Reproductive Health of Adolescents in Nepal: A Perspective from Human Development

Introduction

Early marriage and early pregnancy are the norms of traditional society in Nepal, even though the legal age of marriage is 18 years and 21 for the boys and the girls respectively. Child marriage is a human rights issue, as it concerns with free and full consent in making the right choices in marriage as well as in the reproduction process. The couple married at the early ages are less prepared for making the better reproductive choices with enough literacy on the family planning including the maternal and infant care [1]. According to WHO [2], 30 percent of adolescent girls in low and middle-income countries are married by the age of 18 years that enhance the risk of adverse health conditions of early pregnancy. Similarly, unmet need for modern contraception is high in the least developed countries, where the risk of maternal mortality is the highest. In addition, women with unintended pregnancies are more likely to receive the delayed prenatal care having an adverse impact on maternal and infant health [3]. Early marriage and pregnancy can have numerous complications including unplanned pregnancy and exposure to sexually transmitted infections (STIs) that have the adverse impact on the women’s health. In addition, 13 percent pregnancy-related deaths are attributed to the unsafe abortion, which prevails in the developing countries [4]. Nevertheless, giving birth within the first years of marriage brings a sense of joy to the whole family especially when the baby is a boy.

The unmet needs of contraception are high in Nepal as only 14 percent of marriage adolescent girls aged 15-19 and 24 percent of married women aged 20-24 are using the modern method of contraception [5]. Unsafe abortions followed by post-abortion complications and post bleeding are one of the major causes of maternal mortality in Nepal. Although abortion is legalized in Nepal since 2002, 20 percent of maternal mortality is caused by unsafe abortions as women seek clandestine, unsafe abortions because of the ingrained fears and shame about abortions [6].

Reproductive health is one of the detrimental factors for human development in terms of ensuring good health conditions of women of reproductive age, as well as the infant. Nepal is one of the countries with low human development index, which can be attributed to poor maternal and infant health among the other health indicators.

Reproductive health has a direct association with maternal and infant health causing multiple health problems in later lives of women. Poor health conditions of women and children not only restrict them to participate in other economic and social opportunities for their individual growth but equally impact on the wellbeing of the whole family and overall human development. Although different international agencies have cooperated with local institutions for improving the reproductive health measures, there exists a large gap between the reproductive health policy and everyday practices that demands a serious attention from the global and national authorities.

Relationship between Reproductive Health and Human Development

Reproductive health has been a global phenomenon especially in terms of protecting the reproduction rights of women. It is more critical when early marriage and early pregnancy are the major cultural practice in the developing world. As mentioned earlier, women at younger age are highly vulnerable to their reproductive health for not having access to the information towards the family planning process and pre and post natal care. They are excluded from reproduction rights under which, couples should be free to decide on the number of births, timing, and spacing with sufficient information and means to do so.

The reproduction rights refer to all the decisions to the reproduction to be free of discrimination, coercion, and violence [7]. They include for instance, safe pregnancy, as well as the rights to support for reproduction (care for maternal health by providing antenatal and postnatal care and infant health) and also the abortion rights [7]. While these concepts on reproductive health and rights are ideally accepted by the global authorities, operationalization of such rights becomes critical given the diverse socio-economic and cultural context of the developing countries around the world. Reproductive health has a direct connection with the wellbeing of a family, which is embedded in the aspects of human development.

The human development approach devised by UNDP in 1990 is based on the capabilities approach coined by Amartya Sen [8], in which individuals must have a freedom or capabilities to pursue the life they value. This notion emphasizes on the freedom or capabilities that are entangled with other factors, which in aggregate makes the human development possible. For instance, they include resources for enabling the individuals to have the opportunities for health and education, and at the same, time they must be able to pursue those opportunities without any restrictions from the other members of the household given the intra-household power disparities [9]. In this sense, gender inequality at the household level is an example of the incapability for women to participate in the economic and social front such as participation in health services for the better health options including the information on the reproductive health. This illustrates how the intra-household power relations restrict the capabilities of women to utilize the so-called “reproductive rights” which not only hinder their individual health but her capacity to nourish the future baby and the family, which almost constitute her responsibilities for social reproduction [10].

