95102 Knowledge Brief Health, Nutrition and Population Global Practice + ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH IN BURKINA FASO Rafael Cortez, Diana Bowser, Valeria Gemello, Jini Etolue, Meaghen Quinlan-Davidson, and Haidara Ousmane Diadie March 2015 KEY MESSAGES: S  The adolescent fertility rate in Burkina Faso is 115.4 births per 1,000 women 15-19 years old, slightly below Sub-Saharan Africa’s regional average of 117.4 births per 1,000 women 15-19 years old and well above the global average of 45 births.  Female genital cutting is common in Burkina Faso; even though, it has no health benefits and is a human rights violation.  Policy-makers in Burkina Faso need to raise the legal age of marriage to 18 years and enforce this, as early marriage is common.  Promoting female completion of primary and secondary school and increasing labour force participation; strengthening adolescent girls and young women’s knowledge, awareness, and access to quality sexual and reproductive health (SRH) services (including family planning); and increasing the availability of these services will result in better health outcomes for not only adolescent girls and young women but their families and societies overall. Introduction 60 percent of Burkina Faso’s total fertility rate (INSD, 2012; Soulary, 2011). These rates are highest in rural areas. Today’s adolescents and youth face substantial physical, Contributing to this is low contraceptive use (6 percent of social, legal, and economic barriers to meeting their SRH 15-19 year olds and 17 percent of 20-24 year olds use potential. Key factors underlying these issues are a lack of modern contraception) with over 20 percent of 15-19 year adolescent SRH (ASRH) policies and access to accessible, olds reporting an unmet need for contraception (INSD, affordable, and appropriate health services. The impact that 2012). these factors have on adolescent health and development is clearly seen in Burkina Faso. Burkinabè adolescent girls Maternal and infant mortality and morbidity are twice as face high adolescent fertility rates, early and forced high among young women and their children as that of marriage, an increased risk of maternal mortality, and a older women. In 2010, 14 percent of all deaths due to high unmet need for contraception, among others. Adding maternal complications were among 15-19 year olds and 29 to this issue is a lack of access to education, basic health percent among 20-24 year olds, greatly diminishing a information, and SRH services, contributing to a lack of woman’s chance of continuing her education and limiting awareness and knowledge about SRH and traditional and employment opportunities. Meanwhile, the average age at harmful gender stereotypes. first marriage was 17.9 years with 29 percent of girls The adolescent fertility rate is 115.4 births per 1,000 girls married between 15-19 years and two thirds married by the 15-19 years of age (World Bank, 2014). In 2010, almost a time they turned 24 years (INSD, 2012). Also, female quarter (23.6 percent) of 15-19 year olds had a child or genital cutting (FGC) is widespread with 58 percent of 15– were currently pregnant, and 14-29 year olds represented 19 year olds and 70 percent of those between 20–24 years subjected to it. This is more prominent in rural areas Page 1 HNPGP Knowledge Brief  (Amnesty International, 2009). In fact, Burkina Faso faces high out-of-school rates with over 1 million children estimated to be out-of-school Given the paucity of research on ASRH in Burkina Faso, (UNESCO, 2011). Adolescent girls enrolled in school are the World Bank conducted a three-part research project less likely to engage in sexual activity, while lower that included: (i) a quantitative analysis using Burkina educational achievement and lower school attendance are Faso’s Demographic and Health Survey (DHS) data from associated with: younger age at first marriage; higher 2003 and 2010 among female respondents 15-19 and 20- fertility rates; greater age differences between adolescent 24 years of age; (ii) a literature review on the structural and girls and their partners; negative gender norms and proximal determinants of ASRH; and (iii) a mapping of the domestic violence; increased prevalence of HIV among adolescent girls; decreased contraceptive use; and most recent ASRH policies and programs. The objectives of decreased use of antenatal care. the study were to understand the impact that structural and proximal determinants have on access to ASRH services MARITAL STATUS and health outcomes; and the impact that recently implemented policies and programs have on ASRH. Between 