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Through the Eyes of a 16-year-old Zambian Girl

Guest authors are Marta Pirzadeh, MPH, senior technical officer, research utilization, at FHI 360 and Fariyal F. Fikree, MD, MPH, DrPH, senior research advisor at Pathfinder, who works on the USAID-funded Evidence to Action project.          

No single family planning (FP) method is acceptable to everyone because women and men worldwide have varying levels of sexual activity, differing needs for confidentiality, and various capacities to tolerate side effects. Add to this mix the system barriers that often limit availability of certain contraceptive commodities…and then, envision being a 16-year-old unmarried girl living in a small village in Zambia.

What are the chances that you’ll be able to obtain a family planning method that is acceptable to you?

For purposes of this exercise, let’s assume that you are amenable to a wide variety of methods – the pill, an implant, injectables, or an IUD.  You quickly realize that accessibility to reliable healthcare services greatly narrows your choices. Are you able to walk to a health clinic once every three months to get an injection?  Do you have resources and transportation to go to a hospital to have an IUD inserted?  Are there routine stock-outs of implants or oral contraceptives where you live?

As a young person, you face other hurdles, as well. Like the concern that everyone in your small town will see you entering the family planning clinic and make assumptions about why you are there. Perhaps you are afraid to be branded as promiscuous. You don’t have anyone to talk with about your options to protect yourself from unintended pregnancy and STIs/HIV. You don’t even know where to start.

The hard reality is that an estimated 33 million female youth have an unmet need for family planning; they do not want to get pregnant but, for one reason or another, are not using modern methods.  According to WHO’s Medical Eligibility Criteria for Contraceptives, “Age alone does not constitute a medical reason for denying any method to adolescents.” However, young people are denied access all the time. Even if contraceptive methods are available, laws and policies often prevent unmarried adolescents or those under a certain age from accessing them.

A number of compounding barriers further limit contraceptive access and uptake for youth:

  • Provider bias and lack of youth-friendly provider training – clinic workers from the front desk receptionist to the nurse’s aide to the actual service provider may be judgmental of youth seeking FP services.

  • Mistrust of service providers to keep the visit confidential, decreasing a young person’s willingness to access care

  • Perceived or real health concerns about side effects and fear that certain methods may impact long-term fertility

  • Lack of comprehensive sexuality education, including information on reproductive biology and contraceptive options

What can we do to alter this balance sheet – to pave the way for adolescents in need to obtain FP methods that are acceptable to them?

We can start by doing a better job of talking to adolescents about what they like and dislike about currently available methods and to address their concerns about return to fertility. Recent findings from PSI’s Adolescents 360 research in Ethiopia, Nigeria and Tanzania confirmed that for many girls—especially those with fewer developmental resources—social  value is highly  linked to fertility. Because these girls equate fertility with security and value, contraceptive use is seen as jeopardizing one of their few assets – fertility.

We need to include young people in conversations related to product development like the one held recently during a meeting of the Reproductive Health Supplies Coalition’s Youth Caucus. There, 30 young Francophone Africans discussed their wish lists for the perfect contraceptive method, their current favorite methods, and their dissatisfaction with gender-inequitable contraception.

And, we need to enroll them in clinical trials for new and improved methods that are youth-friendly – methods that can be used confidentially, that allow for self-administration and are not provider-dependent, and that protect against pregnancy and STIs/HIV.

Since 2015, a working group of committed professionals and development organizations has been coming together to promote sexual/reproductive health rights of adolescents and youth. One outcome of these meetings is a global consensus statement in support of full and informed choice of contraceptives for young people. As one representative from the International Youth Alliance for Family Planning reminded us during that discernment, “By not giving adolescents and youth sound, unbiased information and access to long-acting reversible contraception that can meet their needs, we are simply letting youth down.”

As communities, parents, teachers and friends, we need to work harder to break down the inherent societal barriers that impede young people’s journey to adulthood, and to delayed parenthood, if that is their plan. As contraceptive researchers, we need to pay closer attention to youth-specific acceptability concerns. As FP practitioners and health providers, we need to break down structural barriers at the clinic site that impede their attempts to obtain their contraceptive of choice. We need to provide a more youth-supportive environment and ensure policies are implemented to destigmatize youth access.

Perhaps our actions would be bolder if only we could view the world through that 16-year-old Zambian’s eyes….