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Adolescent Sexual and Reproductive Health in Malawi: a Synthesis of Research Evidence

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Adolescent Sexual and Reproductive Health in Malawi: a Synthesis of Research Evidence Adolescent Sexual and Reproductive Health in Malawi: A Synthesis of Research Evidence Alister C. Munthali, Agnes Chimbiri and Eliya Zulu Occasional Report No. 15 December 2004 Acknowledgments Adolescent Sexual and Reproductive Health in technic, College of Medicine and our own documenta- Malawi: A Synthesis of Research Evidence was written tion center at the Centre for Social Research. We would by Alister C. Munthali (Centre for Social Research, like to thank the staff in these libraries for all the sup- University of Malawi, Malawi), Agnes Chimbiri port they gave us. (Centre for Reproductive Health, College of Medicine, The research for this report was conducted under Malawi) and Eliya Zulu (African Population and The Alan Guttmacher Institute's project Protecting the Health Research Centre, Kenya). Next Generation: Understanding HIV Risk Among This synthesis report is a result of the support that Youth, which is supported by the Bill & Melinda Gates we received from many people. At The Alan Foundation. Guttmacher Institute, we are very grateful to Akinri- Suggested citation: Munthali AC, Chimbiri A and nola Bankole, Ann Biddlecom and Susheela Singh, Zulu E, Adolescent Sexual and Reproductive Health in who thoroughly read the report and provided very use- Malawi: A Synthesis of Research Evidence, Occasion- ful and constructive comments. We would also like to al Report, New York: The Alan Guttmacher Institute, thank Dixie Maluwa-Banda of the University of 2004, No. 15. Malawi and Nyovani Madise of the University of Southampton for having reviewed this report. To order this report, go to www.guttmacher.org. In order to obtain literature on adolescent sexual and reproductive health, visits were made to a number of ©2004, The Alan Guttmacher Institute, A Not-for- libraries, including the National Library, Ministry of Profit Corporation for Reproductive Health Research, Health and Population, United Nations Population Policy Analysis and Public Education Fund, the United Nations Resource Centre, Kamuzu College of Nursing, Chancellor College, The Poly- ISBN: 0-939253-71-2 Table of Contents Acknowledgments . 2 Policies and Programs on Adolescent Sexual and Reproductive Health . .33 Executive Summary . 4 Adolescent sexual and reproductive health policies . .33 The National Youth Policy . .33 Introduction . 7 The National Population Policy . .34 Family Planning and Contraceptive Guidelines . .34 The Social Context, Cultural Values and Beliefs . 13 Reproductive Health Policy . .34 The National AIDS Policy . .34 Adolescent Sexual and Reproductive Adolescent sexual and reproductive health programs . .34 Experiences . 15 The National Reproductive Health Program . .34 Age at first sexual intercourse . .15 The Youth Technical Sub-Committee and associated activities . .35 Age at first marriage . .16 Life skills education . .35 Number of sexual partners . .16 HIV/AIDS in the school curricula . .35 Sexual abuse . .16 The “Why Wait?” Educational Program . .35 Unplanned pregnancies and early childbearing . .17 Edzi Toto Clubs . .36 STI and HIV infection: incidence and prevalence . .17 Knowledge and use of contraception and condoms . .18 Conclusion . .37 Contraception . 18 Condoms: knowledge, use and barriers to use . 19 References . 41 Information and Service Sources for Adolescent Figures and Tables . .47 Sexual and Reproductive Health . .23 Sources of reproductive health services and information . .23 Types of information and services available to adolescents 23 Barriers to existing sexual and reproductive health services 24 Adolescent Awareness, Knowledge and Attitudes about HIV/AIDS and STIs . .25 Knowledge about HIV/AIDS . .25 Knowledge about transmission and prevention of HIV/AIDS and STIs . .25 Misconceptions and attitudes about HIV/AIDS . .26 Attitudes about HIV testing and counseling . .27 Attitudes about STI treatment . .28 Risk Assessment . .29 Special Groups at Risk . 31 Orphans . .31 Executive Summary This report is part of a larger, five-year study of ado- Past studies highlight various cultural practices that lescent sexual and reproductive health issues called influence young people’s behaviors, attitudes and mo- Protecting the Next Generation: Understanding HIV tivations related to sexual and reproductive health is- Risk Among Youth (PNG). The project, which is being sues. The socialization process, which involves various carried out in Burkina Faso, Ghana, Malawi and Ugan- forms of initiation ceremonies, has a strong influence da, seeks to contribute to the global fight against the on how adolescents understand their sexual and repro- HIV/AIDS epidemic among adolescents by raising ductive health. Although