2003 and 2010, marriage increased among adolescent girls and young women, regardless of age. Early Study Findings and forced marriage is prevalent (especially in rural areas) in Burkina Faso, contributing to higher fertility rates, WEALTH, EDUCATION, AND EMPLOYMENT unplanned pregnancies, and STIs including HIV/AIDS (Guiella, 2004). The results found that 20-24 year olds showed greater improvements in wealth than 15-19 year olds between 2003 and 2010. The percentage of 20-24 year olds in the poorer SEXUAL ACTIVITY category slightly decreased from 18.8 percent to 17.4 Adolescents engage in sexual activity at a young age. One percent while there was a slight increase in poverty among study found that 12-14 year olds were engaging in sexual 15-19 year olds from 15.2 percent to 16.4 percent. activity, with adolescent boys more likely to be sexually Adolescents increased their level of education during the experienced than girls (5.8 and 2 percent respectively) same time period (figure 1). (Bankole, 2007). Figure 1. Education among adolescent girls (15-19 years of CULTURAL AND GENDER NORMS AND VIOLENCE age) and young women (20-24 years of age) by education level and year (2003 and 2010) (percent) The percentage of females circumcised decreased between 2003 and 2010, and more females were against the practice in 2010 (figure 2). Figure 2. Cultural norms among adolescent girls (15-19 years of age) and young women (20-24 years of age) by norm and year (2003 and 2010) (percent) Source: United States Agency for International Development (2003 and 2010). Measure DHS. Washington, DC: USAID. Indeed, Burkina Faso has been successful at ensuring that females attend school; the country is projected to achieve gender parity in primary school by 2014. However, the gender gap in primary school completion remains wide, with 34 percent of adolescent boys and 24 percent of girls in Source: United States Agency for International Development (2003 and 2010). Measure DHS. Washington, DC: USAID. 2010 completing primary education. Also, literacy rates among females remain low: the country ranks as one of 5 Burkinabè women face rejection, rape, sexual violence, countries with the lowest female (15-24 years) literacy rates early and forced marriage, domestic violence, FGC, (currently at 33 percent) globally. Additionally, 90 percent of intimate partner violence, sexual harassment, and gender poor children do not complete primary education in stereotypes and prejudices (Bigauette, 2007). Several comparison to 54 percent of rich children (UNESO, 2014). articles have documented the prevalence and severity of Page 2 HNPGP Knowledge Brief  gender-based violence (GBV), its high prevalence among ASRH HEALTH SERVICES AND USE young women, and its association with poorer health The percentage of 15-19 year olds who visited a health outcomes and reduced wellbeing (JICA, 2013; Ministère de facility decreased from 42.7 percent in 2003 to 32 percent la Promotion de la Femme, 2009). in 2010. There was an increase among 20-24 year olds SRH KNOWLEDGE, ATTITUDES, AND PRACTICES seeking health care from 40.6 percent in 2003 to 60.4 There is a high unmet need for family planning (FP) among percent in 2010. Delay in seeking healthcare among adolescent girls, particularly in terms of spacing of births. women could be attributed to: (i) Abusive and disrespectful Among 15-19 year olds, unmet need for spacing slightly conditions when seeking health care services, especially increased from 8.2 percent in 2003 to 8.4 percent in 2010. during pregnancy and childbirth (Amnesty International, Although knowledge of modern contraception increased 2009); and (ii) Some national programs that provide between 2003 and 2010, most females stated that they maternity care have not reduced out of pocket or poverty as were not currently using a contraceptive method while over much as was anticipated. 20 percent stated that they would never use a contraceptive method (figure 3). Importantly, a lack of contraceptive use To address these barriers, the government has been puts the female at higher risk for STIs including HIV/AIDS working with organizations to subsidize emergency and unplanned pregnancies (Guiella, 2007). obstetrical and neonatal care, implement community based health insurance, and ensure skilled birth attendance Figure 3. Current use of any contraceptive method among 15- (Ridde, 2011). 