Learning from young people to prevent and manage unwanted pregnancies

Influencing
Sierra Leone
2014
This research briefing addresses an urgent need to understand young people's attitudes towards sexual and reproductive health (SRH) and their use of related services in Sierra Leone.

Results from a Participatory Ethnographic Evaluation and Research (PEER) study conducted by Marie Stopes Sierra Leone, in Kabala, Koinadugu District in 2013.

There is a critical scale of teenage pregnancy and maternal mortality in Sierra Leone, and therefore, an urgent need to improve the understanding of attitudes of young people towards sexual and reproductive health (SRH) and their use of related health services.

This briefing aims to provide decision-makers, health planners and health workers with key information which will help them to adapt health services and messaging.

Introduction

Early childbearing is common in Sierra Leone: one out of three pregnancies occur among teenage girls[i].

Teenage pregnancies have negative effects on the survival of girls: 40% of maternal deaths occur among teenage girls[ii].  

Many young pregnant women risk their life by having an unsafe abortion: 10% of the maternal deaths reported are due to unsafe abortions[iii].

In order to prevent these deaths, more evidence is needed to understand young people’s attitudes towards health services – including family planning – and to support the Government’s strategy to reduce teenage pregnancy.

This research briefing presents findings from a qualitative study[iv] that aimed to understand attitudes to, access to, and use of services related to young people’s (aged 18-24 years) sexual and reproductive health (SRH), in particular contraception and safe post-abortion services, in Kabala, the district capital of Koinadugu District, Sierra Leone. 

Attitudes of young people towards SRH: Findings and recommendations

Approach to learning from young people

The purpose of the PEER study was to enable health providers to understand the drivers of young people’s risk-taking in sexual relationships, their use of family planning, and how providers can scale up the supply of SRH services for young people in Kabala.

The research was conducted on behalf of Marie Stopes International (MSI) and Marie Stopes Sierra Leone (MSSL) by Options Consultancy Services Ltd, and funded by the UK Department for International Development (DFID).

Sixteen PEER researchers – eight men and eight women – were trained in PEER and interviewed two friends each. In total, the peer researchers interviewed 30 friends; 89 narratives were collected.

The data have generated rich insights into the social context in which young men and women make the daily decisions that affect their sexual and reproductive lives.

The key findings are summarised below. 

The context in which sexual relationships are negotiated

Others [young men] have intentions to just have sex with you, so to impress you they will buy you gifts or give you money, and then when they got what they want they leave you.” PR3/F1 female

Sexual transactions are common for young people; young men expect sexual favours for providing financial and material benefits for young women, who, in turn, expect to accrue benefits for each relationship.

Young women were sometimes described as being powerless to refuse men’s sexual advances and often experienced a level of psychological or physical abuse.

Recommendations:

  • Ensure a gender empowerment approach: Health planners should ensure that their approaches empower women to make choices about their SRH needs.
  • Incorporate messages about Sexual and Reproductive Health Rights (SRHR) in Information, Education, and Communication (IEC) activities to promote mutual respect and to raise expectations of women. 

Consequences of sex

“Some girls decide to kill themselves because they (…) will be afraid that her mother will want to poison her or her father will want to kill her” PR3/F2 female

Young people feared the consequences of pregnancy more than sexually transmitted infections (STIs). STIs were considered treatable, and scepticism was expressed that HIV existed.

The consequences of unintended pregnancies among young people in Kabala are severe: when a pregnancy is disclosed, both male and female school attendees will be excluded from school.

The young woman may be ostracised from her family, losing shelter and financial security. The young man risks brief imprisonment; he or his family may suffer financial consequences.

Young couples who wish to avoid such consequences risk health by seeking unsafe abortions which can result in morbidity and mortality.

Others abscond, or, at worst, commit infanticide or suicide.

Recommendations:

  • Identify and develop referral pathways with organisations or services that offer support or care for young people with unplanned pregnancies, to strengthen linkages with services to improve information and advice provided about family planning (FP) methods and services and post-abortion care (PAC) services; to incorporate information about options to manage such unplanned pregnancies into sensitisation mechanisms and IEC materials.
  • Strengthen messaging about HIV to address the scepticism about its existence, and identify communication messages and modes to provide information about risks, prevention and treatment.
  • Strengthen referral to HIV services: Establish referral pathways for HIV Counselling and Testing (HCT) services, ensuring they are accessible for young people. 