Malawian culture values vir- awareness of young people’s sexual and reproductive ginity and condemns premarital childbearing, there is health needs with regard to HIV/AIDS, other sexually a general understanding that initiation ceremonies, transmitted infections (STIs) and unwanted pregnan- which are meant to groom young people to be respon- cy; communicating new knowledge to a broader audi- sible sexual beings, sometimes achieve the undesired ence, including policymakers, healthcare providers and outcome of encouraging young boys and girls to initi- the media, in each country, regionally and internation- ate sexual relationships prematurely because they feel ally; and stimulating the development of improved that the initiation ceremonies mark their transition to policies and programs that serve young people. The re- maturity. The socialization process also reinforces the search involves focus group discussions and qualitative dominance of men and boys and the subordination of interviews with adolescents, teachers and health work- women in sexual relationships. This social orientation ers, as well as national surveys of adolescents. This is likely to weaken women’s autonomy and latitude to synthesis is the first publication of the PNG project in negotiate for safer sex. It is also evident that the tradi- Malawi. It identifies important knowledge gaps and in- tional socialization system’s role in adolescent sexual- forms the project’s communication and advocacy ini- ity and reproductive health has been waning as a result tiatives by providing an overview of current policies of the increasing influence of religion, schooling, ex- and interventions for youth. posure to media and other sources of information on The primary goal of this report is to summarize what these issues. While sexual abuse appears to be a major is known about adolescent sexual and reproductive problem in Malawi, the actual magnitude of this prob- health in Malawi and to identify knowledge and program lem is not known. gaps requiring further research and program action. Indeed, although premarital sexual intercourse is Drawing from a wide range of studies carried out in the disapproved of in many Malawian communities, stud- country since 1990, the synthesis reviews the social, cul- ies have shown that many adolescents initiate sex at an tural and economic context in which adolescents live; early age. For example the 2000 DHS revealed that their sexual and reproductive health experiences; sources 61% of males and 57% of females aged 15–19 had ever of information and services related to sexual and repro- had sex at the time of the survey. Factors associated ductive health; knowledge and attitudes about HIV/ with early initiation of intercourse include low levels AIDS and personal risk assessment; and policies and of schooling, peer pressure to experiment with sex and programs on adolescent sexual and reproductive health poor economic wellbeing. Between 1992 and 2000, in the country. The studies reviewed include the Demo- age at first marriage increased slightly for women aged graphic and Health Surveys (DHS) conducted in Malawi 20–24 (from 17.7 to 18.2) but decreased for men aged in 1992, 1996 and 2000, and other small-scale studies 25–29 (from 24 to 22.7). carried out in different parts of Malawi to inform the de- The major problem with early initiation of sexual re- velopment of specific programs. lations is that many young boys and girls are not aware 4 Adolescent Sexual and Reproductive Health in Malawi of protective measures; they feel vulnerable and lack information for adolescents are youth clubs, the radio, the confidence to demand use of protection against government health workers and friends. Parents are not STIs and unplanned pregnancies. According to the a major source of information because they do not nor- 1992 DHS, 35% of females aged 15–19 were either mally talk to their children about sexual and reproduc- pregnant or mothers at the time of the survey, a figure tive health issues; this responsibility is left to other rel- that remained unchanged even in the 2000 DHS. The atives, such as aunts, grandparents and other people consequences of early initiation of sex and lack of con- within the community such as anankhungwi (tradition- trol are more acute for girls, who usually have to leave al initiators). Barriers to access to information on sexu- school when they get pregnant. Some girls risk their al and reproductive health include ignorance about the lives through illegal abortions and are more vulnerable existence of the services, fear of teachers and parents to STIs, including HIV, because they typically have and poor attitudes of health workers toward adolescents. sexual relations with men who are more experienced Knowledge of HIV/AIDS among Malawian adoles- and older. cents is almost universal. The vast majority know that Although
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