19 year olds and 20-24 year olds by year (2003 and 2010) (percent) Overall, the DHS analysis found that among 15-21 year olds a higher level of education, a higher wealth index, living in an urban area, and regions outside of the Sahel predicted a lower level of unmet need for FP, increased use of health facilities, and a desire to have fewer children. These results were higher among 20-21 year olds than among 15-19 year olds. Married women were more likely to have a higher level of unmet need, increased hospital visits, and a desire to have more children. Government Efforts Source: United States Agency for International Development (2003 and The government has implemented 5 Plans and Strategies 2010). Measure DHS. Washington, DC: USAID. that address young people’s SRH needs in various capacities. These are: It also leads to higher abortion rates. Although it’s legal for (i) The National Health Development Plan 2011-2020 therapeutic reasons, abortions range from 65 percent (PNDS), prioritizes improving young people’s health and among 15-24 year olds to a rate of 60 induced abortions access to health care by strengthening the quality and per 1,000 15-19 year olds in Ouagadougou; with rates accessibility of maternal and obstetric care; accelerating higher among younger women than older age groups support for FP services; building human resource capacity (Rossier, 2006; Bankole, 2013). Illegal abortions contribute for cancer and FGC; promoting clinical and community to high adolescent maternal mortality and morbidity interventions; and integrating nutrition and primary health (MJFPE, 2008), and a number of socioeconomic costs care strategies. However, financial constraints have limited including: direct economic costs; health care costs arising the implementation of the PNDS and quality of services from complications; and social costs associated with provided has been poor (UNFPA, 2012). missing school, stigma and discrimination, and potential (ii) The Consolidated Action Plan for Family Planning mental health issues (Thomas, 2013). 2013-2015 increases awareness and promotes access to FP services. SRH knowledge is limited as well. One study found that 5 (iii) The Program for Strategic Development of Basic percent of adolescent girls and 9 percent of boys stated that Education (PDSEB) (2010) outlines education reforms and they were well informed about pregnancy prevention the importance of strengthening non-formal education (Bankole, 2007). This may be attributed to a lack of family initiatives for young people prioritizing gender equity by and sexual education courses. A reported 10 percent of 2021. adolescent girls and 14 percent of boys stated that they (iv) The National Policy on Education and Technical received family or sexual education in school (Bankole, and Vocational Training involves various governmental 2007). agencies to improve access to vocational training for those 15 to 24 years of age. (v) The National Gender Policy (PNG) was developed Page 3 HNPGP Knowledge Brief  in 2009 to promote: (i) equal rights; (ii) economic FGC, high rates of STIs including HIV/AIDS, and the development and equitable access; (iii) equal participation promotion of gender equality. in decision-making processes; (iv) dynamic partnerships for gender and development; and (v) equity and equality References information and awareness. Financial constraints undermine its current implementation. Amnesty International. 2009. Giving Life, Risking Death. Maternal Mortality in Burkina Faso. London, United Kingdom: Amnesty International Secretaria. Bankole, A., et al., “Sexual Behavior, Knowledge and Information Sources of Very Young Challenges Adolescents in Four Sub-Saharan African Countries.� African Journal of Reproductive Health 2007. 11(3): p. 28-43. Bankole A., R. Hussain, G. Sedgh, G. Rossier, I. Kaboré, G. Guiella. 2013. Grossesse non In addressing the influence of health and non-health Désirée et Avortement Provoqué au Burkina Faso: Causes et Conséquences, New York: policies and access to ASRH services on health outcomes, Guttmacher Institute. Bigauette, M., et al., Études sur la Violence Faite aux Femmes en Afrique de l’Ouest. 2007. there are several challenges: Oxfam Quebec: Montreal. Guiella, G., Santé Sexuelle et de la Reproduction des Jeunes au Burkina Faso: Un Etat des (vi) ASRH outcomes are not often measured in Burkina Lieux, in Occasional Report No. 12. New York: Guttmacher Institute; 2004. Faso. Data on adolescent fertility rates may be Guiella, G. and N.J. Madise. 2007. “HIV/AIDS and Sexual-Risk Behaviors among Adolescents: Factors Influencing the use of Condoms in Burkina Faso.� African Journal of collected and analyzed, however data on maternal Reproductive Health 2007. 11(3): p. 182–196. morbidity and mortality, GBV, and domestic violence is INSD (Institut National de la Statistique et de la Démographie) and Ministère de l’Économie not collected. et des Finances. 