Understanding adolescent pregnancy in Bangladesh

Arnob Chakrabarty, Managing Director, RedOrange Media and Communications

During the liberation war, people living in refugee camps didn't receive any sexual and reproductive health and rights (SRHR) services. Even 50 years after independence, many people living in fragile settings such as refugee camps, coastal areas, slums and char areas of the country still don't have access to SRHR services. We undertook this RISE training programmeto address this gap. Today, we will share the findings of our research study, and discuss what should be done to provide SRHR services to these vulnerable communities.

The research report will be shared with all the relevant stakeholders and will also be available on Share-Net Bangladesh.

Fragility is a critical issue that needs to be discussed further because there is a difference between providing SRHR services to all and providing SRHR services to people who live in fragile settings. We need to discuss further how we will define a fragile setting. We also need to find out to what extent the government can add the issue of SRHR in fragile settings to existing government strategies targeting adolescents so that specific actions can be taken to support these vulnerable groups.

Umayer Abu Omar, Project Coordinator, RedOrange Media and Communications (RISE Project)

The RISE project is an Orange Knowledge Programme Tailor-Made Training course that started in May 2021 and will continue till December 2022. The Orange Knowledge Programme is funded by the Dutch Ministry of Foreign Affairs and managed by Nuffic, a Dutch non-profit organisation for internationalisation in education.

The main objective of the project is to improve the SRHR knowledge of NGO workers in Bangladesh, especially those who work in fragile settings. The project considers the coastal belts of Bangladesh where climate-affected populations live, and areas with Rohingya refugees and host communities as fragile settings.

KTI Royal Tropical Institute, Simavi and RedOrange Media and Communications are the three consortium partners in this project. The project also has two beneficiary partners -- Family Planning Association of Bangladesh (FPAB) and Integrated Social Development Effort (ISDE) -- who are disseminating SRHR knowledge all over the country.

The RISE project has five modules that work as five pillars of the project. Initially, 30 NGO staff including six staff from the NGO Dalit were trained on the first and second modules--basic comprehensive SRHR and SRHR in fragile settings. We chose eight participants from the initial 30 trainees as master trainers. They were then provided ToT (Training of Trainers) training under module three and engaged in providing training on the first and second modules to their colleagues in their respective organisations, and, thus, 50 field levels across the country were empowered with the RISE knowledge. The unique aspect of RISE is that it covers human rights issues including the rights of the LGBTQ community.

After completion of their training on the first three modules, the master trainers are engaged in research as part of modules four and five. They learned about conducting qualitative action research and how to do evidence-based advocacy based on their research findings. The master trainers conducted research in five geographic areas in Bangladesh.

Ophelia Chatterjee, Advisor - SRHR , KIT Royal Tropical Institute

The main goal of this project is to increase the technical capacity of the NGOs and health professionals who work on SRHR issues in fragile settings, specifically from a rights-based and gender-transformative perspective. It also explores the link between climate change and SRHR.

We have incorporated the Training of Trainers (ToT) element to make the project sustainable as part of the second project outcome, which is to improve the capacity of NGO professionals to deliver training to their colleagues. The master trainers are continuing to provide this training programme in their organisation to share knowledge with their colleagues.

The third outcome is to increase the use of evidence-informed approaches in programme advocacy and knowledge translation on SRHR issues, through conducting a research study and developing knowledge products. We have partnered with Dhaka University and Daffodil International University to improve the exchange of training materials between educational institutes and NGOs.

As part of the research project, we held priority-setting sessions, and adolescent pregnancy emerged as the topic of most relevance and interest to the trainers. We conducted a study on this topic in five areas of Bangladesh. We also conducted training sessions and workshops on basic principles of research, research methods, research analysis, knowledge translation and research advocacy.

Professor Dr. Mohammad Bellal Hossain, Department of Population Sciences, University of Dhaka

The study population consisted of adolescent girls aged 13-19 years living in the selected study areas, who were currently pregnant or had delivered a baby in the past six months. Our main objective was to understand issues related to adolescent pregnancy. The study was conducted in five geographical locations -- Cox's Bazaar, Chattogram, Dhaka, Cumilla and Barisal.

