COUNTRY PAPER NEPAL South Asia Conference on the Adolescent ■ 21-23 July, 1998
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- Title
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COUNTRY PAPER
NEPAL
South Asia Conference on the Adolescent ■
21-23 July, 1998
- extracted text
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COUNTRY PAPER
NEPAL
AUNFR4
South Asia Conference on the Adolescent ■
21-23 July, 1998
New Delhi - India
* This document has been reproduced with minor editorial changes.
J
Nepal Country Paper
ADOLESCENTS REPRODUCTIVE HEALTH
IN NEPAL
I
1.1
Introduction
In 1996, young people aged 15-19 was estimated at 519 million, with 83% living
in developing countries. By the next century over half of the world's population
will live in urban areas where young people are estimated to have poverty and
stressful loss of family ties. In developing countries, four out of five of world's
young people live and where more than half of population is under the age of 25.
With 28% of the world's population on between the ages of 10 and 24, 1.5
billion people growing up today will be the leaders, citizens and partners in the
future. Hence, young men and women will become parents of the next
generation. In South-East Asia region. (Bangladesh, India, Maldives, Nepal,
Pakistan and Sri Lanka), more than 30% of the total population is between the
ages of 10-24, of which about 40% are growing into adolescence below the age
of 15. Many adolescents have already married and started own families, but
without information and services which are known to promote healthy and
responsible sexual and reproductive behaviors. More and more young people
are suffering from STDs including HIV. seeking unsafe abortion, resulting into
the consequences of early, close and frequent pregnancies and social problems.
1.2
Adolescents Population in Nepal
The total population of Nepal was 18.5 million in 1991 against 11.5 million in
1971. The share of adolescent population in the age group of 10-14 was 1 1.22%
in 1971, which increased to 11.36% in 1981 and 12.58% in 1991. The younger
male adolescent group i.e. 10-14 age group increased by 31% (1971-1981) and
32% (1981-91) while the corresponding figures for the female were 33% and
42% during the same period. Similarly the older adolescent male population i.e.
15-19 age group increased by 27% (1971-1981) and 27% (1981-1991) while the
increase for female are relatively higher, indicating rapid growth of adolescent
population in Nepal.
1.3
Mean Age at Marriage & Marital Status
Age at marriage is one of the most important proximate determinants of
aggregate level of fertility (Bongaarts and Potter, 1993) and it is also an
important indicator of women's status. The mean age at marriage for female is
comparatively lower in Nepal as compared to other SAARC countries.
However, there has been gradual change in the mean age at marriage during
inter census period 1961-1991.
The mean at marriage for women increased from 15 years in 1961 to 18 years in
1991. The change is more pronounced among young girls between 10-14 years.
In case of young girls between 10-14 years, 25% were already married in 1961
but it changed over time and as a result 8% (82,000 children at the age of 15 in
i
Nepal Country Paper
the marriage category) of such girls were in married category in 1991. This
indicates that over the 30years, girl child marriage in the 10-14 years group
has been reduced by more than two-thirds.
1.4
Adolescents Fertility
During the most recent period (1991-1996), fertility among 15-19 and 20-24 is
1.31 and 2.71 respectively. Fertility rates, despite some visible indication of
decline, are still high in Nepal. The total fertility rate per women was 6.33 in
1976, which declined to 4.6 in 1996. The decline in TFR is largely attributed to
the use of family planning services. Fertility was observed to be highest among
women 20-24 years (266/1000 women) in 1996.
1.5
Adolescent Child-Bearing
Problems of adolescent reproductive health are those resulting from traditionally
early marriage of girls that still prevail in many developing countries, including
Nepal. Twenty-five percent of 14 years old girls in Bangladesh and 34 percent
of girls of 15 years in Nepal were married, although legal minimum age for
marriage is 16 in both the countries. Moreover, 44% of 15-19 age are married
according to the 1996 health survey report.
In South Asia, women under 20 years are married. Highest percentage of young
men aged 15-19 who are married is 12 percent in India, and in most developed
countries it is around 2% or 3%. Children bom to adolescent mothers are about .
40% more likely to die during their first year of life than those bom to women
in their twenties. Forty-percent adolescent childbearing takes place before 18 in
African and Latin America, against 31% in Asia.
1.6
Knowledge of FP Methods among Adolescents
There has been sharp increase in the knowledge of family planning methods in
Nepal over the years. The share of currently married women who know about
modem methods was 21% in 1976 which jumped to 98% in 1996.
1.7
Use of Contraceptive among Adolescents
The trend of modem contraceptive use in Nepal has risen steadily over the last
two decades. Current use of modem contraceptives among currently married
non-pregnant women has increased from 3% in 1976 to 29% in 1996. The
survey indicates that the share of temporary methods has risen from 14% in
1986 to 33% in 1996.
>
1.8
Adolescents Pregnancy and Abortions
Abortion is an illegal phenomenon in Nepal. Anybody, seeking an abortion,
practicing it or willing to be accomplished to such is punishable in accordance
with prevailing laws. There are limited exceptions where the induction of
abortion is permissible after a medical practitioner certifies it on medical
background.
ii
Nepal Country Paper
Nepalese women seek access to abortion for various reasons. The unmarried
woman who finds herself pregnant has the choice of either getting married
rather quickly or terminating the pregnancy at every risk. Any women either
widow or unmarried who became pregnant due to relationships with persons
other than their husband utterly seek abortion to escape from strong social
pressure and abuse.
1.9
Adolescents & Knowledge of STDS, HIV/AIDS
fhe incidence of RTIs and STDs among adolescents has increased markedly
world-wide for the past 2 decades. Gonorrhea, chlamydia, syphilis, herpes,
genital warts and HIV are the most prevalent RTIs/STDs among the teens. Onefifth of people world wide with AIDS are within their twenties.
More than 50% of the female STD patients in Nepal were found to be involved
in commercial sex trade and casual or professional CSWs were identified as the
source of STDs in more than 86% of patients.
2.
National Reproductive Health Strategy for Nepal
2.1
In Nepal, reproductive health is not a new program, rather a new approach which
seeks to strengthen the existing safe motherhood, family planning HIV/AIDS,
STDs, child survival and nutrition programs with a holistic life cycle approach.
This calls for strengthening inter-divisional linkages with the Department of
Health services as well as between other sectors, e.g., education, women's
development, and the legal/justice system. Gender perspectives and empowerment
of women will be built into all relevant program areas.
2.2
The new strategy is consistent with the 1991 Health Policy and 1997-2017 Second
long-term Health Plan. The integrated RH package in Nepal will be delivered
through the existing primary health care system. A substantive gender perspective,
community participation, equitable access and inter-sector collaboration will be
emphasized in all aspects of package;
2.4
The strategy encompasses interventions at various levels. The first level includes
family / decision makers, community / mother’s groups, FCHVs / TBAs, PHC
outreach/EPI outreach clinic, the second level includes SHP/HP, the third level
includes PHCC, and the fourth level includes the district. These levels broadly
envisage information counseling, contraceptive supply and services/referrals.
iii
Nepal Country Paper
1.
RESPONSIBLE SEXUAL & REPRODUCTIVE HEALTH BEHAVIOR
AMONG ADOLESCENTS
1.1
Adolescents in the South Asia Region
In 1996, young people aged 15-19 was estimated at 519 million, with 83% living in
developing countries. By the next century over half of the world's population will live
in urban areas where young people are estimated to have poverty and stressful loss of
family ties. In developing countries, four out of five of world's young people live and
where more than half of population is under the age of 25.
With 28% of the world's population on between the ages of 10 and 24, 1.5 billion
people growing up today will be the leaders, citizens and partners in the future.
Hence, young men and women will become parents of the next generation. In
South-East Asia region, (Bangladesh, India, Maldives, Nepal, Pakistan and Sri
Lanka), more than 30% of the total population is between the ages of 10-24, of
which about 40% are growing into adolescence below the age of 15. Many
adolescents have already married and started own families, but without information
and services which are known to promote healthy and responsible sexual and
reproductive behaviors. More and more young people are suffering from STDs
including HIV, seeking unsafe abortion, resulting into the consequences of early,
close and frequent pregnancies and social problems.
Table-l
Basic Key Indicators of Adolescents Youth in South Asia, 1996
K
....................................................................■
E__............
Total Popn (million) 1997
122.2
NA
969.7
22.6
0.3
137.8
18.7
Teen Popn ages 15-19 (millions)
13.9
0.2
92.7
2.4
NA
14.3
1.9
Average Age At First Marriage
Male
Female
23.9
16.7
23.4
18.7
21.5
17.9
22.1
17.9
24.9
17.6
27.9
24.4
Total Fertility Rate
3.4
6.2
3.4
4.6
6.2
5.6
2.3
% of TFR contributed by ages 15-19
15.0
5.0
9.0
10.0
NA
5.0
7.0
% of Currently Married Females (15-19)
48
38
50
NA
24
7
% Birth of Teenagers
13.0
9.0
9.0
NA
6.0
4.0
% Using Contraception (15-19)
19
19.0
2.5
NA
3.4
20
% Using Contraception (15-49)
40
45
28.9
NA
17.8
66
Sources: - The World's Youth, 1996, Population Reference Bureau, Inc., Washington, DC, USA
- State of World's Population, 1996, UNFPA
1
Nepal Country Paper
1.2
Adolescents Population in Nepal
1.2.1
Adolescents Distribution By Age and Sex
The total population of Nepal was 18.5 million in 1991 against 11.5 million in
1971. The share of adolescent population in the age group of 10-14 was 11.22% in
1971, which increased to 11.36% in 1981 and 12.58% in 1991. The younger male
adolescent group i.e. 10-14 age group increased by 31% (1971-1981) and 32%
(1981-91) while the corresponding figures for the female were 33% and 42% during
the same period. Similarly the older adolescent male population i.e. 15-19 age
group increased by 27% (1971-1981) and 27% (1981-1991) while the increase for
female are relatively higher, indicating rapid growth of adolescent population in
Nepal. (Figure-1).
