Underage: Addressing Reproductive Health and HIV in Married Adolescents
In July, thousands of people attended the 20th International AIDS Conference and the 2014 Girls Summit to work towards an AIDS-free generation and ending child and forced marriage. But such attention is rare; by and large, these girls are invisible to development efforts.
Some 70 million girls under 18 are married in the developing world; 16 million of those girls will have given birth by the end of the year. In addition, of the two million adolescents living with HIV around the world, 65 percent are girls, said Elizabeth Berard, a health science specialist with USAID at the Wilson Center on July 30.
“Globally, this marginalized population of young women has unique needs and rights that need to be addressed and acknowledged,” said Callie Simon, a technical advisor for adolescent sexual and reproductive health with Pathfinder International.
Building on a series of Wilson Center events on child marriage and the sexual and reproductive health and rights of adolescent girls, Berard and Simon were joined in discussion by Suzanne Petroni, senior director of gender, population, and development with the International Center for Research on Women, and Doris Bartel, senior director of gender and empowerment at CARE.
“Fated for Suffering”
As part of the largest-ever generation of young people, today’s married adolescent girls are essential to economic and social development, but social norms and information deficits often isolate them from opportunity, and many are forced to forfeit working or going to school.
In the slums of Dhaka, becoming a wife and mother as soon as possible is the expectation, said Petroni. Although the legal age for marriage in Bangladesh is 18, a study directed by Petroni found the majority of 320 married girls surveyed were wedded between ages 12 and 17 and some reported being pregnant at 15. There is a sense of normality around adolescent marriage, despite the law, she said, which exacerbates poverty and gender inequality.
Most of the girls reported being unhappy in their marriages due to their husbands’ frequent gambling, drinking, infidelity, and lack of financial provision. Gender and sexual-based violence were also frequent among the married girls, Petroni said; the cultural norms around domestic violence and gender roles are so strong, a high percentage of married girls even said it justifiable under certain circumstances.
“What are the good sides?” one girl told Petroni. “I was fated for suffering. I don’t see any positives in my fate.”
Marriage as a Risk Factor
In West African countries like Burkina Faso, Niger, and Guinea, high rates of adolescent marriage, pregnancy, and low contraceptive use are very common, said Callie Simon. This can be attributed, in part, to the influence of family members.
Young married girls are frequently pressured by their mother-in-laws to closely space their births, said Simon. “Isn’t that baby on your back getting heavy by now?” is a common refrain, she said, implying the girl should have another child.
“Married adolescent girls have so little power and decision-making over their bodies, over their choices, [and] over their lives,” said Simon. “[They] felt culturally-extreme pressure to prove their fertility upon entering marriage. A woman who had not gotten pregnant within a year of marriage was considered eligible for divorce.”
Upon being married, these girls are forced to leave school and their homes and live in a much-older husband’s home, usually as junior wives to existing co-wives, Simon said. In the process, young brides become socially isolated and face serious health implications.
Eighty percent of the unprotected sex recorded among adolescent girls in the developing world occurs in marriage, said Elizabeth Berard. This substantially increases the likelihood of contracting HIV, which without treatment can in turn pass perinatally from mother to baby. There’s little definitive information about the number of married adolescent girls living with HIV, but Berard said there is certainly a substantial number. “We need to remember that each young person is unique and has his or her own unique needs,” she said, which may include psychosocial as well as health needs.
Besides increased exposure to health problems, child brides also frequently face problems accessing care. Petroni said the existing stigmas around premarital sex, abortion, delivering in health facilities, and even prenatal care prevents women from accessing services and learning enough to understand what’s happening to their bodies. For example, in her research in Bangladesh, she found that some of the girls reported having a disease, when in reality they were experiencing symptoms of normal menstruation. Married or not, embarrassment, lack of knowledge, and concerns about privacy were some of the reasons adolescent girls decided not to seek care in Dhaka, she said.
Testing Interventions Methods
There are very few organizations and programs around the world targeting the needs of these girls, said Doris Bartel. The TESFA program in Ethiopia is one of a few that works to meet the needs of not only child brides but also adolescent girls that have been divorced or widowed. Implemented by CARE and evaluated by the International Center for Research on Women, the project ran for three years in the Amhara region.
“Half of the girls in the Amhara region are married by the age of 15 and most are already married by 18,” said Bartel. The program targeted 5,000 married girls, age 14 to 19, and provided three different types of interventions: one that focused on financial empowerment, another that focused on sexual and reproductive health, and a third that was a combination of both.
When the TESFA project ended in 2013, significant improvements had been made, said Bartel. Of the three interventions, the strongest outcomes were seen in the sexual and reproductive health programs. There was a 27 percent increase in contraception use, 20 percent increase in HIV testing, and a 29 percent increase in the overall use of health services, she said. Changes in gender equality and communication in marital relationships also improved as gender-based violence and forced-sex reduced drastically.
During the evaluation process, TESFA gave girls a chance to document their own experiences using cameras. In one photo, a girl is shown holding her baby as the caption reads: “This is me taking injection contraceptive. This is after TESFA project. I have one child and I want to wait until my child becomes strong.”
Bartel said such feedback is extremely meaningful, “given the lack of family, community, and clinical support for girls to use contraceptives.”
Diversify Programming, Crackdown on Violations
Such targeted, highly focused interventions need to become more common if the development community expects to reach child brides, said the panelists.
In Bangladesh, 30 percent of the girls interviewed during their research had jobs in the garment industry, said Petroni. She recommended pursuing partnerships with these factories so that information about sexual and reproductive health services would be more accessible. She also suggested the legal age of marriage could be enforced through birth and civil registrations to crackdown on violations (because birth registrations are not enforced, some girls did not know their actual age).
Berard highlighted the importance of male engagement, especially as it relates to HIV transmission, and suggested encouraging more testing by families and couples to improve awareness and stop the inadvertent spread of the disease. She recommended improving access to family planning and counseling for adolescents living with HIV, identifying pregnant adolescents early to prevent perinatal transmission, and improving access to other antenatal care services.
Berard also said more clarification about the legal rights of married girls is needed. For example, in many countries it’s unclear if married girls can even undergo HIV testing without the consent of their husbands. Other areas of uncertainty involve the rights of young girls and their children in cases of abandonment by their husbands, she said.
In addition, more work to reduce cultural stigmas and norms is needed, said Bartel, especially for divorced and widowed women. Given their status, “they are really not supposed to be asking for contraceptive information and are doubly stigmatized.”
Lastly, Simon suggested more collaboration with ministries of health to diversify sexual and reproductive health interventions. Efforts to improve maternal and child health services should always include youth-friendly services, she said. Additionally, health care facilities should have community support groups and other programs that cater to the needs of married adolescents living with HIV, said Berard.
We need to be asking, “What is the reality for you?” said Bartel, “[then] design programs and interventions targeting that reality of their lives.”
Drafted by Katrina Braxton and Edited by Schuyler Null