91291 Knowledge Brief Health, Nutrition and Population Global Practice ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH IN DHAKA’S SLUMS, BANGLADESH Rafael Cortez (World Bank), Laura Hinson (ICRW) and Suzanne Petroni (ICRW) October 2014 May 2014 KEY MESSAGES:  Adolescent fertility is a significant concern in Bangladesh, with 80.6 births per 1,000 women 15 through 19 years of age, more than twice the average in the Asia region.  Results from this study indicate that roughly one-quarter of girls 15 through 19 years of age are already married; and by 19 years of age, 70 percent have had a child.  The modern contraceptive prevalence rate among girls in the Dhaka slums is similar to the national average at 61 percent.  Though three-quarters of pregnant adolescents in the slums receive at least one antenatal care (ANC) visit, only 25 percent receive the recommended number of visits. Introduction related behaviors. To improve and promote adolescent health, development and well-being, it is also important to Adolescents around the world face tremendous acknowledge the broader policies and environment in challenges to meeting their sexual and reproductive which they live, learn, work, and form relationships health (SRH) needs. Inadequate access to health (Sawyer 2012). information and services, as well as inequitable gender norms, contribute to a lack of awareness about puberty, The environmental impact on adolescent health and sexuality, and basic human rights that can have serious development is clearly seen in the slums of Dhaka, implications on their health and welfare throughout the Bangladesh. The Dhaka slums are home to an increasing rest of their lives. These underlying factors lead to high number of adolescents and youth who migrate from rural rates of early pregnancy, sexually transmitted infections areas in search of work and a better life. They end up (STIs), sexual violence, and early and forced marriage finding unhealthy and unsafe living conditions, and find globally. themselves at great risk of sexual and gender-based violence and harassment. Although many girls and young Research has found that adolescence is a profound and women living in the slums are able to find paid work, they complex stage of life that influences future health often lack access to basic health information and outcomes, attitudes, and behaviors. Using a life course- services, face gender inequality, and confront traditional perspective requires understanding the relationships and often harmful expectations regarding marriage and between early childhood health and development and its childbearing. effect on adolescence; the importance of biological changes, cultural traditions, and social norms associated To date, there has been little understanding of the life of with puberty; as well as the influence that social adolescents in the Dhaka slums. To address these determinants have on adolescents’ up-take of health- issues, the World Bank, with the International Center for Research on Women (ICRW), conducted a study to Page 1 HNPGP Knowledge Brief  determine the key barriers to adolescent sexual and youngest was married at 9 years old, and the average reproductive health (ASRH) in Dhaka, and understand age of marriage was 15.2 years. Girls who had completed how these barriers are influenced by programmatic and primary education were significantly less likely to be policy interventions. The Bank and ICRW used mixed married before 13 years. Girls whose mothers had at least methods research, interviewing hundreds of married and some education were also significantly less likely to marry unmarried girls, young men, young women, and key at very early ages compared to those whose mothers had stakeholders in four diverse slums of urban Dhaka. This no education. knowledge brief provides a brief background on ASRH in Married girls participating in the in-depth interviews were Bangladesh and summarizes the results of this study. asked to describe how they met their husbands and how they married. Half reported that they met their husbands The Context: Bangladesh on the way to or from work. The other half stated that family members, often the older siblings, forced the girls Bangladesh is a low- income country with a gross national into a marriage. income (GNI) per capita of US$829 (World Bank, 2013). Young people (10-24 years of age) represent 31 percent When asked at what age they would like to get married, of the total population with a significant proportion living in unmarried girls participating in the qualitative interviews poverty. About a third of Dhaka’s residents are poor and reported that their ideal age would be between 19 and 20 nearly half live in slums. More than half of adolescent girls years; several stating that this was so they could have (55 percent) and 48 percent of boys are enrolled in more time to earn money before getting married. One secondary school. The majority of garment workers are unmarried 15 year-old said, “Marrying now would create female (85 percent), of which 50 percent are adolescent too many physical problems for me. Besides, my family girls. The country has one of the highest rates of child has financial problems. I want to settle those first and then marriage: 29 percent are married by age 15, and 65 get married.” Many of the married girls and young women percent by age 18. The contribution of adolescent fertility in the qualitative interviews reported that their to the total fertility rate in Bangladesh has increased from expectations of marriage were not met, as their husbands 20.3 percent in 1993, to 24.4 percent in 2007 and 25 did not take enough care of them financially and spent percent in 2011 (DGFP, 2013). In Dhaka, almost 29 most of the time outside of the home. percent of girls 15-19 years of