Figure-1
Distribution of Adolscent Aged 15-19 by Sex
Distribution of Adolscent Aged 10-14 by Sex
1792527
</)
.o
o
TJ
<
2500000X
1800000-/
1600000./
1400000./
1200000./
1000000./
800000./
600000./
J’
'iU4/45y
’695746
547493
O
z
200000./
□ Total
1971
G Male
s
O
Z
-
400000./
1981
2000000. /
w
I
178035
----- &44402-
1500000.7
■
o
o
1000000,/
<
500000. /
■
*
i
^1
1971
1981
■ Male
Year
45W4W----
«/ / jr
594192
0.
□ Total
1991
I
■0^.1
919290
T)
1
1707021
12972-1T
1991
Year
□ Female
□ Female
Sources : - Population Monograph of Nepal, 1995
- Statistical Year Book, CBS, HMG, Nepal, 1991
The distribution of adolescent population shows that the percentage decreases more
or less with increasing age in the hills and mountains. The percentage of both
adolescent boys and girls is higher in the hill in comparison to other ecological
regions. The percentage of adolescent boys and girls in the age group 10-14 is also
highest among other age groups among ecological all the regions (Figure-2).
Figure-2
Distribution of Adolscent Aged 10-14 as Percentage of Total
Population by Sex for Ecological Regions
w
o
Distribution of Adolscent Aged 15-19 as Percentage of Total
Population by Sex for Ecological Regions
44,3-----------------------—
io^-X
13.5
13
12.5
s
O
<
_o
o
10.2. Z'
IO./
9.8. /
"O
97ET
33
9.4
9.4
9.2
o
10.5
Mountain
□ Male
■ Female
Ecological Regions
Mountain
□ Male
■ Female
Source: Population Monograph of Nepal 1995
2
Ecological Regions
Nepal Country Paper
1.2.2 Urban/Rural Situation
The percentage of population in both the areas are greater in the age group 10-14
compared to 15-19. The proportion of adolescent population (10-14) in the urban
areas is 34.4 percent in urban areas, which is slightly higher compared to 30.4
percent in rural areas. Similarly the percentage of male and female population is
also slightly higher in urban areas in comparison to rural areas except for female in
the age group 10-14 (Figure-3)
Figure-3
Distribution of Adolscent Aged 15-19 as Percentage
of Total Population in Urban and Rural Areas
Distribution of Adolscent Aged 10-14 as Percentage of Total
Population in Urban and Rural Areas
13.2
9-5
5
JU
13.
12.8. X
12.6. S
12.4. X
5
12.3
T3
11.8.
11.6.
11.4.
9.8
8.
6.
O
2
Urban
□ Total
0>
4X4-
12.2. X]
12. XI
O
9.3
10.
12.5
Rural
■ Total
Urban/Rural Area
■ Male
■ Male
□ Female
□ Female
0.
Urba n
Rura I
Urban/Rural Area
Source: Population Monograph of Nepal 1995
1.2.3 Adolescent Sex Ratios
Sex ratio, measured as number of men per 100 women, is one of the most important
indicators of women's status. Generally, more boys are born than girls, but more
women survive to old age than men. A preponderance of men over women in the
overall population indicates social discrimination against women, as well as male in
migration. (Meena Acharya). The following Figure-4 shows that the sex ratio
which was 118 in 1971 decreases to 108 in the age group 10-14 in 1991 and the
ratio also decreased in the older adolescent group which was less than the national
average. . Similarly the Figure-4 also shows that the sex ratio is higher in the
younger adolescent 10-14 age group than the older adolescent group 15-19.
2
Nepal Country Paper
Figure-4
Source: population Monograph, 1995 CBS, HMG/Nepal
Adolscent Sex Ratio by Year
T
1991
'______________________
■Sn108
£21
ro
>
.
1981
_________
B 110
-
■ 15-19
17
□ 10-14
___________________
1971
£=£
0
20
40
60
100
80
110
118
140
120
Adolscent Sex Ratio
The age specific sex ratios are greater than one hundred in urban areas and are
greater than those in rural areas. The urban sex ratios are particularly higher in
working age group. This could be mainly due to the male selective out-migration
from rural areas. Among those at age 15-19, most of them might have gone outside
the country for work or study, indicating decreasing trend of sex ratios among the
rural people (Figure-5).
Figure-5
Adolscent Sex Ratio by Urban and Rural Area
1)9
Rural
SO______________ .
112
B15-19
O 10-14
98
Urban
»»
e
90
95
100
105
110
Adolscent Sex Ratio
Source: Population Monograph of Nepal, 1995, CBS, HMG/Nepal
4
115
Nepal Country Paper
1.3
Mean Age at Marriage & Marital Status
Age at marriage is one of the most important proximate determinants of aggregate
level of fertility (Bongaarts and Potter, 1993) and it is also an important indicator of
women's status. The mean age at marriage for female is comparatively lower in
Nepal as compared to other SAARC countries. However, there has been gradual
change in the mean age at marriage during inter census period 1961-1991. The
mean age of marriage is found to have been increasing steadily in Nepal since 1961.
This is an encouraging trend. (Table-2).
Table-2
Trends of Mean Age at Marriage
Mean Age at Marriage
Married among 10-14 Age (%)
15
25
J
17
14
_______ _
18
8
Source: CBS, 1995, pp. 173-190
The mean at marriage for women increased from 15 years in 1961 to 18 years in
1991. The change is more pronounced among young girls between 10-14 years. In
case of young girls between 10-14 years, 25% were already married in 1961 but it
changed over time and as a result 8% (82,000 children at the age of 15 in the
marriage category) of such girls were in married category in 1991. This indicates
that over the 30years, girl child marriage in the 10-14 years group has been reduced
by more than two-thirds. Whereas in 1961, nearly three-fourth of the females in the
age group of 15-19 were married, it declined to just below 50% in 1991. Moreover,
Family Health Survey 1996, (MOH) suggests that 47% of the females are married
by age 17, percentage married increases rapidly between 15 and 16 years.
There exists an inequality by sex in the mean age at marriage. Most of the women
are compelled to get married by their parents even in utter disregard to their
interest. The cultural heritage and religious norms of Nepal still insist the girls to be
married before their first menstruation whereas for male there is no such socio
cultural interference to get married at the early age. The legal age at marriage is 16
years for female and 18 for male (with consent of guardian) and 18 years for female
and 21 years for male (without consent of guardian). However, most of the women
in the hinterland are married before 15 years. Immediate after the marriage most of
the women enter into sexual union and become mother earlier than their legal age at
marriage. Before 20, they have either two or three children in general which have
weakened their health status as well in Nepal (Gender Equality and Empowerment
of Women, Dr Mina Acharya, 1997).
1.4
Marital Status in Rural/Urban Residence
According to the 1991 census report, the proportion of the currently married
persons in urban areas has decreased in 1991 compared with the proportion in 1981.
The proportion of currently married females has decreased significantly compared
to the male counterparts. Table-3 below shows that urban areas (as compared to
rural areas) are characterized by higher proportion of single, lower proportion of
5
Nepal Country Paper
married, lower proportion of widowed and lower proportion of divorced/ separated,
for both men and women.
Similarly in urban areas the proportion of single adolescent girls (31%) is lower
than male counterparts (42%) while in rural areas it is 35% in adolescent boys and
35% in adolescents girls. This is due to the early marriage in rural areas (Table-3).
Table-3
Marital Status among Adolescents in
Rural/Urban Residence
(Percentage)
&
Rural;
’emale
M“e
Female
35
“25
61
66
96
78
92
51
4
21
7
47
42
31
56
61
97
88
95
66
3
5
32
_______
All
Ages
10-14
15-19
Urban
“aH
Ages
10-14
15-19
11
Sources: Population Monograph of Nepal 1995
1.5
Age At Marriage and Age at Menarche
Many countries have raised the legal age for marriage but with little impact,
especially in traditional societies, where the earlier the women start having children,
the more they will be valued in societies. Those who start having children early
generally have more children at shorter intervals than those who embark on
parenthood later.
In Nepal, data on adolescent females show that the proportions of females are
getting married at an early age, showing a decreasing trend over the years. In 1971
and 1981, the proportion of ever married females aged 10-14 was between 13
percent and 14 percent respectively but this has decreased to 8 percent in 1991.
Similarly the proportions of females aged 15-19 getting married has declined from
61 percent in 1971 to 47 percent in 1991. (CBS, HMG/Nepal, 1987 & 1995)
Child marriage exists widely in Nepal although it is illegal. According to a survey
conducted by UNICEF in 1996, about 40% of marriages take place before the girl
reaches her legal age. Likewise, polygamy is also a criminal offence, yet it exists
and is traditionally approved in many parts of Nepal. Since the penalties for
polygamy and child marriages are not very severe, the number of child marriages
and polygamy are increasing in Nepal.
6
Nepal Country Paper
Increasing level of nutrition, in general, lowers age at menarche. In Nepal where
marriage is early the gap between age at menarche and age at first marriage is not
big. However in the absence of national level data this situation cannot be
examined. A recent study reveals that in rural areas of Nepal the age at marriage is
lower than the age at menarche. Only among the women completing 6-years of
schooling or more the mean age at marriage is higher than the mean age at
menarche.
