Impact Data - Reproductive Health for Married Adolescent Couples Project (RHMACP)
Date
Reproductive Health for Married Adolescent Couples Project (RHMACP) was designed to address the large population of married Nepalese adolescents with unmet needs for reproductive health information and services. The ACQUIRE Project, in association with CARE Nepal and with funding from the United States (US Agency for International Development (USAID), worked in close collaboration with District Public Health Offices in Parsa and Dhanusha to develop an ecological model incorporating interventions at multiple levels - from individual to health system/policy levels - to bring about behaviour change and improve health outcomes. In short, the RHMACP established a peer education network to disseminate reproductive health information to married couples; supported local health facilities to provide youth-friendly services; and fostered an enabling environment among parents, in-laws, and influential community members to increase married adolescents' access to, and use of, health services.
Methodologies
The baseline survey was carried out in September 2005; the endline was conducted in October 2007. Quantitative data were collected using the Demographic and Health Surveys (DHS) model, which involved structured questionnaires that were designed, pretested, and translated into Bhojpuri and Maithali (two languages widely spoken in Nepal). The sample size for both surveys was 960 individuals - 480 for each sex and 480 for each district. In addition, at the endline, 120 peer educators (60 from each district) out of the total 1,242 peer educators in the project village development committees (VDCs) were selected randomly and interviewed. Qualitative data were collected principally through focus group discussions (FGDs).
Knowledge Shifts
Higher proportions of respondents, especially young men, reported receiving information on family planning/reproductive health services from health workers, from female community health volunteers, and from their peers during the 6 months preceding the endline survey.
The percentage of married adolescents who were aware of 2 or more modern methods of contraception was over 90% for both sexes in the 2005 baseline survey and was almost universal at the endline in 2007 (98% among young women and 99% among young men; n=480). Further analysis revealed significant increases in the knowledge of individual methods. At baseline, female sterilisation and injectables were the most commonly cited methods among female adolescents, while female and male sterilisation, condoms, and injectables were the most widely known methods among male adolescents. By the endline, there were significant increases in young women's knowledge of condoms, hormonal implants, oral contraceptives, male sterilisation, and injectables and in male adolescents' awareness of oral contraceptives (which rose from only 4% to 84%). In addition, awareness that condom use can prevent pregnancy rose significantly, from 65% to 93%, among female adolescents, and increased from 90% to 98% among male adolescents. The percentage of young women who knew where to get contraceptives also rose, from 84% in 2005 to 98% in 2007, while awareness of sources among young men increased from 96% to near universal (99.8%) (n=980).
Married adolescents' knowledge of HIV and AIDS and its symptoms, modes of transmission, and preventive measures also increased significantly, but levels of awareness remained lower among female respondents than among males. At endline, approximately one-third of female adolescents (32%) (n=480) had heard of HIV and AIDS, compared with 86% of male adolescents (n=480); also, 6% of young women were aware of three ways to avoid becoming infected with HIV, compared with 35% of young men. However, data show that the proportions of female married adolescents who were aware of three HIV prevention measures more than doubled over the project period. Awareness that condom use prevents HIV transmission also increased dramatically over the 2-year period, from 0.0% to 41% of all adolescents, though at endline there was still a large gap in awareness between female respondents (12%) and males (70%).
The proportion of married adolescents who were aware of sexually transmitted infections (STIs) was unchanged over the project period (42% at baseline; 41% at endline). Once more, knowledge of the types and symptoms of STIs, as well as about prevention measures, was much lower among female adolescents than among male adolescents.
Comprehensive knowledge of the danger signs for pregnancy, delivery, and the postpartum period was extremely low and showed little improvement over the duration of the project. For example, among the 480 respondents, only 0.2% of married adolescents were aware of all 5 danger signs for pregnancy, and 0.0% were aware of all 5 danger signs for delivery. However, this general assessment of respondents' knowledge concealed significant changes in awareness of individual danger signs among both female and male respondents. For example, 93% of female adolescents and 84% of male adolescents were aware that labour lasting more than 8 hours without progress was a sign to seek immediate medical help. Peer educators' lack of knowledge of danger signs could have contributed to the low levels of awareness among married adolescents. For example, of the 120 peer educators interviewed in the endline survey, only 8% were aware of all 5 pregnancy danger signs, and 8% of respondents were aware of all 5 delivery danger signs.
The percentage of female married adolescents who were aware of the need for at least 4 antenatal care visits improved from 19% (n=463) to 28% (n=472).
