact The Republic of Niger is a landlocked sub-Saharan African on whether or not she has sex before age 18. In particular, country, where more than half of the population lives below each additional year of education reduces the likelihood of the poverty line. Niger has the highest fertility rate in the sex before age 18 by 4.5 percent, and rural residence can region and the world, estimated at 7.6 children per woman increase the likelihood by 18 percent. in 2012 (8.1 in rural areas). At current rates, the population will double in the next 15 years. While half of the population Early marriage and childbearing greatly affect maternal and is under 15 years of age, adolescents represent nearly a child health. Maternal mortality accounts for 35 percent of quarter of the population. all deaths occurring among women aged 15 to 19. Births to women aged 15-19 years old have the highest risk of infant Poverty affects adolescents in various ways. They mostly and child mortality as well as a higher risk of morbidity and live in rural areas (80 percent). Access to education is mortality for the young mother. There is also evidence that limited. Only 4 percent of women 15-19 years of age and 7 elective abortion presents a high risk of mortality for the percent of men of the same age have completed primary young mother. school. The vast majority of adolescents work. Some 74 The median age for childbearing is 18.5 among young percent of young boys (12-14 years old) and over 80 percent of young girls (same age) declare working in the women. But a quarter of them already have had their first family’s business or on family land. Cultural and social child at the age of 16. Early child bearing is more frequent norms tend to disempower adolescents. In Niger, even among the poor and in rural areas. Almost 70 percent of though a child is seen as a blessing for the family, and the poorest women 20-24 years old have had a child before he/she is considered to be worthy of investment to prepare age 18, compared to 41 percent of their richer for the future, a vast hierarchical structure is in place to counterparts. Similarly, while more than 80 percent of the ensure that young people obey their elders, thus restricting rural women in the same age group already had a child, their ability to express themselves and make decisions half of the urban women did not. within their family and community. Violence against Page 2 HNPGP Knowledge Brief  Even though female adolescents lack awareness of their However, the opposition of the women and their husbands reproductive cycle and fertile period, their knowledge of was the main reason for their non-use of services (28.9 modern family planning methods is surprisingly good and percent), while the perception of negative effects on health has improved over time. In 2012, an estimated 73 percent did not seem to dominate their opposition (8.9 of female adolescents had fair knowledge of contraception percent).Utilization of modern FP services is misperceived methods. Furthermore, knowledge appears to be and generally not understood by male spouses, especially accumulating with age. More than 80 percent of women during the early stage of marriage. above 18 years old are aware of modern family planning methods. Qualitative information reveals however that NATIONAL POLICIES AND PROGRAMS ON ASRH youth may lack precise knowledge about the exact role, utility and prescription of contraception. Adolescent-friendly policies have been increasingly mainstreamed in national strategies for poverty reduction, Utilization of SRH services including FP is limited among health, education and jobs. For example, the 2011 National adolescents. Overall, some16.4 percent of women aged 15 Strategy for Economic and Social Development aims by to 19 did not receive any ante-natal care during their 2024 to “ensure that the youth are contribute to the pregnancy. Although female adolescents aged 15 to 19 country’s sustainable development.” Four main pillars of visit antenatal care clinics, they do not deliver in formal the strategy directly refer to adolescents and their role in health facilities. Indeed, 63.4 percent deliver somewhere economic progress: (i) control of the demographic pressure other than a health center, without health care through increased use of family planning services; (ii) professionals, often at home. Place of residence is the integration of the youth in economic life through inclusive variable that most affects where female adolescents give growth, better involvement in decision-making and birth. In urban areas, only 18.2 percent of female professional skills development; (iii) improvement of SR adolescents aged 15 to19 gave birth most recently outside health for the youth through free provision and community- of a health facility, without medical assistance, compared based distribution of FP commodities; and (iv) reduction of to 68 percent in rural areas. Even when young women gender-based inequalities, with a particular focus on under the age of 19 are aware of modern family planning education and jobs. However, much remains to be done to methods (see section 2.2), they rarely use it. Some 93 enhance national ability to effectively mainstreaming percent of women aged 15-19, who are currently married, adolescent SRH issues across programs. A review of the do not use any form of contraception. implementation of the strategy shows little progress toward adolescent-specific outputs. The main obstacles to accessing sexual and reproductive health services for women aged 15 to 19 have to do with The emerging sexual and reproductive health agenda has financial and geographical barriers. Money is cited in the relatively favored the inclusion of youth issues in the policy majority of cases (52.3 percent), while distance and formulation process in Niger. The adoption of the transport constitute the two other main barriers (for 38.7 Reproductive Health law in 2006 marked a milestone in percent and 38.3 percent of the surveyed female acknowledging sexual and reproductive health rights, adolescents respectively. It is worth noting that in over 20 especially for young women, as a top priority for percent of the cases young women needed approval from government action. It particularly recognized right to parents, husbands/partner or other relatives to seek access adequate care and prevention services for healthcare. Adolescents are reluctant to use formal care pregnant (and in childbearing age) women. The Family services. Location, purpose, utility are generally ignored Planning Action Plan (2012-2020) also made room for among adolescents. Self-medication