The educated adolescent and youth female populations of Nepal, as in other
developing countries, are therefore, experiencing increasing gap between sexual and
social adulthood as indicated by the declining age at menarche and the rising age at
marriage. This gap represents the non-marital fecundity. During this period,
adolescents and youths are exposed to the risks of unwanted, premarital pregnancy
for more years than previous generations.(Survey Report of Vision 2000, 1998).
1.6
Adolescents Fertility
There is higher adolescent fertility in developing countries than in the developed
countries. There are 171 live births per 1000 woman in Bangladesh, 32 in Sri Lanka
while only 4 in Japan. However, fertility rates for women under 20 are declining,
while number of births to adolescents are increasing. The number of children born
to women under 20 is 4 per 1000 in Japan, while 200 per 1000 in Bangladesh.
During the most recent period (1991-1996), fertility among 15-19 and 20-24 is 1.31
and 2.71 respectively. Fertility rates, despite some visible indication of decline, are
still high in Nepal. The total fertility rate per women was 6.33 in 1976, which
declined to 4.6 in 1996. The decline in TFR is largely attributed to the use of family
planning services. Fertility was observed to be highest among women 20-24 years
(266/1000 women) in 1996 .The annual rate of births per 1000 women in 20-24
years showed a declining trend for the past two decades (Figure-6). Cross-country
comparison shows that percentage of TFR contributed by ages 15 is 10 as against
15 in Bangladesh, 9 in India and 7 in Sri Lanka. (Table-1)
Figure-6
Age Specific and TFR by Age
290
300-ZT
266
248
I
250
200
145
150./
100./
50./
G3 15-19
6.33
0
1976
1981
1986
■ 20-24
Year
□ TFR
Source: NFHS, 1996 (PP 39)
7
1991
1996
Nepal Country Paper
The TFR estimated for 1985-86 seemed to be very low. This could not be accepted
as a real picture because this may be due to data quality problem in the 1986 survey
rather than of a true drop in fertility at that time. The* pattern of age-specific
fertility rates before 1981 indicates that women in Nepal had high fertility at 20-34
years of age with a peak at ages 25-29. From 1986 onwards an earlier peak in
fertility at 20-24 years has emerged. The decline in fertility after age 34 is quite
marked between 1986 and 1996, which indicates some fertility-limiting behavior
among Nepalese women. Fertility trends have to be interpreted within the context of
data quality and sample size. (Family Health Survey, 1996, HMG, Nepal.)
1.7
Adolescent Sexual Attitude and Behaviour
Depending on cultural and social values, there is a variation in the age at which
young men and women begin sexual relations. According to the Family Health
Survey, 1996, among the currently married women aged 15-19, some 63 percent
were sexually active in the last four weeks compared to 67 percent aged 20-24.
Marital sexual activity was reported to be the highest (73%) among women aged 2534. Similarly, 3 of 4 women were sexually active in urban areas compared with 2
of 3 rural women.
According to a study on Reproductive Care, Knowledge, Attitude and Practice
Among Adolescents sponsored by PLAN International in Makwanpur district, there
is a high level of ignorance among adolescent girls about genital hygiene or safe
sanitation practices during menstruation, over two thirds of the adolescent girls
faced some menstruation related health problems immediately before or at the end
of menstrual period. A large majority of adolescent girls mentioned that they were
experiencing some symptoms of urinary tract infection (UTI). One in four
adolescent girls complained about burning with urination, one in eight experienced
foul smelling discharge, and one in 20 complained about sore or ulcer around
genital area.
Unmarried adolescents are becoming more sexually active. One in ten unmarried
adolescent boys of age between 15-19 years are sexually active. More than half of
them (54%) had multiple sex partners. Interestingly, close to half of the sexually
active adolescent boys did not feel themselves to be at risk of contracting STD and
HIV/AIDS and only one fourth (27%) perceived to e at risk of contracting such
diseases.
Similarly, a study conducted by CREHPA among men in five border towns of
Nepal showed that 41% of unmarried adolescent aged 18-19 were sexually active.
Moreover, among the sexually active unmarried men, a large majority (77%) had
their first sexual contact while they were 19 years or below. The mean age of first
sexual contact was 17.9 years. The first sex partner of these unmarried men were
also adolescents, either younger to their age (42%) or the same age (35%). The first
sex partner for one in ten was a commercial sex worker. One in five men of age 1819 have had a non-regular sex partner in the last 12 months preceding the study.
The sexual activity rate is highest in the hill (69%) as compared to other regions.
The activity rate in the mountain region was 67 followed by 67% in terai region.
Sexual activity varies positively with education and ranges from as high of 76%
-
Nepal Country Paper
among women with a S.L.C to a low of 68% among women with primary education
or no education. (Source: .Population monograph, 1995)
Young people's premarital sexual encounters are generally unplanned, infrequent
and sporadic. Data on premarital sexual activity is not available in Nepal, However
recent studies revealed that adolescents are engaged in premarital sex. According
to the survey findings conducted in three districts (Kathmandu, Makwanpur &
Chitwan), it is reveals that premarital sex in Nepal is 19% and 16.2% have extra
marital sex. (Sexual Behavior Pattern In Nepal, Dr.B.L. Gurbacharya and B.K.
Subedi, 1992) Similarly according to Macfarlane (A study of Gurungs of Nepal,
Cambridge, London, 1976) Gurungs enter into sexual union for two to three years
before marriage. Among the high caste Hindus there is a high value placed on
virginity before marriage but for the other ethnic group there is no particular
concern that the bride be a virgin.
1.8
Adolescent Child-Bearing
Problems of adolescent reproductive health are those resulting from traditionally
early marriage of girls that still prevail in many developing countries, including
Nepal. Twenty-five percent of 14 years old girls in Bangladesh and 34 percent of
girls of 15 years in Nepal were married, although legal minimum age for marriage
is 16 in both the countries. Moreover, 44% of 15-19 age are married according to
the 1996 health survey report.
There is the end of schooling for girls and young women when they have child
bearing in most of developing countries. Early pregnancies have a tendency to lead
to large families with serious consequences for their health and well being. Child
bearing before girls’ bodies are fully mature carries risks to both mother and baby
as does going on to have a large number of children-more likely when girls marry
young.
Pregnant adolescents do not get early and adequate prenatal care, which leads to
higher mortality and morbidity. The lower the age of mother, the greater the risk
associated with pregnancy and childbirth. Maternal mortality rate in developing
countries average about 450 per 100,000 live births, compared to 30 per 100,000
live birth in developed countries. Research findings reveal that pregnancy related
deaths are the main cause of death for 15-19 year old women worldwide. Both
infant and child mortality are higher for children of mothers aged under 18 years;
and babies are more likely to be born prematurely and have low birth weight.
Traditionally, teenage childbearing has been common in many parts of the
developing countries.
In South Asia, women under 20 years are married. Highest percentage of young
men aged 15-19 who are married is 12 percent in India, and in most developed
countries it is around 2% or 3%. Children born to adolescent mothers are about
40% more likely to die during their first year of life than those born to women in
their twenties. Forty-percent adolescent childbearing takes place before 18 in
African and Latin America, against 31% in Asia. (Present Status and Needs of
Adolescent Reproductive Health in Nepal, Role of NGOs, H. Khanal, WHO
Workshop, Kathmandu). Of all adolescent married females aged 15-19 about 24 per
Nepal Country Paper
cent bear children. The practice of early marriage is a major factor responsible for
relatively high proportion of teenage child bearing in Nepal.
1.9
Knowledge of FP Methods Among Adolescents
There has been sharp increase in the knowledge of family planning methods in
Nepal over the years. The share of currently married women who know about
modern methods was 21% in 1976, which jumped to 98% in 1996 (Figure-7). The
level of knowledge is so high in Nepal, and there is little difference by age groups.
The high level of knowledge is a result of the successful dissemination of FP
messages through the mass media.
Figure-7
Percentage of Currently Married Women Who Know at Least one
Contraceptive Method by Age
96.9
98.7 98 4
92.7 92.6
100 .X
90. /
■D
O
£0)
S
Q.
OT
.£
$o
c
<-<
o
Q
Q.
□ 15-19
■ 20-24
80./
70./
60./
50.1
52
51.9
50./
40./
30./
20./
10./
0.^
I
1981
1991
Year
□ All ages
Source: l.NFHS, 1996 (PP 51)
2. FFPHS, 1991(PP 102)
3. CPSR, 1981(PP83)
10
1996
Nepal Country Paper
The share of adolescents who have ever heard of family planning is about the same
as those of women of reproductive age. The sources of FP knowledge for all
adolescents as in the case of women of reproductive age consists largely of mass
media (Radio, Television) and print media (Newspapers, Posters, Booklets,
Pamphlets etc)
The family planning program in Nepal has been using the electronic media to
promote contraceptives. The Fertility, Family Planning and Health Survey (FFHS),
1991 reveals that about 35% of the currently married women has been found to be
using the electronic mass media (radio and television) for family planning message.
According to the Family Health Survey, 1996, 11% of ever married women
revealed that they had heard family planning messages on radio or television.
However, radio is more effective media than television in Nepal because television
services are mostly limited to urban areas. Percentage distribution of ever-married
women by age-group whether they have heard a radio and/or television message
about FP according to selected background characteristics, Nepal 1996 could be
seen by the following (Figure-8).
Figure-8
Percentage of Ever Married Women by Source of FP Message
I 47
k5
Heard on Neither
.4
CD
ro
V)
(D
o
1.3
12
Headr on both
a.