age have already started childbearing (NIPORT et al., 2013). EARLY PREGNANCY AND CHILDBIRTH Research Methodology Recent reports indicate that in Dhaka, almost 29 percent of girls 15 through 19 years of age have already started The study included a three-part research project: (1) childbearing, with the vast majority taking place within Quantitative household surveys involving 320 married marriage (NIPORT et al., 2013). The current study adolescent girls; (2) Qualitative interviews, including a indicates that these rates are significantly higher in the donor scan and interviews; in-depth interviews with 16 slums where nearly 52 percent of girls aged 15-19 years married and unmarried adolescent girls; focus group have had at least one child (Figure 1). The majority (83 discussions with young women; and key informant percent) of the girls who were married but did not yet interviews with health care providers, representatives have children said they wanted to have two children, and from non-governmental or community-based almost half wanted to wait at least two years before their organizations, traditional healers and staff from first birth. government centers / clinics; and (3) Formative Research with young men in the form of focus group discussions. Although the majority of married girls interviewed had been pregnant by the age of 19, when asked their ideal age for first pregnancy 89 percent of them said that Findings of the ASRH Study women should be at least 20 years of age before The study findings are consistent with existing data and becoming pregnant for the first time. evidence regarding adolescent sexual and reproductive health and rights (SRHR) in Bangladesh. The findings CONTRACEPTIVE KNOWLEDGE AND USE show that adolescents and youth in Dhaka slums face even more barriers in exercising their SRHR than their Nearly all (99 percent) married girls knew of at least one counterparts not living in slums. The following is a method of contraception, while 61 percent stated that they summary of the study findings. used modern contraception (equal to the national average). Nearly 7 percent used traditional methods, and 32 percent reported using no method at all. The specific ADOLESCENT MARRIAGE methods that girls knew about coincided with the Roughly one-quarter of girls 15 through 19 years of age contraceptive methods they were using. Only 40 percent living in the slums are already married. Of the 320 married of the girls knew about male sterilization or IUDs, and just girls (15-19 years old) surveyed, the vast majority were 10 percent had heard of emergency contraception. Of married between the ages of 12 and 17 years. The those who were not using contraception, the primary Page 2 HNPGP Knowledge Brief  reasons were: a desire to become pregnant (37 percent), services, with lower rates in the slums. While three- currently pregnant (31 percent), or prohibited from using quarters of pregnant girls received at least one ANC visit, contraception by their husband or cultural reasons (3 only 25 percent received the recommended number of percent) (figure 2). checkups. Girls who received ANC received it from either a government or municipal hospital or center (38 percent), a center affiliated with a non-governmental organization or Figure 1. Percentage of 15-19 year olds who have ever university (39 percent), or a health worker visiting their been pregnant, by age (N=320). home (40 percent). 90 80 The majority (70 percent) of girls who had given birth 70 delivered at home (their own home or that of a relative). Percent of girls 60 50 These findings are similar to national level results. The Had ever been 40 reasons given for not delivering in a health facility were 30 pregnant 20 that it was not customary (66 percent), expense (24 10 percent), and lack of time (9.5 percent). Nearly 5 percent 0 Had never been of girls who delivered at home did so because their pregnant husband or other family member did not allow them to visit a health facility at birth. Midwives or relatives assisted the majority of girls’ deliveries, and most girls who gave Age of girls birth (71 percent) said that they had not met with a health Source: World Bank Group and the International Center for Research worker in the three months prior to the delivery. on Women. Household Survey 2014: Adolescent Sexual and Reproductive Health in Bangladesh. 2013. GENDER-BASED VIOLENCE The study found that sexual and gender-based violence Figure 2. Reasons married adolescents (15-19 years) was quite common in these communities (figure 3). While do not use contraception (percent) (N= 102). many respondents expressed disapproval of such violence, a high percentage believed that spousal abuse Culturally inappropriate 1 was acceptable in a number of circumstances. Over 13 Reason for non-use Husband prohibits use 2 percent believed a husband was justified in beating his wife if she refused to have sex with him, almost 29 Concerned about side effects 3 percent believed it was acceptable for him to beat her if Not sexually active/husband… 10 she went out without telling him, 35 percent believed it Don’t think at risk of pregnancy 16 was acceptable if she did not take care of the house or Currently pregnant 32 children, and 55 percent said it was acceptable if the wife disrespected her in-laws. Similar beliefs were found in in- Want more children soon 38 depth interviews and focus group discussions. Forced or 0 10 20 30 40 coerced sex —both inside and outside of marriage — was reported as fairly commonplace in the qualitative Source: World Bank Group and the International Center for Research on Women. Household Survey 2014: Adolescent Sexual and interviews. Reproductive Health in Bangladesh. 