Decisions about fertility

“She got pregnant (…) the mother took her to [a traditional practitioner] ... to abort (…) so after that the lady died.” PR3/F2 female

Religious and cultural ideals restrict termination of pregnancy, but termination can be considered more favourable than seeing a pregnancy to term – i.e to avoid the ‘shame’ of pre-marital birth, or when an additional child can plunge an already poor family further into poverty.

Relatively little was known about abortion or PAC; importantly, no narratives described the use of oral medication to terminate pregnancy.

Recommendations:

  • Create dialogue with religious and traditional leaders to develop pathways to support young people in making SRH decisions, reflecting the reality in which young people experience sexuality.
  • Create a more open dialogue about abortion: Identify mechanisms to improve young people’s knowledge of safe procedures for abortion and PAC, based on the legal grounds for abortion in Sierra Leone (to preserve a woman’s life or to maintain physical or mental health). 

Accessing accurate information about contraception

“A man can decide just to use condoms by himself. Once a boy has decided, a woman cannot go against this... When a woman initiates this, the boy just suspects that the lady suspects he has an infection.” PR8/F2 male

Young people had a high level of awareness of different methods of FP but there was little mentioned about emergency hormonal contraception.

Condoms were favoured among men as an affordable, controllable but less pleasurable option, sometimes inferring a lack of trust within a relationship.

There were many misperceptions surrounding SRH issues, including confusion about the cost and efficacy of different methods.

Young people mostly seek information from their friends.  

Misperceptions and preferences for non-invasive traditional methods contribute to the non-use of modern FP methods.

Recommendations:

  • Review and strengthen IEC materials and communications about the risk of pregnancy and about different methods of FP in order to dispel or correct the multiplicity of false beliefs about FP methods.
  • Review IEC dissemination and consider the feasibility of using peer educators to increase the dissemination of correct information about methods of FP and management of unwanted pregnancies.
  • Promote inter-generational communication about SRH matters: consider developing a series of communication and IEC materials that promote confidence in knowledge of, and how to communicate about, SRH matters between parents and children.

Decision-making about modern FP methods and unwanted pregnancy

“Because when you impregnate a woman, you have to go to prison (…)  so you don’t want to have a baby.” PR10/F2 male

Financial considerations and assurances of confidentiality seemed to be the main drivers in selecting a provider. Decisions about FP are often made among couples and financed by young men.

The risks associated with abortions were widely acknowledged, but for some, these risks were preferable to continuing the pregnancy.

Traditional practitioners were reported as preferred providers because of the ability to seek consultation in secrecy.

Quality of services and commodities affected decisions about FP and DRH services. Having trained and skilled health workers who treat young people with respect and courtesy was highly valued.

Some government-approved private clinics were seen as providing care of high-quality but less affordable.

The government hospital was described as a setting with limited choice of FP options, and trained but impatient, rude and indiscreet staff, providing affordable services.

Recommendations:

  • Addressing perceptions of cost barriers: young people make treatment-seeking decisions based on the assumption of high costs. Wider awareness of the fees charged is needed.
  • Making government-approved private clinics more acceptable to young men: Communication materials need to be reviewed to identify ways to promote services that might attract men.
  • Improve knowledge among health workers that impolite staff discourages use of services and leads to negative health outcomes, in particular among young people.
  • Improving care pathways for young people with unwanted pregnancies: Identify how to increase access to emergency contraception, safe PAC, and quality FP - working with traditional practitioners. 

References

[i] Statistics Sierra Leone, Ministry of Health and Sanitation [Sierra Leone], & ICF Macro. (2009). Sierra Leone 2008 Demographic and Health Survey. Freetown: Statistics Sierra Leone, MoHS, & ICF Macro.

[ii] Statistics Sierra Leone, & UNICEF. (2011). Sierra Leone Multiple Indicator Cluster Survey 2010 Final Report. Freetown: Statistics Sierra Leone, & UNICEF.

[iii] Ministry of Health and Sanitation, and Evidence for Action. (2012). Maternal deaths reviews. A national call to action. Freetown: MoHS

[iv] Nam, S.L., Juana, S., Missah, T., Brown, E. & Grellier, R. (2013). Qualitative Research to Improve Health Services to Prevent and Manage Unwanted Pregnancies. Kabala, Koinadugu District, Sierra Leone. Results from a PEER Study, February 2013. London: Options and Marie Stopes Sierra Leone. 

Evidence for Action (2014). Research briefing : Learning from young people to improve health services to prevent and manage unwanted pregnancies. London: Evidence 4 Action
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