I
u
>_
o
Television Only
J
1.6
1.5
1.6
CO
OH 10.1
-BSffijl 42
Radio Only
£^40.6
■ All Age
EJ 20-24
□ 15-19
o
10
20
30
40
50
No of Ever Married Women
(Percentage)
Source: NFHS 1996 (PP69)
More than 40 percent ever married women at age of 15-24 years had heard family
planning messages only on radio, which was slightly, more than overall percentage
of radio. The percentage under the television who had heard family planning
messages remained same compared to overall age group.
There has been significant percentage of ever-married women who were exposed to
family planning messages through the print media according to the background
characteristics. The NFHS Report, 1996 indicated that 23% of women reported that
they had seen a message about family planning in any type of print media, while
22% saw a message in a poster. This indicated that posters play an important role in
transmitting family planning information/messages in Nepal. Younger women (less
H
Nepal Country Paper
than 35 years) are more likely to be exposed to print media than older women (40
years or older). Younger women (20-24 years) received messages about family
planning through newspaper/magazine which is highest (12 percentage) than other
age groups. Similarly, the highest percentage of receiving family planning messages
through poster and leaflet/brochure are 27% and 9% under the age group of 20-24
years (Table-4).
Table-4
Percentage of Knowledge through print media among
ever-married Adolescent, Nepal 1996.
Age
15-19
20-24
All Ages
| Any source
24
29
23
Newspaper/Magazine?.
8
12
8
Poster
21
27
22
Leaflet/brochure
6
9
6
Source: NFHS 1996 (PP73)
1.10
Use of Contraceptive Among Adolescents
The trend of modern contraceptive use in Nepal has risen steadily over the last two
decades. Current use of modern contraceptives among currently married non
pregnant women has increased from 3% in 1976 to 29% in 1996. The survey
indicates that the share of temporary methods has risen 14% in 1986 to 33% in
1996. This is because the more women are now using contraception to space rather
than limit births (Table-5).
Overall 25% of current married women were using a modern FP method in 1991,
of which, about 24% of currently married, non pregnant women, were using a
modern FP method while only one percent of the women were using the traditional
methods (withdrawal and abstinence). About 29% of currently married women in
Nepal are now using modern FP methods, of which 26 % are using modern
methods and only 3% are using traditional methods. Thus it is cleared that the
increase in overall percentage of currently married women using FP methods led to
increase the percentage of both methods (modern and traditional) over the period of
1991 to 1996.
Among individual methods, female sterilization has gained tremendous popularity
over the years. Only 0.1 percent of currently married, non pregnant women were
reported to have been sterilized in 1976 and this increased to 13 percent in 1996.
Likewise the male sterilization recorded as 2 percent in 1976 and this increased to 6
percent in 1996, a three times increase in 20 years period (Table-5).
12
Table-5
Percentage of Currently Married Non-Pregnant Women
Currently Using Contraceptive Method
Method
_______
Any modern method
Female Sterilization
Male Sterilization
NFS 1976
2.9
0.1
1.9
NCPS 1981
7.6
2.6
3.2
NFFS 1986
15.1
6.8
6.2
NFHS 1991
24.1
12.1
7.5
NFHS 1996
28.8
13.3
6.0
Source: /. Nepal Family Health Survey, 1996 (pp 55)
2. Fertility, Family Planning & Health Survey, 1991 (pp 108-111)
Iniectables & pills were the most commonly used methods among adolescent and
vouth in 1991 whereas in 1996 it was condom and withdrawal. It is therefore clear
that most of the women at age 15-19 switched FP method to condom and
withdrawal from injectables and pills, it was just reverese compared to the practtce
in all other age groups. The main reason behind this is the shift FP methods on
condom and withdrawal were lack of proper specific methods among,adolescents.
This reflects the fact that the adolescents in Nepal are in dire need of counseling on
family planning methods. Figure 9 below gives the method-wise use of
in 1996.
contraceptives among currently married non-pregnant women
\.
Figure-9
Method Mix of Contraceptives used by Married Wonmen of Age
15-19 (1996)
0.3
I
■ Hi
--------- (M-
□ Pill
□ Injectablcs
□ Dia I’hragin
□ Condom
□ F.Stcrilization
□ M. Sterilization
□ Traditional
1.11
Need for FP Services
Although, the knowledge of FP among adolescents is found to be as equal as that
among women of reproductive age, yet the use of contraceptives by this age group
(15-19) has been significantly low. The use of FP among adolescents of 15-19 age
'
2.5 ,per centt in
group
was 2.5
i 1991- which
----- increased to 6.7 in 1996 (NFHS, 1996). The
pattern of current use by age shows a peak at age 35-39 in both in 1991 and 1996
period. While at age 15-19 and 20-24 falls lowest percent in the year 1991 and
1996 Current use also varies markedly by the level of education. Women who have
never been to school are less likely to use than the women who have been to school.
Use of contraceptives is more prevalent among women than among men and there
are more urban women acceptors than rural women acceptors.
13
Nepal Country Paper
The following Table-6 reveals that in 1991 the unmet nee of FP among the 15-19
age group was 25% which increased to 41%in 1996, while the contraceptive use
was 2% which increased to 7% during the same period. Likewise, under the age of
15-19 among currently married women 47 percent expressed demand for FP in
1996 whereas in 1991 it was 28 percent. However, only 8 per cent of women 15-19
years are currently using contraceptives were satisfied in 1991which increased to 14
per cent in 1996. All this is indicative of the fact that counseling and provision of
FP services are required more than what is actually available at present for
adolescents in Nepal.
Table-6
Percentage of Currently Married Women with an Unmet Need/Met Need
for FP and the Total Demand for FP Services
Unmet Need for FP
Met Need for FP
Total Demand for FP
Percentage of Demand Satisfied
For Spacing
All Methods
For Spacing
All Methods
For Spacing
All Methods
1991
15-19 _ All Ages
24
12
25
28
—1
~2
2
23
26
14
28
8
51
45
_____ 1996
15-19
All Ages
39
14
31
41
—5
7
44
47
14
29
17
60
48
Source: 1. FFPHS 1991 (PP 83)
2. NFHS 1996 (PP 94,95).
1.12
Adolescents Pregnancy and Abortions
WHO has estimated that there are 20 million illegal and 30 million legal abortion
every year worldwide. In South Asia (mainly India), South East Asia and Latin
America, there are 4 to 7 million abortions annually.
Abortion mortality is estimated to be about 70,000 women globally per year. The
data on abortion among adolescents are scarce at cross-country levels. In a study
conducted in the Mohammedpur Fertility Centre in Bangladesh, persons aged
between 15 and 24 years constituted more than 30 percent of the total menstrual
regulation clients.(Adolescence, The Critical Phase, The Challenges and the
Potential, WHO, 1997)
Research studies around the world indicate that poorly-timed pregnancies have
serious bearing on the health of both mother and child. Pregnancies occurring at too
young an age (younger than 20) or too old an age (40 and above) are risky for both
the child and the mother and the infant mortality rates are much higher than when
the mother is 20 to 39 years old. Today, in Nepal about 5% of all births occur to
mothers younger than 20 or older than 40 (Population and Development in Nepal,
March 1995).
Although, the legal age at marriage in Nepal is 18, about 60 percent of marriages
take place below 18 (Ministry of Health, HMG, Nepal, 1993). A girl in Nepal may
bear her first child when she is 14 or 15, while the years between 20-30 is
considered to be the safest period for childbearing.
14
Kepiil Country Paper
Abortion is an illegal phenomenon in Nepal. Anybody, seeking an abortion,
practicing it or willing to be accomplished to such is punishable in accordance with
prevailing laws. There are limited exceptions where the induction of abortion is
permissible after a medical practitioner certifies it on medical background.
Nepalese women seek access to abortion for various reasons. The unmarried woman
who finds herself pregnant has the choice of either getting married rather quickly or
terminating the pregnancy at every risk. Any women either widow or unmarried
who became pregnant due to relationships with persons other than their husband
utterly seek abortion to escape from strong social pressure and abuse.
Although abortion is legally restricted in Nepal, yet there have been sufficient
practices of abortion al the backdoor. Unqualified persons perform most of the
induced abortion cases with crude and primitive methods. However, the adequate
data and information are not available on the types, specific age group reasons for
abortion and use of contraception, post abortion health complications etc. The IIDS
(Research Institution in Nepal) conducted a study on abortion through interviewing
1241 women at hospitals or private clinics in Kathmandu Valley. The study
revealed that 65% of the abortion cases were spontaneous because of overwork
inside and out side homes; 7.2 percent induced abortion as a result of the women
working as paramedics without any formal training using traditional herbs
domestically; 11.2 percent induced abortion in higher income groups through
registered private nursing home; 11.1 percent induced abortions performed by
untrained paramedics and TBAs outside their homes.
The study being confined only to the hospitals and private clinics in Kathmandu
valley does not represent the real picture portraying abortion in the country. There
might be tremendous cases of unsafe abortion in Nepal.
Another hospital-based Abortion Study conducted in Nepal, during one year period
of 1984-85 reported 124 cases as induced abortion, of which, 41 cases were
possibly induced cases. The survey also revealed, the higher proportion of all cases
of induced abortion was 30-34 age groups, and the smallest in less than 20 years
age group. The age specific data according to the Survey indicated that the
percentage of abortion cases was 6.7% in less than 20 years, and 20% in 20-34
years.
An Article on a study of Abortion Practices in Rural Nepal published in Journal of
Nepal Medical Association in 1994, interviewed 13,229 women in reproductive age
group (15-49). Out of the total pregnancies, 22 were terminated through induced
abortion during six months study period. Asides from these 22 cases, 87 percent
abortions were reported to have taken place some times in two years preceding the
survey. The survey identified a total of 109 induced abortion cases for a period of
approximately 30 months from among the 13,229 women of reproductive age. Of
the 22 prospectively identified cases in the six months surveillance period, 50
percent were in the age group 25-29.