The major challenge is that global policy on reproductive health and rights are less authentic towards the ground reality that prevails in most of the developing world. It is almost impossible to address the reproductive health issues in isolation from the rights-based perspectives without paying attention to the overall human development or the wellbeing perspectives. There is a significant association between the reproductive health and human development as reproduction roles are overburdened on women both biologically and socially.

For instance, while a woman cannot deny giving a birth nor can she undermine her responsibilities of motherhood, but her rights to be a healthy mother with access to information and health services are often jeopardized. This worsens the situations of underage mother. Such a situation further harms her social reproduction capacity as well as biological reproduction affecting negatively on the well-being of the family.

Marriage, Pregnancy and Abortion Practices

Marriage is the deep bond between two individuals to live together with legal and socio-cultural acceptance. It is often regarded as a joyful incident for celebration and a milestone in adult life throughout the world. However, the marriage practices in many developing countries often characterized by a taboo than a cause of celebration due to the early marriage with numerous negative implications. According to Wonkiest and Akhtar [11] early marriage is synonymous with women’s new gender- defined role of motherhood based on the cultural expectations emerging from the husband, and in laws and their own parents. High rate of early age marriages is compounded with the common practice of early conception of the first pregnancy, which is culturally considered to be a sign of fertility that rests heavily on women [12]. Lee [13] also commends that marriage is closely associated with high fertility beyond the legal and socio-cultural bond. Early marriage is directly proportional to early proportional. About 16 million births occur every year to young women age between 15- 19 years in the world representing 11% of all births.

Nearly one quarter of the women (23%) in the world is child bearing by the age of 19. Nepal ranks at top 10 countries with the highest rate of child marriage and third highest in Asia [14]. Thirty seven percent of the girls are married before reaching 18 and, 17 percent of women age between15-19 had begun child bearing in Nepal. In addition, child marriage rate for the girls in some high risk populations is as high as 70 to 80 percent [15]. High prevalence of child marriage in Nepal is attributed to poverty, lack of education and awareness and the socio- cultural values such as dowry and the preference of sons over daughters. The government of Nepal has endorsed a National Strategy on Ending Child Marriage in 2016, and has set the legal age of marriage for the girls to be 20.

As stated earlier, women’s entry into early marriage and thereafter the reproduction cuts off their opportunities to pursue academic and/or professional goals. Women at early age of marriage on the one hand are not familiar with family planning techniques, neither matured enough to make the reproduction decisions including the birth spacing and the number of births. In many cases, the couples rely on the traditional birth practices without planning and/or using contraceptives, so women continue to give a birth until the birth of a son that provides her enough of security in a familial and social relations. In addition, use of the family planning methods if any, is often decided by the males due to the intra - household power dynamics, where women is regarded to be immature and incapable to make such decisions.

The teenage pregnancy is often marked by unforeseen complications including the death of mother and the infant besides other mental and physical injuries. The major direct cause of maternal morbidity and mortality include hemorrhage, infection, high blood pressure, unsafe abortion, and obstructed labor [16].

Unwanted pregnancies are often reported to be a cause of high abortion in Nepal leading to the risk of maternal and infant health. Such pregnancies often occur in the coercive environment either within or outside marriage that carries the trauma and taboos for women, for which abortion is only an option. While abortion has been legalized in Nepal since 2002, 20 percent of maternal mortality is reported to be due to the unsafe abortions with no trained health personnel and lack of health equipment in the health clinics. This is truer in rural setting where health clinics are least accessible, and those available clinics are left with low skilled health personnel and inadequate equipment. More than half of abortions and miscarriages occur among the women of low socio-economic background resulting into high risk of complications with least chance of obtaining the urgent medical services. Similarly these are the group of population who rarely utilize the pre and post natal care services that are often located in urban centers. According to National Demographic Survey [17] around 17 percent urban and 53 percent rural Nepalese women do not receive pre natal care due to unavailability as well as inaccessibility of such services and unawareness on the importance of such care. Proper delivery and care during the child birth is another critical issue causing to high maternal and infant death in Nepal. While institutional delivery within health care system has been growing over the years with increasing facilities, many are still adopting the traditional ways of delivery especially in the rural areas resulting into the high risk of maternal death.

