Creating access to sexual and reproductive health services

Posted by Maria Codina on May 27, 2019 at 12:02 pm



Empowering young women in Burundi to avoid early pregnancy

Many mothers in Burundi are nursing their first child when they are still adolescents. That this is very common doesn’t mean it is what the girls want. Early childbearing often has devastating effects on the girls’ lives. The young mothers often drop out of school and are abandoned by their families, which makes escaping poverty even more unlikely. Maternal mortality, moreover, is the number one cause of death for young women in Sub-Saharan Africa – and Burundi is no exception.

Unwanted adolescent pregnancies might be avoided if these young women had access to sexual and reproductive health services such as SRH information, contraception and testing for sexually transmitted infections (STI). In Burundi, however, such services only cater for married women. Unmarried girls who seek information are stigmatised or named prostitutes.

Photo credit: AMISOM Public Information -  Flickr

The research project ‘Empowering young women in Bujumbura to improve their sexual and reproductive health and rights and claim to their rights‘ is funded by NWO-WOTRO Science for Global Development and looked into the barriers and solutions to early pregnancies in Burundi. The researchers came up with recommendations for the design of effective and sustainable SRH programmes for Burundian youth to prevent these pregnancies. The project took a twin-track approach. The core of the research revolved around the active participation of girls and young women to understand the issues at stake from their personal perspective. In addition, the team interviewed 46 key informants from the Ministry of Health, NGOs and health clinic workers about the structural constraints for accessing SRH services.

‘We can’t assume that the reasons behind early pregnancies in Burundi are the same as in other Sub-Saharan countries,’ says Jocelyn Finlay, based at Harvard T.H. Chan School of Public Health, who leads the research project. ‘Burundi has the second highest fertility rate in the world. It is also ranked as the poorest country today. The recent history of violence and insecurity makes it a fragile society too. To know which interventions might work in this challenging context, we wanted to tap the young women’s minds and experiences first-hand as much as possible.’

Local ownership

In early 2015, only a decade after the Burundian civil war had ended, tens of thousands of Burundians were fleeing their homes in response to the nationwide unrest sparked by the upcoming presidential elections. People feared that the president’s controversial decision to run for a third term would jeopardise the fragile peace in the country. This was just before the research was supposed to start.

Photo credit: Christopher Morley-Pegge / Shutterstock.com

Harvard university, Finlay’s employer, issued a travel ban to Burundi which up to today was never lifted. Despite the disappointment of not being able to visit her partners in Burundi, this reality also had a positive effect: it has hugely strengthened the local ownership for the project. ‘The team in Burundi has been amazing. There is such a strong sense of collaboration.’ Finlay admits this wouldn’t have been possible when she first started working in global health research fifteen years ago. ‘The communication infrastructure has improved so much. I have biweekly conference calls with my Burundian colleagues and the quality of the lines is almost crystal clear.’

Playing real life

The team chose to use the participatory workshop method of concept mapping. Especially because they were concerned that the girls might be too shy to speak about what is a taboo subject in Burundi: sex. ‘Conventional focus group discussions are easily dominated by one participant who is most eloquent or comfortable to speak out’, says Finlay. ‘Concept mapping ensures everyone an opportunity to have their say.’ The method includes verbal and written contributions – collected in small break-out groups – as well as role plays that the participants script and direct themselves. Together, they discuss, cluster and rank everyone’s input. By the end of the day there is a tangible concept map in which the young women see their every-day lives and trials reflected. About 120 girls and young women between the ages of 15 and 24 years joined the workshops. Finlay: ‘For many of them, participation in this exercise in itself was an empowering experience.’

The pregnant adolescent – on stage as much as in real life – is on her own

At the inception phase of the project, the team had discussed at length the potential vulnerability of young girls speaking about a culturally sensitive topic. NWO-WOTRO’s hallmark – multi-stakeholder research consortia – played an important role in addressing this concern. Pathfinder, the NGO that is part of the research consortium, has vast experience worldwide working with communities on sexual and reproductive health and rights. Finlay: ‘The compassion and commitment their staff bring in are so touching and inspiring. They know how to create a safe environment and quickly built up very good rapport with the girls. We had not expected that so many of them would be so eager to participate.’