The most frequently cited reasons for undergoing abortion was economic burden
due to large family size (68%). Desire for spacing for the next birth was the reason
for 8% of the women. 10% gave poor health as the primary reason and 9% did not
15
Nepal Country Paper
want to continue the pregnancies because of being unmarried or widowed. The
remaining 5% cited miscellaneous reasons for terminating.
In Nepal, legislators have declared induced abortion a criminal act under all
circumstances, punishable by imprisonment of both the women undergoing abortion
and the abortion service provider. Because of this restrictive legal status, only a few
Nepalese women can obtain medically safe abortion services provided covertly in
various medical clinics in urban areas or provided legally in neighboring India.
Understandably, majority of the women have to resort to clandestine abortion
services available through folk practitioners.
1.12.1 Children Born To Adolescents
The NFHS Report, 1996 reveals that one teenage among five women has at least
one child. About 15 percent have one child and 4 percent have two or more child.
The proportion of teenage women who have two or more child is negligible until
age 18 and then increases substantially to 12 percent among women age 19. (Table-
Table-7
Percent Distribution of Women 15-19 Number of Children
Ever Born (CEB), Nepal, 1996
Age
15
16
17
18
19
All
ages
0
98.9
93.6
85.0
68.8
55.9
81.3
2+
0.0
1.1
1.8
4.7
12.4
3.7
Total
100
100
100
100
100
100
Source: NFHS, 1996 (PP 47)
Adolescent fertility is a major social and health concern. Teenage mothers are more
likely to suffer from severe complications during pregnancy and childbirth, which
can be detrimental to the health and survival of both mother and child. The Table-8
below presents the percentage of women aged 15-19 who are mothers or who are
pregnant with their first child by selected background characteristics. Overall, 24%
of adolescent women age 15-19 are already mothers or are pregnant with their first
child. The practice of early marriage (almost 44 percent of women age 15-19 are
already married) is the major factor accounting for the relatively high proportion of
teenagers who have begun childbearing, particularly in their late teens. The low
level of early teenage childbearing is largely due to the proportion of young
teenagers who are currently married and partly due to adolescent subfecundity.
16
Nepal Country Paper
Table-8
Percentage of Women 15-19 who are mothers or pregnant with their first child,
by selected background characteristics, Nepal, 1996
J
Aoe
Percentage who .are
Pregnant wi.l, lst
emm
2
5
8
5
7
Mothers
___________
r
15
16
17
18
19
Percentage who
have
6
15
31
44
b£E±ld
3
12
23
36
51
Source: NFHS, 1996, p.47.
1.12.2 Maternal Mortality and Nutrition
NFHS report 1996 reveals that there is strong relationship between certain
characteristics associated with fertility behavior and children's survival chances.
The probability of dying in infancy is much greater for children born to mothers
who are younger than 18 years or too old (over 34 years) at the time of delivery. If
they are born after a short birth interval (less than 24 months after the previous
births), or if they are born to mothers with high parity the probability of dying in
infancy is much greater for children born to mothers.
Maternal mortality in Nepal is one of the highest in the world. The maternal
mortality rate, which is the annual number of maternal deaths per 1000 women age
15-49 for the period 1990 - 1996, is 0.875. Similarly the maternal mortality rate in
annual number of maternal deaths per 1000 women age 20-24 and 15-19 for the
period 1990-1996 is 0.952 and 0.864 respectively which is higher than other age
groups. The maternal deaths accounted for 27% of all deaths to women age 15-49
years. The maternal mortality ratio for Nepal for 1990-1996 is 539 deaths per
100,000 live births or 5 deaths per 1000 live births. It is not surprising that women
in Nepal have lower life expectancy than men. The main reasons are early
marriage, do not get early and adequate prenatal care and unwanted pregnancies
especially among adolescent. (Table 9)
Table-9
Direct estimates of maternal mortality for the period
0-6 years prior to the NFHS, 1996, Nepal
Age15-19
20-24
15-49
■ Mortality
0.864
0.952
0.875
Source: NFHS, 1996 (PP 157)
17
toTema
30
42
27
Nepal Country Paper
The nutritional status of most rural Nepali women of childbearing age is extremely
low. While in some communities, pregnant women are known to consume special
foods especially if their families are relatively wealthy, in general women are not
acknowledged to have special dietary needs during pregnancy.
Micro-level studies have shown that rural Nepali women work an average of 14 to
16 hours per day, and the work load remains relatively the same even during the
pregnancy. Nutritional anaemia is one of major contributors to the high maternal
mortality rate in Nepal.
The adolescent girls have tremendous nutritional deficiencies, which may affect
their children, resulting in infant's low-weight birth, disabilities or death. As they
grow older, repeated pregnancies, anemia, continued malnutrition and excessive
workload can result in early death, and Nepal is one of the few countries in which
women's life span is shorter than men's (Situation Analysis of Women and Children
in Nepal, UNICEF, 1996
Nepalese society has been tremendously influenced by son preference. Son has been
regarded as economic insurance against the insecurities of old age, while daughters
have been treated as all-time liability to the parents as they are to be given away in
marriage. Although receiving the same care and nutrition as boys when infants,
older girls often receive less health care and less food, resulting in their higher
mortality and morbidity rates than boys. In middle and late childhood, they assume
a large share of domestic responsibilities, including sibling care, often to the
detriment of their education and social participation.
1.13
Adolescents & Knowledge of STDS, HIV/AIDS
The incidence of RTIs and STDs among adolescents has increased markedly world
wide for the past 2 decades. Gonorrhea, chlamydia, syphilis, herpes, genital warts
and HIV are the most prevalent RTIs/STDs among the teens. One-fifth of people
world wide with AIDS are within their twenties.
More than 50% of the female STD patients in Nepal were found to be involved in
commercial sex trade and casual or professional CSWs were identified as the source
of STDs in more than 86% of patients.
A large number of young girls are trafficked out of the country to different brothels
in India and other South East Asian countries. They return home after they are
found to have RTI/STD or AIDS. Moreover, many young girls and boys have
migrated frc rural areas for better livelihood in garment and carpet industries,
where they are exposed to infection of RTI/STD and HIV.
>
As of April 1998, the total number of HIV/AIDS cases accounted for 1050 in
Nepal, of which 34.4% female had HIV positive and AIDS. The highest percentage
of HIV positive and AIDS were recorded on 20-29 age groups (58.6%) in both
sexes followed by 30-39 age (20.4%) and 14-19 (16%) age groups However, the
possibility of HIV Positive and AIDS under the adolescent of youth groups is higher
due to girls trafficking and premarital sex (Figure-10).
18
Nepal Country Paper
Figure-10
HIV/AIDS Situation of Nepal by Age and Sex
April 30,1998
1200 sy
1050
1000./
3
5
3
o
800./
689
□ 6-13
600. /
0 14-19
361
400
□ All Age
168
47
-rrn
Male
Female
200.
Jfl I
Total
Sex
Source: National Centerfor AIDS and STD Control, Kathmandu, Nepal
The adolescents receive knowledge about HIV/AIDS largely through mass and print
media. Accordingly, 27% of ever-married women have heard of AIDS. Women in
the younger age group (15-19) are more likely to have heard about AIDS than
woman in the older age group. Urban women and women with some education are
three times more likely to have heard of AIDS than rural women who have never
been to school. Knowledge of AIDS is very high among women who have
completed secondary school. The most common source of information is the radio
reported by 79% (Figure-11).
Figure-11
Source of Knowledge about HIV and AIDS
15.1
Other
i 20
c
E
Health Worker
f 1.6
7.9
5127.7
Printed Material
2 8.2
a
"o
w
u
o
CZ3
26
2~~] J,)-4
TV
M ^6.8
22.9
15.3
Friends/Relativs
,
.......
78.7
|
80.8
79
Radio
T
0
10
□ All Age
H20-24
20
30
40
50
Percentage
Source: NFHS, 1996 (PP 161)
19
60
70
80
90
0 15-19
Nepal Country Paper
1.14
Exploitation among Adolescents
1.14.1 Adolescents and Prostitution
Nepal has a culture of traditional prostitution like Deuki & Badini. In the culture of
some of the ethnic groups, the parents or rich people offer young girls to the
temples. These girls (deuki), are deprived of their rights to marry as they are not
accepted by the communities for this purpose and they eventually become
prostitutes.
South Asian cultural practices unfortunately support sexual abuse and commercial
sex particularly among adolescent girls as young as ten years or so. These are
common in Badi and a few other communities in Nepal. In India, child sex is a
rapidly growing business where nearly 500,000 children are prostitutes before they
are 15 years old. Ironically, the scare of killer AIDS virus has given rise to an
increase in demand for supposedly "uninfected” children. Most of these children
belong to the schedule castes. Most come from the southern states of India and
West Bengal. Less than three percent are from Nepal and Bangladesh (Alyar, S.A.,
Child Prostitution: A symptom of our sick society. The Times of India, April
16,1997).
Girl trafficking is one of the major forms of sexual exploitation in Nepal. Every
year, a large number of girls of Nepalese origin are trafficked to India and other
parts of the world for prostitution. The Nepalese girls working as commercial sex
workers in India are estimated at 200,000. (Durga Ghimere, Red Light Traffic,
Trade of Nepali Girls, ABC, Nepal, 1994).
Factors responsible for girls trafficking include poverty and hardship, lowest status
of girl child, lack of employment opportunities, tradition and culture, modernization
and development process, highly lucrative business and open border.
