Mobilizing Married Youth in Nepal to Improve Reproductive Health: The Reproductive Health for Married Adolescent Couples Project, Nepal, 2005-2007

This report evaluates the 2-year Reproductive Health for Married Adolescent Couples Project (RHMACP), implemented in Nepal in 2005 by the ACQUIRE Project in association with CARE Nepal and with funding from the United States Agency for International Development (USAID). The project utilised an ecological model to improve health outcomes for married adolescents in the 2 target districts (Parsa and Dhanusha). In close collaboration with District Public Health Offices, 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.

An excerpt from the report follows:

"Project impact was significant at all levels of the intervention - individual, relationship, family, community, and health system. At the individual level, data collected from baseline and endline evaluations show improvements in key reproductive health indicators among married adolescents. At the relationship level, interventions encouraged communication and joint decision making by couples on reproductive health, as well as greater participation of husbands in maternal health services. Empowered by the training and support offered by the project, many peer educators developed into 'champions' for youth behavior change and catalysts for broader community development. In particular, female peer educators served as powerful role models to promote adolescent women's access to essential health education and services.

At the family, community, and health system levels, interventions raised awareness of the needs and rights of married adolescents. Noticeable changes in attitudes among influential family and community members contributed to a more enabling environment for married adolescents' access to reproductive health information and services, while complementary improvements in capacity occurred at the health system level. Training for providers on youth-friendly services, together with the supply of essential medical equipment, increased the demand for health services and facilitated access to services by women and disadvantaged groups.

The leadership development training provided to 69 peer educators - one from each participating village - in the second year of the project was particularly successful in building a highly motivated and influential youth leadership. Following the training, peer educators established community-based development groups, conducted public hearings regarding health services, and identified and accessed government funds to complete health infrastructure projects at village level. The work of peer educators garnered widespread community approval, with health management committees and local government authorities inviting youth participation. Case stories of outstanding peer educators clearly reflect the transformative nature of RHMACP interventions as young people seized opportunities offered by the project to make positive changes in their lives and their communities.

Project impact was measured through baseline and endline surveys using household surveys structured after the Demographic and Health Surveys model. The sample size for both surveys was 960 individuals - 480 for each sex and 480 for each district. In addition, at endline, 120 peer educators (60 from each district) out of the total 1,242 peer educators in the project village development committees were interviewed. Data on reproductive health indicators show that the percentage of married adolescents visiting government health facilities for services rose from 36% (n=463) in 2005 to 42% (n=472) in 2007 and that the percentage of female adolescents who made four or more antenatal care visits during their last pregnancy increased significantly, from 29% to 50%. The proportion of young married women who delivered with the help of a skilled birth attendant also rose from 24% to 31% over the two-year period, and the proportion of deliveries taking place at home fell from 75% to 67%. In addition, the percentage of married adolescents who discussed where to deliver with their spouse increased significantly from 24% to 40%.

Adolescents' awareness of two or more modern methods of contraception, as well as their knowledge of where to obtain contraceptives, was almost universal at endline. Further analysis revealed significant increases in knowledge of individual methods. For example, the proportion of female adolescents who were aware that condom use can prevent pregnancy rose from 65% to 93% (n=480). These findings indicate greater potential for informed choice of contraceptives, especially among young women. In addition, a strong change was recorded in couples' perceptions about who is responsible for deciding whether to use family planning. At endline, 65% of female adolescents and 79% of males considered that husband and wife together were responsible for family planning decisions, up significantly from 37% of women and 57% of men at baseline.

Use of contraception before first pregnancy, however, remained low (only 4.8% among female respondents [n=333] and 11.3% among male respondents [n=283]), and no delay in childbearing was recorded. 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). Discussions with mothers-in-law further revealed the widespread belief that contraceptive use before first pregnancy causes infertility. All of these findings indicate that early proof of a woman's fertility remains a powerful social norm....Longer intervention timeframes with more intensive targeting of influential family and community members will be needed to affect cultural beliefs and behaviors that negatively impact youth reproductive health decision making and outcomes. Data, though, show a trend to postpone marriage and gauna (the local custom when a married girl moves into her husband's home following menarche, for consummation of the marriage). Median age at marriage rose from 14 to 16 years (a statistically significant increase), while median age at gauna rose from 15 to 16 years. The change in age at marriage indicates improved community awareness of the health needs of youth, which in turn sets the stage for increased impact on delayed childbearing if community engagement is maintained.

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.

Of important note, the project was implemented during an extremely volatile political period in Nepal....Health facilities were shut down, sometimes for months. However, the highly politicized atmosphere in the two districts may have heightened participants' awareness of their power to bring about social change. The ecological model successfully accommodated an expanded project focus that embraced peer initiatives in community development, local governance, and citizens' rights - all of which strongly supported the core project goal of effective access to quality reproductive health services for all married adolescents.

In particular, 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 - a considerable achievement in one of the most culturally conservative areas of Nepal.

To achieve major changes in individual behavior and social norms, and for systemic improvements in health provision, a two-year pilot intervention is extremely short. Results to date, however, indicate that the project's ecological model and multilevel implementation strategy is an effective and sustainable approach for improving the reproductive health of married adolescents in Nepal. In the endline survey, 71% of the peer educators (n=120) reported their willingness to continue their work after the project was phased out. Post-intervention visits in December 2007 and January 2008 - six months after project completion - confirmed that many peer educators were still performing key roles in their communities. Participants were active in local government, community development forums, health management committees, theater groups, livelihood projects, and savings and credit societies, as well as working to maintain project activities and networks at local and district levels. With advocacy and funding support from government authorities, including health facilities, these institutions and individuals have strong potential to secure long-term benefits. The project model is recommended for expansion in the pilot districts and to other areas of Nepal. Experience from the intervention further suggests that the model would be applicable to health development and governance initiatives in diverse country settings."

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