The percentage of married adolescents who were aware of 2 or more modern methods of contraception was over 90% for both sexes in the 2005 baseline survey and was almost universal at the endline in 2007 (98% among young women and 99% among young men; n=480). Further analysis revealed significant increases in the knowledge of individual methods. At baseline, female sterilisation and injectables were the most commonly cited methods among female adolescents, while female and male sterilisation, condoms, and injectables were the most widely known methods among male adolescents. By the endline, there were significant increases in young women's knowledge of condoms, hormonal implants, oral contraceptives, male sterilisation, and injectables and in male adolescents' awareness of oral contraceptives (which rose from only 4% to 84%). In addition, awareness that condom use can prevent pregnancy rose significantly, from 65% to 93%, among female adolescents, and increased from 90% to 98% among male adolescents. The percentage of young women who knew where to get contraceptives also rose, from 84% in 2005 to 98% in 2007, while awareness of sources among young men increased from 96% to near universal (99.8%) (n=980).
Married adolescents' knowledge of HIV and AIDS and its symptoms, modes of transmission, and preventive measures also increased significantly, but levels of awareness remained lower among female respondents than among males. At endline, approximately one-third of female adolescents (32%) (n=480) had heard of HIV and AIDS, compared with 86% of male adolescents (n=480); also, 6% of young women were aware of three ways to avoid becoming infected with HIV, compared with 35% of young men. However, data show that the proportions of female married adolescents who were aware of three HIV prevention measures more than doubled over the project period. Awareness that condom use prevents HIV transmission also increased dramatically over the 2-year period, from 0.0% to 41% of all adolescents, though at endline there was still a large gap in awareness between female respondents (12%) and males (70%).
The proportion of married adolescents who were aware of sexually transmitted infections (STIs) was unchanged over the project period (42% at baseline; 41% at endline). Once more, knowledge of the types and symptoms of STIs, as well as about prevention measures, was much lower among female adolescents than among male adolescents.
Comprehensive knowledge of the danger signs for pregnancy, delivery, and the postpartum period was extremely low and showed little improvement over the duration of the project. For example, among the 480 respondents, only 0.2% of married adolescents were aware of all 5 danger signs for pregnancy, and 0.0% were aware of all 5 danger signs for delivery. However, this general assessment of respondents' knowledge concealed significant changes in awareness of individual danger signs among both female and male respondents. For example, 93% of female adolescents and 84% of male adolescents were aware that labour lasting more than 8 hours without progress was a sign to seek immediate medical help. Peer educators' lack of knowledge of danger signs could have contributed to the low levels of awareness among married adolescents. For example, of the 120 peer educators interviewed in the endline survey, only 8% were aware of all 5 pregnancy danger signs, and 8% of respondents were aware of all 5 delivery danger signs.
The percentage of female married adolescents who were aware of the need for at least 4 antenatal care visits improved from 19% (n=463) to 28% (n=472).
Practices
The percentage of married adolescents visiting government health facilities for services rose from 36% (n=463) in 2005 to 42% (n=472) in 2007. The proportion of women attending antenatal care at least once during their last pregnancy rose significantly, from 79% (n=240) to near universal coverage (98%) (n=269). The proportion making 4 or more antenatal care visits increased significantly, from 29% to 50%. Overall, the mean number of antenatal care visits increased from 2.7 to 3.7 visits. Use of postnatal care services also increased, from 20% (n=240) in 2005 to 30% (n=269) in 2007.
Use of a skilled attendant (a doctor, nurse, or auxiliary nurse midwife) rose from 24% to 31% over the 2-year period. The proportion of deliveries taking place at home fell from 75% to 67%.
Contraceptive use before the first pregnancy rose only slightly among female respondents over the project period, from 4.4% (n=294) to 4.8% (n=333), and did not change among male respondents (about 11% both at the beginning and at the end of the project period). Despite evidence at the endline that more than 97% of married adolescents perceived that postponing the first birth reduced health risks to the mother, the median age at first birth remained at 17 years (n=265). When asked in 2005 their reasons for not using family planning before their first pregnancy, similar proportions of female and male respondents (76% [n=277] and 84% [n=240], respectively) reported that they wanted to have a child. However, in 2007, the percentage of female adolescents citing this reason declined to 70% (n=323), while the proportion of male respondents giving this answer increased to 92% (n=238). These findings appear to indicate a growing demand for contraception before first pregnancy among women, particularly among very young adolescents (those aged 16 and younger), but a corresponding decline among young men in support for delayed childbearing.
Use of a skilled attendant (a doctor, nurse, or auxiliary nurse midwife) rose from 24% to 31% over the 2-year period. The proportion of deliveries taking place at home fell from 75% to 67%.
Contraceptive use before the first pregnancy rose only slightly among female respondents over the project period, from 4.4% (n=294) to 4.8% (n=333), and did not change among male respondents (about 11% both at the beginning and at the end of the project period). Despite evidence at the endline that more than 97% of married adolescents perceived that postponing the first birth reduced health risks to the mother, the median age at first birth remained at 17 years (n=265). When asked in 2005 their reasons for not using family planning before their first pregnancy, similar proportions of female and male respondents (76% [n=277] and 84% [n=240], respectively) reported that they wanted to have a child. However, in 2007, the percentage of female adolescents citing this reason declined to 70% (n=323), while the proportion of male respondents giving this answer increased to 92% (n=238). These findings appear to indicate a growing demand for contraception before first pregnancy among women, particularly among very young adolescents (those aged 16 and younger), but a corresponding decline among young men in support for delayed childbearing.