2010. Enquête Démographique et de Santé et à Indicateurs Multiples (vii) The lack of monitoring and evaluation of policies and (EDSBF-MICS IV) Burkina Faso 2010, 2012, ICF International: Calverton, Maryland, USA. Mitsubishi UFJ Research and Consulting Co. Ltd.2013. Country Gender Profile: Burkina programs makes it difficult to accurately estimate Faso, JICA. impact. Ministère de la Jeunesse, de la Formation Professionnelle et de L’emploi, Politique  Current social norms support withholding information Nationale de Jeunesse, 2008. Ministère de la Promotion de la Femme. Politique Nationale de Gender. 2009. Available at: from adolescents and youth. http://www.mpf.gov.bf/. (viii) A lack of adequate and transparent funding has Ouedraogo C., V. Woog and G. Sondo. 2006. Expériences D’adolescents en Santé been a key challenge to the implementation of ASRH Sexuelle et Reproductive au Burkina Faso, in Occasional Report. New York : Guttmacher policies and programs as the demand for health Institute. Ridde, V., et al., 2011. “The National Subsidy for Deliveries and Emergency Obstetric Care services and supplies has rapidly increased over the in Burkina Faso.� Health Policy and Planning, 2011. 26: p. 26:ii30–ii40. past few decades. Rossier, C., et al. 2006. “Estimating Clandestine Abortion with the Confidants Method— (ix) Government expenditure remains insufficient. In 2009, Results from Ouagadougou, Burkina Faso.� Social Science and Medicine 62(1): 254-266. Soulary, C. 2011. Santé de la Reproduction: Protéger la Nouvelle Génération, in Population only 6 percent of the total health budget was allocated Africaine: Passé, Présent et futur. VIème Conférence Africaine sur la Population: to reproductive health, of which 5 percent was spent on Ouagadougou. maternal health and FP (Amnesty International, 2009). Thomas M and N. Burnett. 2013. Exclusion from Education: The Economic Cost of out of School Children in 20 countries. Ed EA Child. Educate a Child. Results for Development. United Nations Organization for Education, Science and Culture. 2011. Education for All Addressing each of these issues through policies and Global Monitoring Report 2011. Geneva: UNESCO; 2011. programs improves ASRH, contributes to the social and _____. 2013/4. Education for All Global Monitoring Report 2013/4. Geneva: UNESCO; 2014. Available at: http://unesdoc.unesco.org/images/0022/002256/225660e.pdf. economic development of the country and results in UNFPA. 2012. Service de l’évaluation Division des Services de Contrôle interne, Évaluation reduced fertility rates; delayed voluntary and forced à mi-parcours du Fonds thématique pour la Santé Maternelle. Burkina Faso Country Report marriages; and reduced rates of FGC and physical abuse, 2012., in Évaluation de l’appui du FNUAP à la santé maternelle. Editor 2012: New York. _____. 2010. Investing in Young People as a part of the Poverty Reduction Strategy New leading to improved status for women in society, healthier YorkUNFPA. communities, and economic growth and development World Bank Group. 2014. World Development Indicators: Burkina Faso. Washington, DC: (UNFPA, 2010). World Bank. Available at: http://data.worldbank.org/country/burkina-faso. Conclusion This HNP Knowledge Brief highlights key findings from a World Bank study on “Adolescent Sexual and Reproductive Health in Burkina Faso� prepared by a World Bank team including, Diana Bowser (Researcher, Brandeis The study findings confirm what is known about ASRH in University), Valeria Gemello and Jini Etolue (Consultants) and Rafael many parts of the world: adolescents and youth lack access Cortez (World Bank’s Team lead). This report is part of the World Bank’s to basic SRH information and services. Traditional gender Economic Sector “Paving the Path to Adolescent Sexual and Reproductive norms and stigma and discrimination associated with SRH Health� conducted by the Health, Nutrition and Population Global Practice and financed by The World Bank-Netherlands Partnership Program are prevalent and contribute to low levels of knowledge, (BNPP). poor access to accurate and quality information and services, as well as harmful practices and norms. Early marriage and high adolescent fertility rates are the norm among adolescent girls. Promoting and enforcing ASRH policies using a gender approach while implementing ASRH programs and services, particularly in rural areas, can help prevent early/unplanned pregnancies, early marriages, The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of Page 4 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.