The study found that adolescent pregnancy is quite common among married adolescent girls, and child marriage is the primary reason behind its high prevalence. Other reasons include the improper use of contraceptives and lack of access to SRHR information and services before and immediately after marriage. There is a massive pressure on married adolescent girls to conceive shortly after marriage. Adolescent girls are also not in a position to negotiate due to their lack of agency. Insecurity about infertility and wrong perceptions about hormonal contraceptives also contribute to the high rate of adolescent pregnancy in Bangladesh.

It is also found that unmarried young women lack access to family planning services. Their knowledge about contraception is also poor. They know about pills and condoms but are not aware of long-term methods. Health service providers also harbour stigma around providing SRHR services to unmarried young people.

The study identified major consequences of adolescent pregnancies that include physical and mental health problems, parenting pressure and economic strain. The study also found that women's reproductive autonomy generally improves after the birth of their first child. It also improves their access to SRHR services. However, for unmarried adolescent girls, the situation is different. They suffer more because of social shame and stigma. In many cases, pregnancy leads to early marriage and the pressure to abort.

The study offers several important recommendations, including strengthening women's agency and increasing their participation in pregnancy-related decision-making; making family members, teachers, health workers and religious leaders aware of the importance of sex education and involving them in the process; increasing the use of social media and telemedicine to provide SRHR knowledge and services. 

Anke van der Kwaak, Team Leader, SRHR, KIT and moderator of the session

Although the study started off focusing on how climate change would make people more vulnerable, the issue received less priority in the course of the study. We should focus more on the linkage between fragility and climate change since gender-based violence and poverty are increasing due to climate change. In the report, we talked more about fragility in rural settings and didn't pay adequate attention to the vulnerabilities in urban slums.

We need to discuss how we can address the interlink between fragilities caused by climate change and the lack of access to SRHR services, and how we can engage men in SRHR programmes more effectively.

Dewan Tanvir Ahmed, RISE Master Trainer & Program Officer (Knowledge Management Center), FPAB 

Men need to be empowered with adequate knowledge of SRHR to engage them in pregnancy-related decision-making processes. Our study found that they are reluctant to know about family planning services and generally pass the decision-making authority to their mother.

Mushfiqua Zaman Satiar, Senior Policy Advisor, SRHR and Gender, Embassy of the Kingdom of the Netherlands

Ministry of Women and Children Affairs (MOWCA) runs adolescent clubs where adolescent girls can learn about pregnancy, contraceptives, child caring, etc. However, there is no such facility for married girls. So, while visiting houses, health workers and family welfare assistants can hold joint meetings such as uthan boithok (courtyard meeting) with family members, especially husbands and mothers-in-law. We have done this in our ASTHA project, which helped men understand their responsibilities regarding family planning.

The government has adopted the GEMS (Gender Equity Movement in Schools) curriculum, and it will be implemented in all government schools. Therefore, we need to do advocacy with the Ministry of Education to bring back the SRHR issues in this curriculum.

The study findings must be shared with all the relevant ministries and development partners.

Dr Md Ikhtiar Uddin Khandaker, Director, Health Programme, Care Bangladesh

The effort of building agency among adolescent girls should be started in the early stages, particularly when they are in school. They need to have adequate access to SRHR information.

Frontline health workers and multi-purpose health volunteers can be the first contact for young couples' counselling. Besides contraceptives, they should advise them about long-term family planning. Some organisations provide newlywed kits, which can be helpful to increase the agency of new couples. Parents also need to be engaged in this process.

We all know about our national adolescent health strategy, which is the policy document for our country. Addressing adolescent vulnerabilities is a key strategic area of the policy. It also covers how they will be protected during disasters. There is a lack of data on how the climate crisis negatively impacts adolescent well-being. I believe this study will help to address this gap. There is also an opportunity to incorporate the learnings of the study with the national strategy. However, a broader study, covering a larger population and area and combining both quantitative and qualitative data, is required.

Dr Noor Mohammad, Executive Director, PSTC

The study should have followed a mixed method combining qualitative and quantitative research methodologies.

The study findings need to be shared with concerned ministries and other relevant stakeholders. 