2014. Challenges The qualitative interviews and focus groups found low levels of knowledge and use of contraception among As is the case with adolescents and youth in many parts unmarried girls. None reported using contraception. Given of the world, adolescents living in the Dhaka slums lack that premarital sex is highly stigmatized in Bangladesh, access to basic information pertaining to their bodies and unmarried adolescents face extremely limited access to regarding their rights to reproductive autonomy and bodily contraception (whether due to organizational policies, integrity. Gender and cultural norms, stigma related to perceptions of such policies, or stigma), creating a adolescent sexuality, myths and misperceptions, poor implementation of existing laws regarding age at significant impediment to their understanding of and ability marriage, and unclear policies and practices related to the to express their SRHR. provision of services for unmarried adolescents all contribute to low levels of knowledge and access to ANTENATAL CARE (ANC) AND CHILBIRTH accurate and quality information and services, as well as Young women in Bangladesh access health services, to harmful practices and norms. Early marriage and including ANC, at very low rates. Recent data indicate pregnancy are the norm for girls, despite the legal age of that even in urban areas, only 45 percent of pregnant marriage being 18 years. women attend the recommended number of four ANC checkups. The current study found low use of ANC Page 3 HNPGP Knowledge Brief  Recommendations information and counseling about SRH, including de- stigmatizing normal body functions and dispelling the To address the above challenges, the following superstitions and fears that keep girls from using SRH interventions are recommended. services in the formal sector (such as delivering in health First, basic fertility awareness education for boys and girls facilities). Even groups that simply bring girls —married is needed. Misperceptions, myths and poor knowledge and unmarried—together can help to reduce the social related to puberty, the menstrual cycle, and gender roles isolation they face in these communities. can be addressed through programs targeted at different age groups within the slum communities. Fifth, in addition to programs for adolescents, outreach should target older family and community members, such Second, there should be more opportunities for as the mother-in-law, on the importance of ANC and the collaboration between the formal and informal sectors advantages of skilled birth attendance. Results indicate providing SRH information and services, as well as that older family members and community stakeholders training on the benefits of facility-based births and the are often the ones reinforcing limited ANC checkups and differences between normal reproductive bodily functions home delivery. and symptoms that may be cause for concern. Figure 3. Reason husband is justified for hitting his Conclusions wife (among adolescents 15-19 years of age) (percent) Through numerous forward-looking policies, the government of Bangladesh has indicated its intent to advance the agenda for ASRH. With the political will to follow through on these policies, and with the support of donor governments and other agencies, much can be done to provide adolescents and youth in the slums of Dhaka, Bangladesh, with access to the information and services they need to not only survive, but to thrive in more equitable, safer, and healthier communities. References 1. Goes out without telling husband; 2. Does not take care of children/house; Cortez, R., L. Hinson, and S. Petroni. 2014. Adolescent 3. Gives different opinion than husband; 4. Refuses to have sex with husband; Sexual and Reproductive Health in Dhaka’s Slums, Bangladesh. 5. Does not cook food; 6. Suspected of being unfaithful; and 7. Shows 2014. HNP Discussion Paper. The World Bank, Washington, DC disrespect to in-laws (Forthcoming) Source: World Bank Group and the International Center for Research National Institute of Population Research and Training on Women. Household Survey 2014: Adolescent Sexual and (NIPORT), Mitra and Associates, and Macro International. 2013. Reproductive Health in Bangladesh. 2014. Bangladesh Demographic Health Survey 2011, Bangladesh and Caverton, MD: NIPORT, Mitra & Associates and Measure DHS. Third, the government should ensure that laws regarding sexual violence are enforced, and support is provided to Sawyer, S.M., Afifi, R., Bearinger, L., Blakemore, S.J., Dick, B., Ezeh, A.C. and Patton, G.C. 2012. Adolescence: A local programs that sensitize community members to the Foundation for Future Health. Lancet, 379: 1630-40. dangers of gender-based violence, helping girls and community members to respond to violence. This HNP Knowledge Brief highlights the key findings from a Study “Adolescent Sexual and Reproductive Health in Dhaka Slums, Fourth, to address some of the harmful gender and social Bangladesh” Health, Nutrition and Population (Forthcoming), Rafael norms surrounding early marriage and girls’ education, Cortez (World Bank), Laura Hinson (International Center for Research there should be more socialization campaigns involving on Women, ICRW), and Suzanne Petroni (International Center for Research on Women, ICRW). This report was part of a series of multi- men and boys that emphasize the benefits of joint country adolescent SRH analysis prepared under the Economic Sector decision-making and dispel inequitable gender norms. Work (P130031) conducted by the Health, Nutrition and Population Global Practice and funded by the Bank-Netherlands Partnership Program. Local organizations that develop and facilitate clubs and groups for adolescent girls and boys (separately) should be supported. Ideally, these groups would provide 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