Parents are reported to be involved in the trade of their daughters, teenage girls
from poor and disadvantages communities of certain areas are vulnerable targets. It
is reported that these girls are sold in Indian brothels upto Rs.70,000. According to
same reports, some ethinic groups as Tamang & Rai are particularly at risk. 40% of
the girls sold in the Indian brothels are under the age group of 18 years. (Madhavi
Singh, cheli beti ko bartaman abastha).
i
There are also a lot of women working as commercial sex workers in Kathmandu
and other major towns of Nepal. According to a Article published in Journal of
Medical Association of Nepal, 1994 (Shyam Thapa & Puspa Bhatta), the average
age of CSWs working in the Kathmandu Valley is 21 years, about 42% are in the
age group of 15-19 and 39% are in the 20-24 age groups, indicating that majority of
the CSWs belongs to unmarried groups.
According to another study on Commercial Sex Workers in Kathmandu Valley:
Their Profile and Health Status, Valley Research Group, Kathmandu Nepal, 1993,
over 60 percent of commercial sex workers working in Kathmandu valley were
unmarried and nearly 45 percent were below 20 years of age. For 95 per cent of
20
Nepal Country Paper
those CSWs, the age at first sexual union was below 19 years. For most CSWs the
main reason for entering into commercial sex trade was economic deprivation.
Government has initiated certain measures against girls trafficking in Nepal. Most
of the programs under government agencies on trafficking are preventive in nature,
while non-governmental organizations involved in prevention inter-section and
rehabilitation. The government has adopted certain policy instruments against
trafficking and commercial sex exploitation of children:
•
Public awareness programs against girl trafficking and the flesh trade will be
carried out on a large scale in various districts and villages.
•
Equal laws will be established for women removing unequal laws on them.
•
Programs to control girl trafficking and prostitution will involve HMG, non
governmental organizations, international organizations and the private sector.
•
The Ministry of Women and Social Welfare will be the focal point to carry out
programs against girl trafficking.
•
By establishing bilateral and multilateral cooperation with other countries. HMG
will make efforts to control girl trafficking.
•
HMG will adopt different ways to protect human rights and special rights
regarding women.
•
Necessary programs will be organized to provide payment to children suffering
from sexual exploitation. The people responsible for the children's fate will be
made to compensate.
•
Necessary steps will be adopted to solve problems on girl trafficking, AIDS and
other sexual diseases, which are interrelated with each other.
•
A coordination committee at the district level will function as a communication
center to collect, coordinate and spread news regarding the control on girl
trafficking and prostitution.
•
HMG will establish coordinating committees at the national, district, and village
level to control girl trafficking and prostitution.
•
Provisions will be made to carry out formal and vocational education and skill
oriented programs to control girl trafficking.
Moreover, Ministry of Women and Social Welfare (MWSW) has entered into an
agreement with the ILO- IPEC in November 1997, for a period of two years, with
an objective of combating trafficking and sexual exploju^fitt^fif^children.
Programme in the agreement include:
•
•
Creating National and District Level Task Forces
Preparation of a National Plan of Action
2!
yr1
J
Nepal Country Paper
•
•
•
•
•
Setting up of a rescue/re-integration fund
Reviewing the law and its enforcement
Coordination and networking with GOs, NGOs. donors and
bodies/governments
Recommending action programmes through the National Task Force
Working with GOs and NGOs on Advocacy and awareness creation
Prevention, protection, rescue and re-integration.
regional
1.14.2 Violence Against Adolescents
Violence against adolescents here refer violence against women and girls which
include all forms of violence which includes domestic violence, sexual slavery,
prostitution and international trafficking of women, incest reproductive right,
violence, rape, abuse of women with physical and mental disabilities, sexual
discrimination etc.
A situation analysis of violence of women and girls in Nepal undertaken in 1997 by
SATHI and Asia Foundation at Jhapa, Nuwakot, Banke and Kanchanpur districts
and Kathmandu Valley revealed that beating was the most common of physical
violence against women and girls in Nepal (82%) followed by rape (30%) and
prostitution (28%).
In Nepal, women of all ages, castes, class and ethnic groups are subjected to
physical, psychological and sexual violence. Moreover, domestic violence in Nepal
are child abuse, wife battering, child marriage, polygamy and physical and mental
torture. Since domestic violence is a private affair and unless extremely severe, it
is not considered as a cause for concerns.
The study also indicated that psychological violence was most prevalence in urban
metropolis of Kathmandu: physical violence was seen to be most prevalent in the
hill district of Nuwakot,: traditional forms of violence was most common in mid
western district of Banke. 51 per cent in Banke and 49% in Kanchanpur reported
traditional violence against women and girls practice of Deuki & Badi, the tradition
of jari was also reported by 42% of the respondent of Banke. The highest
percentage (17%) of children assaulted were reported to be male children between
the age of 11-15 followed by male children between the age of 5-10 (10%) and
female children between the age 11-15 (8%). In violence against women and girls,
commercial sex workers are the high-risk groups. Violence normally occurred in
the night under the cover of darkness and on weekends.
Ministry of Women and Social Worker has initiated certain measures for the cause
of women in Nepal, especially after 1994 ICPD. The measures include in
establishment of Home for Destitute Women, A Bill on Domestic Violence.
1.14.3 Adolescents and Drugs Dependency
There are about 50,000 drug dependants all over the country, of which 50% are
from Kathmandu Valley and the rest were scattered all over the country particularly
in Dharan and Bokhara. Among the drug dependence, 75-80 percent were from the
age group 20-29, 15% at the age of 20 and 5% after 29 years of age. Similarly, 6022
Nepal Country J
80% of drug dependence use injection (Tidigesic, Buprenoplint) and r
brown sugar injection.
According to a survey of CABP in relation to risk of HIV and HIV prevalence
among injecting drug users in Kathmandu, in 1994, the average age of drug
dependence was 17 years of age, while the average age at which first injected a
drug was 22 years. According to the sources close to the individuals associated with
the agencies dealing with drug abuse issues, the tendency of drug dependency of
adolescents has been on the increase in the country, and, moreover, if concrete
measures are not intensified with the active support of parents/families,
communities, educational institutions and private and public, the country has to bear
a heavy cost in the future.
1.14.4 Child Labor
According to the 1991 census, the economically active population in the 10-14 age
group was 2.4 million in 1991. However, a 1993 estimates that as many as 60% of
the child population are engaged in some form of labour, totaling about 5.7 million
child laborers in Nepal. Children work in almost all sectors of the rural and urban
economy, with approximately 80% employed in agricultural and other allied
occupations in the country. There are approximately 200,000 children working in
urban areas
Nepal, where 90% of population are rural based, children are generally found to be
participating in the family labor force by necessity and domestic child labor is not
necessarily exploitative, provided it does not deprive children of their rights to
education, etc However. Many children are engaged in labor that is exploitative and
injurious to their well-being. Children work as household servants, construction
laborers, carpet weavers, restaurant servants, tea pickers and porters.
There exists a system of bonded labor in Nepal, under this system children are
forced to work in partial payment of their families' debts to landlords and money
lenders. These children are rarely paid, generally receive little or no education or
health care and have no right to terminate their employment. The Kamaiya is a type
of bonded labor system found in western and far western Nepal. Something around
35,000 are estimated to be working as bonded laborers under the Kamaiya system in
Nepal, of which 6000 are bonded child laborers.
A recent study indicates that there are approximately 30,000 street children
nationwide, of which 26,000 are children on the street. According to a study
undertaken in 13 cities of Nepal, majority of the children are boys; most of the
children are between the ages of 9 and 16, majority collect and sell recyclable goods
for a living, and no access to education and a high drop-out rate in school are
correlated with children living on the street.
23
Nepal Country Paper
2.
LITERACY AND EDUCATION STATUS
2.1
Formal Education Among Adolescents
2.1.1
There have been tremendous improvements in educational status of both male and
female in Nepal for the past 3 decades. However, the status of male literacy is
higher than female literacy due to the fact that the growth of male literacy has been
greater than female literacy. The overall national literacy rate was 40% in 1991
(Male - 55%, Female - 25%) which was estimated to have increased to 48% (Male
- 66%, Female - 30%) in 1996/1997. The acceleration in the growth of literacy is
primarily responsible for increasing educational facilities geared towards educating
illiterate masses. During 1971-91, the overall literacy has increased three fold
(Figures 12, 13 & 14) and (Tables 10 & 11). The increase behind overall literacy in
the country could be illustrated by massive education programs of the government
through formal and non-formal sectors to provide free education upto secondary
level; scholarship programs for girls to raise female literacy rate; launching of
"Education for All" campaign by the government.
2.1.2 The urban literacy (all ages) increased from 51% in 1981 to 67% in 1991. The
overall male literacy increased by 17% from 61.1 percent in 1981 to 78 percent in
1991, the increase in overall female literacy was also 17% (38.2 percent in 1981 to
55 percent in 1991). The gain in the literacy rate during 1981-1991 was greater for
males than females in rural areas while such gender bias was not observed in the
urban areas. The higher literacy rate in the urban areas is due to greater necessity of
being literate in the urban areas, greater access to educational facilities and tendency
of educated rural people to migrate to the towns.
2.1.3 There is an increasing trend of literacy rate of male and females in the age range of
6-11 in both rural and urban areas. After age eleven, the rate shows declining trend.
Among the age groups, the highest literacy rate is found in the 10-14 age group. In
1991 the literacy rate in this age group was 61 percent in rural areas against 83
percent in urban areas. (Figure-21). At ages 15-19, the rate in rural areas was 52%
and that in urban areas was 79%. Generally there are greater differences in the
literacy rate by gender in the rural areas compared to urban areas. For the younger
adolescent age group (10-14), the rural literacy rate for male was 74.8 percent and
for females the rate was 47 percent, whereas in urban areas the male literacy rate
was 88 percent and the female literacy was 78 percent.