Similarly, the post natal services is only utilized at minimum due to the factors related to the poverty, ethnicity, low access to health services and socio cultural practices such as seclusion of mother and infant immediately after delivery.

The reproductive health that specifically concerns with women’s health is a critical concern to address the issues of maternal and infant mortality in Nepal. While maternal mortality ratio (MMR) has declined in Nepal, it still stands at second highest in South Asia [18]. A female child is discriminated since the birth that goes until she reaches the adulthood, and beyond her reproductive age. Mortality rate under 5 years’ age is higher (112.4:104.8) for females as compared to the males (NDHS, 2008). It is often women who take the burden of unwanted pregnancies as they continue to give births for the preference of sons. On the one hand, rural health centers are not well equipped with adequate reproductive health services, and there is information gap for utilizing the health services and information for better maternal and infant health.

Reproductive Health Policies Challenges in Nepal

The National health policy (1991) was implemented in Nepal with an emphasis on preventive, promotive, and curative measures to provide basic health services including reproductive and maternal health. Since then medium term strategic plans, the National Reproductive Health Strategy (1995), the Adolescent Health and Development Strategy (2000) and the Nepal Health Sector Program II (NHSPII) 2010-2014) highlighted the broad strategies for reproductive health in Nepal. For instance, the National Adolescent Sexual and Reproductive Health Program has made an effort to link with several other programs that provide specific services including safe motherhood, family planning, HIV/AIDs and STI programs. Similarly, a new HIV/AIDs National Strategy (2011-2015) have been developed and approved by the government. Additional policies for research, information, education and communication (IEC), safe motherhood, and adolescent reproductive health are in place. The national health sector policy also devised the operational guidelines for reproductive health care at all levels (from village to district and national) [19] with increased attention on training and management.

All these efforts have been conducive to improve the quality and efficiency of health services including reproductive health services. The different layers of health system at the community level are organized effectively in cooperation with local and district organizations [20]. Better relations are built with the community to expand reproductive health services through primary health care centers and a nationwide network of female community health volunteers (FCHs). At the national level the health indicators reflect an important progress in meeting reproductive health needs of the diverse population of Nepal, however, they still remain lowest in Asia. In addition, the functional aspect of health services to provide better, care and to cover the wider segment of the population is still questionable. Due to the difficult topographic conditions and lack of infrastructures such as communication and transportation make it harder to reach the health services for the majority of the population. On the other hand, the available health services are not well equipped in terms of having sufficient skilled medical personnel, health equipment, and the medical supplies that lead to low quality of services resulting to little motivation to many patients to attend the health services [20].

The general health policy at the national level is not based on the knowledge or evidence based to cater the needs of the diverse population around the country. Although the national health policy has focused on the reproductive health needs of adolescent and youth and identified them as vulnerable groups requiring specific services to address their needs, there are very limited programs and projects to reach them [1]. Different government departments have also worked collaboratively with bilateral, multilateral and nongovernment agencies to reach the young population with appropriate sexual and reproductive health and information and services [21]. Nevertheless, it is critical to have continuous support for the better implementation of reproductive health services, monitoring and evaluation in order to take corrective actions with appropriate measures based on the experiences and insights gained from the community, staff, and volunteers in delivering the better health care.