Attitudes
The percentage of female respondents who thought there were benefits to delaying childbearing increased from 90% to 99% (n=480); for male respondents, the figure rose from 93% to 96%. The vast majority of young women and men perceived that postponing the first birth reduced health risks to the mother.
Substantial changes were recorded in several key indicators for gender attitudes among married adolescents. Notably, at the end of the project period, majorities of both male and female respondents considered that it was acceptable for women to insist upon condom use, and almost half of all respondents felt that a man does not have the right to decide when to have sex with his wife. In addition, more than half of male adolescents (55.7%) felt that a woman has a right to go to a health facility without her partner's permission. More than 80% of both female and male adolescents believed that it is not acceptable for a man to beat his partner.
Strong change was also recorded in perceptions among couples about who is responsible for deciding whether to use family planning. At endline, 65% of female adolescents and 79% of males considered that the husband and wife together are responsible for family planning decisions, up significantly from 37% and 57%, respectively, at baseline.
Significant changes were found in married adolescents' perceptions of the ideal ages for gauna (the local custom when a married girl moves into her husband's home following menarche, for consummation of the marriage) and for motherhood (n=480 for each gender throughout this paragraph). For example, the percentage of adolescents who thought that the ideal age at gauna for women was over 20 significantly increased over the 2-year project period, from 6% to 34% (for female respondents) and from 9% to 28% (for male respondents). The proportions of adolescents who also considered the ideal age at gauna for men to be over 20 rose from 55% to 91% among female respondents and from 54% to 82% among male respondents. Similarly, at endline, 83% of female respondents and 71% of male respondents believed that the ideal age of motherhood was over 20, up from 50% and 53%, respectively.
Traditionally, mothers-in-law and sisters-in-law exercise decision-making power over daughters-in-law within Nepali households. Therefore, raising the awareness of these family members about the reproductive health needs and rights of married adolescent women was critical. Evidence from FGDs with mothers-in-law conducted at baseline and endline indicate significant changes in attitudes and health practices, particularly in attitudes toward early marriage and childbearing.
Substantial changes were recorded in several key indicators for gender attitudes among married adolescents. Notably, at the end of the project period, majorities of both male and female respondents considered that it was acceptable for women to insist upon condom use, and almost half of all respondents felt that a man does not have the right to decide when to have sex with his wife. In addition, more than half of male adolescents (55.7%) felt that a woman has a right to go to a health facility without her partner's permission. More than 80% of both female and male adolescents believed that it is not acceptable for a man to beat his partner.
Strong change was also recorded in perceptions among couples about who is responsible for deciding whether to use family planning. At endline, 65% of female adolescents and 79% of males considered that the husband and wife together are responsible for family planning decisions, up significantly from 37% and 57%, respectively, at baseline.
Significant changes were found in married adolescents' perceptions of the ideal ages for gauna (the local custom when a married girl moves into her husband's home following menarche, for consummation of the marriage) and for motherhood (n=480 for each gender throughout this paragraph). For example, the percentage of adolescents who thought that the ideal age at gauna for women was over 20 significantly increased over the 2-year project period, from 6% to 34% (for female respondents) and from 9% to 28% (for male respondents). The proportions of adolescents who also considered the ideal age at gauna for men to be over 20 rose from 55% to 91% among female respondents and from 54% to 82% among male respondents. Similarly, at endline, 83% of female respondents and 71% of male respondents believed that the ideal age of motherhood was over 20, up from 50% and 53%, respectively.
Traditionally, mothers-in-law and sisters-in-law exercise decision-making power over daughters-in-law within Nepali households. Therefore, raising the awareness of these family members about the reproductive health needs and rights of married adolescent women was critical. Evidence from FGDs with mothers-in-law conducted at baseline and endline indicate significant changes in attitudes and health practices, particularly in attitudes toward early marriage and childbearing.
Increased Discussion of Development Issues
The proportion of couples who discussed where to deliver increased significantly, from 24% (n=463) to 40% (n=472).
The project encouraged debate on social and gender norms that impact adolescent health and personal development, including early marriage and the dowry system. Child marriage eradication committees were established by youth in 33 villages of Dhanusha, and a peer-led, district-level conference in Dhanusha was organized by the RHMACP to advocate for the abolition of these long-standing practices and to support compulsory education for all children. At this gathering, representatives from all political parties expressed their commitment to these issues.
The project encouraged debate on social and gender norms that impact adolescent health and personal development, including early marriage and the dowry system. Child marriage eradication committees were established by youth in 33 villages of Dhanusha, and a peer-led, district-level conference in Dhanusha was organized by the RHMACP to advocate for the abolition of these long-standing practices and to support compulsory education for all children. At this gathering, representatives from all political parties expressed their commitment to these issues.
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