Figure-12
Literacy Rate Among Adolscent Aged
10-14 by Age
Literacy Rate Among of Adolscent Aged
15-19 by age
76
3ro
or
BO^-Z
80^
70./
70./
60./
50./
50.8
60. /
49.3
O)
35.8
38.8
CD
0)
10.
10
__ :
□ Female
30.
20.
20
■ Male
38.6
>» 40J/
30
□ Total
7ZT
50. /
40 ]/
ro
48.2
0)
1971
0.
1991
Source: Population Monograph of Nepal,
1995,CBS, HMG/Nepal (pp282)
1971
□ Total
■ Male
□ Female
24
1981
Year
1991
f
Nepal Country Paper
Figure-13
Rural Literacy Rate Among Adolscent
Aged 10-14
(1981-1991)
Rural Literacy Rate Among Adolscent Aged
15-19
(1981-1991)
70
70 -/
60./
■4T
O
nj
46_________
fM
0)
37^
tr
ro
or
ro
<D
y' j
• B:
EJ Male
30.
1
5 20. /
10.
1981
□ Total
31
>>
M-
1991
0
i:
1981
1991
■ Male
□ Female
-3S-
/I - -I
□ Total
Year
52
Year
□ Female
Figure-14
Urbanl Literacy Rate Among Adolscent Aged
10-14
(1981-1991)
93
90/I
80./I 68
0
□ Total
□ Male
PC
88
90./
80./
HL28.
I___
70./
60./
I
Urban Literacy Rate Among Adolscent Aged
15-19
(1981-1991)
o
IF
or
>»
<XJ
a>
60. /
50./
r/ ■
□ Total
1...
^11 IL
X—
1981
GJ Male
Year
A
40. z
30./
20./
0.
1981
73
1991
Year
□ Female
□ Female
Source: Population Monograph of Nepal, 1995, CPS, HMG/Nepal.
2.1.4 The distribution of adolescent population by level of education and by age and sex
indicated that there was an increasing tendency in the proportion of adolescent
population who were literate but had no formal education. This revealed that trend
of people learning to read and write on their own was on the increase over the past
three decades.
2.1.5 Similarly the proportion of adolescent population who had gone through primary,
secondary and who had done S.L.C and studied up to Intermediate also shows
increasing trend. This is evidently due to the expansion of educational facilities in
the country. Graduates and Post-graduate persons constituted a small portion in both
the census years. There has been considerable improvement in different level of
educational attainment during 1981-1991. In all the age groups the proportion of
persons with different educational attainment levels was higher in 1991 compared to
1981. This was true both in male and females. (Table 10)
25
Nepal Country Paper
Table-10
Percent Population by Level of Education Among Adolescents
1981
15-19
4.32
5.32
3.21
12.93
18.46
6.85
14.60
22.00
6.45
1.69
2.33
0.98
0.07
0.10
0.05
10-14
No Schooling
Primary(l-5)
Secondary(6-10)
SLC/lntennediate
Graduate
Level Not Stated
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
Total
Male
Female
3.49
4.12
2.76
29.37
38.71
18.47
5.87
8.17
3.44
0.12
0.02
0.01
All ages 10-14
5.50
6.95
8.13
7.28
2.75
6.59
1 1.33
44.24
15.65
53.56
6.80
34.14
4.80
10.34
7.55
13.29
1.92
7.14
1.23
0.02
1.98
0.02
0.45
0.02
0.39
0.65
0.13
1.40
1.63
-
Tj?
1991
15-19
7.06
7.33
6.80
15.09
19.37
10.99
27.64
38.33
17.38
3.54
4.88
2.26
0.05
0.07
0.04
1.06
1.20
0.23
1.80
2.53
03
T09
All ages
8.98
12.06
5.95
16.15
21.18
11.19
8.88
12.85
4.97
2.88
4.48
1.31
0.64
1.06
Sources: Population Monograph , 1995, CBS, HMG/Nepal
2.1.6 The proportion of school attendance for different age group in the rural areas was
53 56 percent for 10-14 years, and 26.18 percent for 15-19 years population. The
male attendance rate was also higher than those for females. This is true of all age
groups. Simdarly, the proportion of different age groups (for both sexes) in the
urban areas were 74.6 for the 10-14 years population, 38.04 percent for the 15-19
years population. Highest level of attendance is seen for the 10-14 years population
bOlh11f ^ale 3nd femaIe P0Pulat>°n- The proportion attending school among 10-14
and 15-19 years populations were 78.8 and 42.6 percent respectively for males, the
corresponding values for females were 69.81
in
69.81 and
and 33.02
33.02 percent
percent. mhip
(Table 11)
Table-11
Proportion of Adolescent Population with below
SLC level of Education by current status of School Attendance,
Sex & Age for Rural/Urban Areas, 1991
Not Attendance ^School b
Sex
Both Sex
Male
Female
Age Group
10-14
15-19
10-14
15-19
10-14
15-19
Rural
’ 54
26
67
38
40
15
Urban
~5
38
79
43
70
33
WKfiendeffl
but Attended earlier (%) • vnC
Rural
3
15
4
19
3
12 ~
Urban
16
4
17
3
16
..
Sources: Population Monograph, 1995, CBS, HMG/Nepal (PP 396,397)
26
Rural
3
7
3
8
3
6
Nepal Country Paper
Gender disparity is more evident in secondary than in primary education. Girls
comprise only 33% of lower secondary students and 30% of all secondary students.
There has been high rate of drop-out in both age groups of male and female
students, specially in secondary schools. The drop-out is particularly severe in the
case of girl students. The drop-outs are attributed by the following factors:
•
The drop-out rate at the primary school level because children are an important
workforce in a impoverished rural society.
• Schools, particularly above the primary level are often located far from
children's houses, which discourages some from attending school.
• Caste discrimination is a major reason among lower caste groups for staying
away from schools or dropping out after a few years.
• Many poor parents are found to have been unable io pay for the costs of
uniforms and textbooks.
• There is a tradition in Nepalese society that girl children must look after
domestic chores and child care activities.
• Many families hold the traditional view that a girl’s education is unnecessary
and economically unfeasible as she will be given in marriage, usually at a very
young age.
2.2
Non-Fonnal Education
2.2.1
The execution of non-formal education programs has been stressed in educational
and national development policies for the past many years. Literacy is a basic need
of the people, it enables people to communicate effectively and raise the
productivity of the work they are engaged in. The goal of the non-formal education
program of the government are to
provide basic skills in reading, writing as necessary
provide information essential to daily life on topics such as agriculture,
health population, education, sanitation, forestry, environment
facilitate on increase in adults’ self confidence and awareness
supplement the formal primary school system to reach primary school age
children who cannot utilize the formal system with an emphasis on serving
the needs of girls
strengthen the literacy skills by providing post literacy materials to the
literate.
2.2.2 The Ministry of Education (MOE) has been implementing literacy programs for
adults (15-49 years) and also of school programs for children who cannot afford to
attend the formal schools. The literacy course is of six months duration. Moreover,
27
~
'
Nepal Country Paper
population education is included for the general body of the adults as well as
workers in organized and semi-organized sectors.
2.2.3
The government of Nepal has adopted several policies and strategies in order to
increase the literacy rate, non-formal education schemes, particularly literacy
programmes implemented on a national campaign basis. For out-of-school children
6-14 years of age, education will be provided through non-formal approaches such
as 'cheli-beti' and 'sikchha sadan' programmes.
2.2.4 Non-formal and literacy education aims at providing educational opportunities to the
children of 8-14 years of age group who missed primary school. Graduates of these
NFE programmes are encouraged to enter into regular primary schools. The adults
of 15-45 age group are also taught. In addition, functional knowledge and skills are
imparted in order to build self-confidence and raise their standards of living. In
these programmes women deserve special priorities.
2.2.5 The neo literates are provided with additional opportunities of learning in order to
retain, apply and continue their literacy skill and functional knowledge through post
literacy and continuing education progrrammes. A provision is made to link such
programmes with development activities operating at the local level.
2.2.6 The implementation strategies of such programmes are based on local participation.
Therefore, local communities are involved in collecting base line data, coordinating
activities of various agencies and directing their involvement at the implementation
level. The literacy campaign as a main strategy, is being implemented gradually in
all districts. GOs, NGOs and INGOs have been mobilized to participate in such
programmes.
2.2.7 Poverty, children's work obligation and the rigidity of the formal system of
conventional education have been identified as reasons for non-enrolment and low
retention in primary school. Recognizing these realities, non-formal approaches to
education have been introduced to make education available to children, in
particular girls, who are unable to attend primary school.
2.2.8 Classes for out-of school children, specifically girls aged 8-14 years, first started
through the Seti Education for Rural Development Project, popularly known as the
"cheli beti" programme. Subsequently the Primary Education Project introduced the
"Siksha Sadan" functional education programme for both boys and girls. Bal Siksha
classes for out-of school children, particularly girls and children of disadvantaged
caste and ethnic minorities were introduced in 1989.
)
2.2.9 The objective of the Bal Shiksha programmes is to provide children an opportunity
to join primary schools at the Class Two and Three levels or to complete primary
equivalent education if they are unable to attend school. Bal Shiksha coverage
expanded from 45,000 in 1992/1993 to over 70,000 in 1994/1995. However,
preliminary findings from the 1995 Bal Shiksha Tracer study indicates that only 50
percent of those enrolled in these classes are girls. (Children and Women of Nepal,
A Situation Analysis, 1996, HMG/Nepal, UNICEF Nepal. Therefore efforts are
being made to increase their enrolment. At least 70 per cent enrolment of girls is
desired.