Professor Dr. Abu Naser Zafar Ullah, Dean & Professor, Faculty of Allied Health Sciences, Daffodil International University

The involvement of men in family planning campaigns is not new in Bangladesh. We need to look at the issue from a different perspective to make their involvement more effective.

Bangladesh has one of the highest rates of child marriage in the world. Lack of education, social and economic vulnerability, low status of women and poor support from the social system are driving the early marriage in Bangladesh. There are several platforms and campaigns to make people aware of the SRHR issues. We need to scale up the coverage of these interventions.

Different climate change impacts cause different types of fragilities, and that need to be considered while formulating our plans and policies.

Dr. Nazneen I.Khan, Researcher, (Lead, Gender, and Climate Change) ICCCAD

We need to look beyond male-female gender binaries and consider the vulnerabilities of persons with other gender identities.

Dr Saleemul Huq, director of the International Centre for Climate Change and Development (ICCCAD), is closely involved with the formulation of the 9th Five-Year Plan. There will be a separate chapter on SRHR and gender in this new plan.

Religious leaders can play a significant role in disseminating SRHR related information.

Professor Dr Mohammad Mainul Islam, Department of Population Sciences, University of Dhaka

Climate change is a major concern for us. Climate-change-induced displaced people in Bangladesh are facing severe challenges in terms of getting access to SRHR services. We need to consider the impact of climate change on reproductive health and conduct more research in this area. We also need to talk about how we can ensure the reproductive health rights of both men and women during climate disasters.

We have to address poverty in targeted areas. More emphasis should be given to female education and comprehensive sexuality education. We also need to address existing gender imbalances and social values and norms that make adolescent girls more vulnerable.

Masuma Billah, Programme Head, Gender Justice and Diversity, BRAC

The study shows that mothers-in-law exercise authority over the decision of their daughters-in-law's pregnancy. Therefore, we should work with them and make them understand the risks of adolescent pregnancy and other SRHR issues.

Rowshon Akhter Urmee, Project Coordinator, RHRN-2, Social Empowerment & Legal Protection Programme, BRAC

SRHR issue is taboo in our society. It has been included in the education curriculum, but teachers are hesitant to talk about it in the classroom. We have formed a youth group that does advocacy with teachers in community schools, and, as a result, teachers are now more comfortable with these issues. Students also now talk comfortably about their SRHR needs and take services from health centres. We need to create an enabling environment by engaging young people in the communities. The local administration and school management committees also need to be engaged more in the process.

Tanjim Ferdous, In-Charge, NGOs & Foreign Missions, Business Development Team, The Daily Star

We need to think about how to make projects like RISE sustainable since it takes time to bring change to policies and behaviours. An enterprise model can be a possible solution.

We need to increase the use of social media to disseminate SRHR information to younger generations.

The government has taken various measures for climate adaptation and resilience. SRHR issues must be considered as a key component of these interventions.

Dilruba Nasrin, Programme Manager, BRAC

There should be strong coordination between the Ministry of Health and Family Welfare and the Directorate General of Family Planning (DGFP).

Although MOWCA has different platforms, such as adolescent girls' clubs across the country where issues like child marriage and violence against women are discussed, adolescent pregnancy and SRHR issues are not addressed on these platforms. We need to make proper use of these platforms for the dissemination of SRHR messages.

Recommendations

• Add the issue of SRHR in fragile settings to adolescent-related government strategies and action plans.
• Strengthen women's agency and participation in pregnancy-related decision-making.
• Make family members, teachers, health workers and religious leaders aware of the importance of sex education and involve them in the process.
• Increase use of social media and telemedicine to provide SRHR knowledge and services. 
• Empower men with adequate knowledge of SRHR to engage them in the pregnancy-related decision-making process.
• Conduct more research on the impacts of climate change on reproductive health.
• Consider SRHR as a key component of climate adaptation and resilience action.
• Address gender imbalances and harmful social norms and values that put adolescent girls in a vulnerable position.
• Integrate specific groups such as mothers-in-law in more adolescent pregnancy-related programmes.
• Engage both print and digital media to disseminate SRHR information to younger generations.
• Use adolescent and youth platforms to disseminate SRHR messages.