and traditional adolescent specific issues. A specific National Plan for medicine are the first care seeking behaviors when needs Adolescent Sexual and Reproductive Health was adopted emerge among unmarried adolescents. Low quality sexual in 2011 in Niger. Niger was one of the pioneer countries for and reproductive health services are also a major obstacle introducing such strategic guidance for the sector in the from the supply-side, as well as lack of adolescent-friendly sub- region. The Action Plans relies on four strategic approaches within public facilities. A Gender and Health pillars: (1) improve access to information responsive to Survey conducted in 2013 showed that the behavior of needs; (2) improve adolescents and youth access to, and health workers toward adolescents constituted a barrier to use of health services; (3) promote an environment accessing SRH services. Additionally, adolescents cited supportive of adolescent and youth health; and (4) improve strong cultural and social opposition in Niger as reasons for management of operations targeting adolescents. not using FP services. Overall, nearly half of the women surveyed in the 15 to 19 age group (42.6 percent) cited Government interventions have mostly focused on “opposition” as the main reason for not-using modern strengthening the supply of adolescent health and contraception methods (DHS 2006). Opposition tends to wellbeing services. Interventions on the demand-side have pertain to both social and religious values against FP and been scarce. Efforts to increase national capacity to misperceptions of FP commodities for medical reasons. provide user friendly SR services for adolescents shall be Page 3 HNPGP Knowledge Brief  pursued. Some 48 health centers (8 for each province) are  Scaling-up of adolescent-friendly training to all health now adolescent-friendly, with staff trained on adolescent cadres. specific health issues and provision of adequate services  Inclusion of adolescent-related monitoring indicators in and commodities. Specific guidelines have been health facility supervision guidance. developed with the support of development partners,  Tailored approaches to engage with traditional leaders. mainly WHO and UNFPA, to define standards and norms  Mobilization of school teachers to actively relay for adolescent-friendly services, and train health personnel information on SR and FP to the youth in the community. accordingly. Training has reached over half of the health  Decentralized authorities are better involved in ASRH. personnel in the country. In their medical practices, provider behaviors remain, however, largely influenced by  Prioritizing demand-side interventions: cultural and religious norms that condemn sexual  Scale-up financially sustainable Demand-side intercourse before marriage for females. Government’s interventions. interventions have often been implemented in silos with  Dissemination of results to policy-makers. little coordination developed between the education, health  Demand-side initiatives based on best practices and and jobs sectors. Strategic linkages and partnerships tailored approaches for the Nigerien socio-cultural context. between schools, health facilities and youth centers need  Community-based interventions that include community to be reinforced to allow better dissemination of SR health dialogue with traditional leaders. awareness among adolescents.  Empowering the youth: Demand-generating actions have been developed at small  Adolescents’ views to be integrated in the design of scale and are largely under-funded. Life skills future adolescent-related strategies and interventions. development, peer education and behavior change  Youth centers to be upgraded, better equipped and activities are the three main interventions under staffed throughout the territory. implementation on the demand-side to generate greater  Youth to be engaged in community relays/peers demand for ASRH services. While interventions aim to identification. improve knowledge and practices towards SR services,  Life skills, capacity development programs are scaled- they also tend to contribute to enhancing the empowerment up. of adolescents within the Nigerien society. Peer education  Professional training opportunities to be offered to activities have been practiced by a number of youth- adolescents. oriented organizations, but scaling-up needs to be further  Future research and programmatic efforts need to encouraged. Such activities are generally practiced on a address gender norms and consider the influence of other voluntary basis and many peer-based interventions remain family members, such as mothers-in-law. on the informal side. The turnover of peer educators is high, as they move on to study or get involved in income-  Designing and implementing multi-sectoral generating activities. Since peer educators work as unpaid interventions: volunteers, their commitment is limited. Furthermore, peer  Better coordinated and integrated initiatives for youth to education remains largely under-supervised and would be implemented across education, health and job sectors. require further supervision and guidance to be effective on  Flagship initiatives to be developed jointly between a larger scale. Behavior change communication programs MoH, Ministry of Youth and Labor. have been implemented with relatively good results at a  Schools and health facilities to partner for joint health small scale with support from development partners. The education sessions, especially in rural areas. scaling-up of those pilot activities coupled with mass media  Community peer educators to be trained in multi- communication campaigns would help to reach a larger sectoral approaches. audience. MAIN RECOMMENDATIONS This HNP Knowledge Brief highlights the key findings from a study by the World Bank titled “Addressing Adolescent Sexual and Reproductive Health  Mainstreaming ASRH in national programs: in Niger: A Policy Note” (2015), prepared by a WBG team including, Barroy H., Lejean N., Wang H; and R. Cortez (World Bank’s Team Lead). This study  Inclusion of youth and adolescents issues in all health was part of the Bank’s Economic Sector Work “Paving the Path to Adolescent policies and programs. Sexual and Reproductive Health" conducted by the Health Nutrition and Population Global Practice and financed by the World Bank-Netherlands Partnership Program (BNPP). The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP- related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the Regions. For more information on this topic, go to: www.worldbank.org/health. Page 4