Challenges of Human Development

Reproductive health especially in relation to early marriage practices, unplanned pregnancy, and abortion have a huge negative impact on maternal and child health affecting negatively on overall human development in Nepal. As stated earlier younger age of marriage indicates the higher fertility as well as higher mortality for both mother and infant that contributes to low human development index [2]. Reproductive health is more burdened for women than men not only because of the biological factor (that women have to give the birth) but also because of gender expectations of motherhood from family members including husbands, and higher social reproduction responsibilities (e.g. nurturing and caring for children and, in-laws, cooking and cleaning etc.) [11]. In addition, women’s health deteriorates with multiple pregnancies due to the preference of sons in South Asian society that restricts their capabilities to participate in both production and reproduction roles impacting negatively on the human development [8]. Due to the absence of effective health services, and lack of awareness among the population, reproductive health issues (e.g., use of contraception and fertility, unwanted pregnancy and abortions) have the severe impact on human development. As observed from the different studies in the past, many women were not aware of the safe abortion facilities while unsafe abortions were rarely reported [20, 22]. On the other hand, the majority of the populations, particularly from low ethnic groups see the abortions as unethical and sin due to the likelihood of immoral sex. Women with higher socio-economic class are inclined to have sex-selective abortions impacting negatively on population distribution and human development [22]. While clinical abortions are rare, there were likely to have unsafe abortions without a notice of public especially among the unmarried teenagers that often carried further complications making their life into risk. Antenatal cares are of least a priority among the majority of women from low socio-economic backgrounds, and the pregnancy was just taken for granted, so regular checkups and special dietary practices remain out of the question. Regular antenatal care service promotes safe motherhood and delivery with improved maternal and neonatal outcomes (UNICEF, 2009). It often presents first contact opportunities for pregnant women as an entry point for integrated care promoting healthy home practices, influencing care-seeking behaviors, and linking women with pregnancy complications to referral system, thus impacting positively on maternal and fetal health. Most of the delivery among the women from lower strata takes place at home with traditional birth attendant that can lead to high risk of maternal and infant death. Safe delivery is a critical for both mothers and infant health affecting them in later lives, and yet many were out of reach of such practices. Postnatal care is very significant for improving maternal and infant health, which occurs at two levels. At first level, the ethnic based cultural practices of caring the mothers and newborn that prevailed in different ethnic community such as Newar in Nepal. On the other hand, postnatal care based on the health institutions is very negligible especially for monitoring the maternal and infant health and preventing any kind of infection at an early stage of maternity. The traditional practice involved keeping mother and baby separate from the family members in the secluded area that often discourages women to go to postnatal check- ups [23]. Such situation indicated the high risk of morbidity and mortality affecting negatively to the overall health of women and children and thereby their capabilities. The reasons behind not using antenatal natal and postnatal care services are mainly due to their traditional beliefs of using local medicines, less support from husbands and mother in laws for visiting health posts and ineffective and discriminative services in the health posts (personal observation, 2008). For instance, one of the ethnic community Tharu believes their village boundary to be protected by Deities, and did not feel safe to move beyond the boundary to utilize the health services. However, low access to the modern health institutions is often a major dilemma in rural setting preventing many women to utilize the antenatal, natal and postnatal care and services. This is supported by the evidence from around the developing countries indicating that women from poorer households have worse reproductive health outcomes and make less use of health services further restricting their capabilities for production and reproduction [24]. On the other hand, among the rich households the intra-household disparity and gender inequality still result in high fertility, and high morbidity and mortality impacting negatively on human development [25, 26].

Conclusion

Early marriage and early pregnancy have been very critical phenomenon of Nepalese society. Despite the amendment on the civil code to increase the age of marriage to 20 years, the problem of child marriage and its worsening consequences continue to persist. Nepal has been signatory in various international treaties and conventions regarding child right and ECM and has also adopted the National Strategy to End Child Marriage by 2030 as indicated in Sustainable Development Goals globally. However, the practice of teen age marriage still remains a great challenge of Nepalese society with huge negative implications on reproduction rights and capacities of women, which, in turn largely affects the human development.

Women of early age at rural areas are unaware of their reproductive health problems, nor do they have choices for making reproductive decisions for number of reasons as indicated earlier. The problems are further worsening with the population of low strata as they are often marginalized from the mainstream society being unable to have easy access to health information, lack of resources to pay for health services, and denial of the modern techniques due to their deep rooted traditional cultures among the others.

Reproductive health need is one of the basic needs similar to food and shelter that are fundamental to survival, however, are beyond the reach of majority of population in the developing world including Nepal. It especially restricts women’s capabilities to function for the well being of their own and of their families with the deteriorating health conditions, which is evident with low human development index.

Despite the effort of global authorities to address the reproductive health problems from the rights based perspectives, maternal and infant mortality is still higher in South Asia. On the one hand there is high investment in modern health services and equipments to increase quality of reproductive health through invention of diagnostic techniques and family planning methods, while on the other large section of the society are restricted in accessing the basic reproductive health such as antenatal and post natal services. This has presented a great dilemma in the reproductive health measures that is being focused on sustainable and millennium development goal.