On their own

The role plays, Finlay smiles, were written, directed and acted with such keenness, they were almost ‘Hollywood material’. The storylines revealed the complexity of the situation the girls find themselves in. Many girls agree to have sex because of the gifts they hope to receive in return, such as credit for their mobile phones, or perhaps even a new pair of jeans. But given that the young boyfriends are equally short of cash, these promises are rarely fulfilled. The new jeans don’t materialise, and often a pregnancy starts showing instead. The girl, whose status among her friends was raised for being sexually active, suddenly finds herself in a very difficult situation. Pre-marital sex is taboo in Burundian culture. And thus ‘all is well that ends well’ is not part of the plot that is acted out by the girls who participated in the workshops. On the contrary, in most role plays the boyfriend at this point denies the baby is his and ends the relationship. The mother is deeply upset and the father expels the girl from the household. At school, she is no longer welcome either. The pregnant adolescent – on stage as much as in real life – is on her own.

Sex = stigma

Stigma is the central concept in the research outcomes. The confusing reality of this double-edged stigma is painfully illustrated by the stories acted out and was confirmed to be a major problem by the key informants who were interviewed. The young girls are pulled between the shame of being a virgin, and the shame of not being a virgin. Added to this mix is the shame of poverty. The researchers found this to be one of the drivers of commodified sex, which is very pervasive among the female youth. If having sex can buy you a fizzy drink, that short-lived display of “wealth” may make it worthwhile to tamper with the cultural norms – or even to briefly close your eyes to the risks of pregnancy or STIs.

Rebranding of the term “family planning” would be a first helpful step

The stigma attached to premarital sex in Burundi, creates an inequity in access and use of sexual and reproductive health services by young women. The term “family planning” that is used as shorthand for the SRH services offered at clinics, reinforces this stigma. It excludes young, single women, who would want to visit the clinics – but not for reasons of ‘family planning’. Rebranding of term “family planning” to a more neutral term such as contraception, the researchers suggest, would be a first helpful step.

Striking a balance

But how can interventions help these girls? The research findings suggest that for any SRH intervention to be effective, it will need to strike the right balance between the protection of the young girls and their empowerment. Protection can take the form of legal protection: laws and policies in Burundi should be changed. For instance, to enable young women to seek SRH services without parental or partner consent.

Empowerment lies, as a first condition, in better information. Although the girls all acted very knowledgeable in their role plays, they underestimate the risks of having sex, especially the likelihood of contracting STIs. Meanwhile, HIV is on the rise among young girls in Burundi.

Photo credit: EC/ECHO Martin Karimi -  Flickr

Empowerment could also take the form of helping the girls to speak about this subject with their parents. Most girls see no other option but to turn to the universal lie of “I’m going to do homework at my friend’s place” when meeting their boyfriends. Yet the researchers noticed a real desire among the girls to be able to discuss this aspect of growing up more openly with both their parents. This hints at another research conclusion, that is, that male involvement is critical to the advancement of SRHR in Burundi. ‘The fathers need to be sensitised and educated too, so that they might consider other responses instead of simply expelling their daughters as soon as they receive the news of pregnancy.’

Finlay says it has helped that the current research is funded by NWO-WOTRO. ‘The Netherlands has a great reputation globally in terms of its commitment to sexual and reproductive health and rights.’ She hopes to keep on working with the same team. ‘Burundi is not a hotbed for research like for instance Kenya or Nigeria. This was a great opportunity for the Burundian researchers to take on leadership roles in a North-South collaboration project. We are all equally committed to translating our findings to practical recommendations – and seeing those being implemented. Our project ends mid-2019, but impact comes when you can follow through with something over a longer period of time’.

This project is funded within the Sexual and Reproductive Health and Rights research programme of WOTRO Science for Global Development.


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