28
Nepal Country Paper
2.2.10 The trend in literacy rates shows that remarkable progress has been made since
1950 when the literacy rate was estimated al 2 percent. However, the national aims
to reach all adults in the 15-45 age group by the year 2000. This involve providing
education to over eight million illiterates. Of these, nearly 500,000 persons were
reached during 1995/1996 through various adult education programmes including
those for women. (Women & Children of Nepal: Situational Analysis)
2.2.11 Between 1952 and 1995. the male literacy rate increased from 9.5 to 57 percent,
while female literacy rates only increased from 0.7 to 23 per cent. Although the
data indicates that significant progress has been made, the fact remains that with the
rapid growth of population, the absolute number of illiterate adults, especially
women, has increased over the years.
2.2.12 The lack of education for women limits their awareness of the importance of
learning for their children. Unless women are educated, efforts to open up learning
opportunities to children from poor families are not likely to succeed.
2.2.13 At present, approximately 280 non-governmental organizations, including
community based,
are coordinated with the Non Formal Education Council
Secretariat. In 1991, with the change in political environment, the strategy of the
campaign was redirected in order to base literacy centers in schools so that strong
linkages are established between the formal and non-formal education systems.
(Children and Women of Nepal, A Situation Analysis, NPC, HMG/Nepal,
UNICEF, 1996)
2.3
Population/Family Life Education
2.3.1
The evolution of population education is directly related to the rapid growth of
population experienced by Nepal. There are several aspects of population situation
that are relevant to population education programs. These are the growing rural to
urban migration, continuing high fertility rate, relatively low family planning
practice, high infant death and low life expectancy level. In Nepal the total
population of the country was found to be 18.49 million in 1991 and the compound
annual growth rate of population was 2% over the period 1981-91. The population
growth rate has come down considerably over the 1981-91 period. Various factors
such as wider spread of education, a rise in age at marriage, greater acceptance of
family planning as reflected in the increase in contraceptive prevalence rate, greater
awareness of population and environmental problems, as well as growing
competitiveness in securing jobs may have accounted for this decline.
2.3.2 Population education programs have been implemented in the country since 1980
with the objectives of developing in the students and participants of formal and nonformal education programs an insight into the inter-relationship between population
growth and social and economic development, and developing proper attitudes and
behavior in the teachers, students and community at large towards population
issues, as well as to institutionalize population education in formal and non formal
education programs. A number of government agencies and educational
organizations have been involved in population education activities for over a
decade. The introduction of population education in the education system is more
than a response to the population policy. It is also stressed in realization of the need
29
Nepal Country Paper
and role of the education system in contributing to development efforts of the
country. It is strongly felt now that education can serve as means of creatine
awareness of the population issues and modifying social values in regards to family
size and other population issues. Hence. Population Education and Environment has
been made compulsory subject at lower secondary level.
2.3.3 Under the MOE, office of population education coordinator was established in 1983
in response to the need of coordinating the population education programs of
different agencies in the formal education sectors. The long-term objectives briefly
are contributing to attainment of population policy goals of the government, to
develop awareness and desirable attitude & behavior among students, teachers and
community towards population and development issues and to institutionalize
population education in the education system.
2.3.4
The government has implemented population education program in all of the 75
districts through both formal and non-formal education schemes. The programs
thus seek to provide knowledge about concept of population and designing
curriculum required for both school and university level students. Moreover, the
government also implemented programs for the promotion of family health and
welfare through the involvement of primary school teachers. The project was
implemented in 20 Tarai districts for a period of 3 years (1994-1997). The program
aimed at creating awareness about the benefits of late marriage, delay of the first
pregnancy, use of FP methods, birth spacing and MCH care. Moreover, at the
lower secondary level the teaching of health and physical education has been made
compulsory, which includes A1DS/STD and reproductive health.
2.3.5 NGOs like FPAN implemented the family life education programs for quite some
time. However, these programs sought to impart education through group
discussion, lectures and orientation relating to population issues, family planning
needs, nutrition, breast feeding, sanitation and environment. The target groups for
these programs were mainly women of reproductive age. After the 1994 ICPD
conference, FPAN adopted a new strategy and designed programs on reproductive
health and sex education. Family life education centers to be established by FPAN
aim at providing information and services pertaining to young people’s needs to
deal with the realities of their lives.
)
3.
STRATEGIES & PROGRAMMES FOR ADOLESCENTS
3.1
ICPD and After
3.1.1
Until quite recently, the health program of the government of Nepal was being
implemented in utter disregard to the issues pertaining to the adolescent
reproductive health. Despite the fact that adolescent population constitutes a
significant fraction of the total population in Nepal, adolescents are found to have
been facing serious difficulties relating to early child bearing, unwanted
pregnancies, sexually transmitted diseases, social and economic hardships.
Adolescents have not been recognized as a priority target group and are not
reflected as such in national program.
30
Nepal Country Paper
3.1.2 In relation to the needs of adolescents, the ICPD sought to address adolescent
sexual and reproductive health (unwanted pregnancy, unsafe abortion, STDs and
H1V/AIDS) through the promotion of responsible and healthy reproductive and
sexual behavior and the provision of appropriate services and counselling suitable
for that age group.
3.1.3 In line with the overall approach of the ICPD, the government of Nepal recognized
the need for improving the reproductive health services in Nepal. As a first step
towards this end, a national workshop on reproductive health was organized in
March 1996 in Kathmandu. This workshop evolved a strategic framework for
reproductive health services to make operational. The workshop identified a
reproductive health package, coordination mechanism and indicators for monitoring
the reproductive health activities for Nepal. Eventually, the government of Nepal
has now been able to formulate a national policy and strategy for reproductive
health.
3.2
National Reproductive Health Strategy for Nepal
3.2.1
In Nepal, reproductive health is not a new program, rather a new approach which
seeks to strengthen the existing safe motherhood, family planning HIV/AIDS,
STDs, child survival and nutrition programs with a holistic life cycle approach.
This calls for strengthening inter-divisional linkages with the Department of Health
services as well as between other sectors, e.g., education, women's development,
and the legal/justice system. Gender perspectives and empowerment of women will
be built into all relevant program areas.
3.2.2 The new strategy is consistent with the 1991 Health Policy and 1997-2017 Second
long-term Health Plan. The integrated RH package in Nepal will be delivered
through the existing primary health care system. A substantive gender perspective,
community participation, equitable access and inter-sector collaboration will be
emphasized in all aspects of package.
3.2.3 The strategy encompasses interventions at various levels. The first level includes
family/decision makers, community/mother’s groups, FCHVs/TBAs, PHC
outreach/EPI outreach clinic, the second level includes SHP/HP, the third level
includes PHCC, and the fourth level includes the district. These levels broadly
envisage information counseling, contraceptive supply and services/referrals. The
types of program interventions at these levels could broadly be classified as follows:
Family Level
•
•
•
•
•
•
Condom promotion
Recognize RTI/STD symptoms and seek care
Parent-children communication
Delay the age of marriage
Families to provide nutritious food for adolescents (in particular to daughters)
Promote girl child education
31
MM-
11^3
§
Nepal Country Paper
Community
•
Information on sexuality and gender information
Increasing awareness of family planning methods, availability of contraceptives,
awareness of the risks associated with teenage pregnancy.
Sub-Health Post/Health Post
•
•
•
•
•
Free availability of oral pills, condoms
Antenatal, delivery, post-partum, newborn care services as per Nepal Medical
Standard.
Modification of existing MCH/FP services to make them more accessible to
adolescents.
Conduct family life education clinics
School Health Programs
PHC Center
FP/HIV/STD/Infertility services modified and delivered as a package e.g. Family
Life Education Clinics in selected areas
•
•
•
Linkage with the school system and indigenous NGOs
Publicity regarding Family Life Education Clinics in selected areas
Antenatal care, care during delivery, post-partum and newborn care
District Hospital
FP/HIV/STD/ services modified and delivered as package, e.g.. Family Life
Education Clinics in selected areas
•
•
•
•
•
Linkages with school system and NGOs
Publicity regarding Family Life Education Clinics in selected areas
Maintenance of privacy and confidentiality
Antenatal care, care during delivery, post-partum and newborn care as per
guidelines.
FP services as per national guidelines
3.3
Program Interventions for Adolescents
3.3.1
National Planning and Policies
In an attempt to promoting young people’s health and addressing their health
problems, the HMG/N should first of all define priorities, develop common targets
and consensus to implement program strategies, as well as establish indicators for
monitoring and evaluation of adolescents reproductive health programs. In the
planning process, the government needs to get the situation assessment and
problems analysis done pertaining to adolescents. Moreover, while initiating for
national planning and policies for young people's health and development, the
government could strengthen and develop partnerships and in this context various
—-
:
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Nepal Country Paper
groups/institutions, including NGOs, could be involved. Further more, the
government needs to take necessary steps towards establishing the health
coordination center for coordinating the programs and activities undertaken by
various groups/institutions and NGOs for meeting the needs of adolescents in the
country.
3.3.2 Counselling:
The pregnancies and pregnancy related cases constitute one of the serious problems
facing adolescents in Nepal. This problem could be prevented through counseling.
Adolescents have a right to complete and detailed knowledge and information
relating to their development, health and sensitive sexual issues. Adolescents have
higher chances of complications and death. Motherhood in adolescence usually
means an end to education, training and economic opportunities for the development
of the female adolescent outside home. Counseling contributes to clarifying the
feeling and thinking of adolescents and enables them to take more advantageous
decisions. Effective counseling may help adolescents to prevent pregnancy through
appropriate means such as abstinence and use of contraceptives.
Many adolescents need one to one counseling, especially when they have particular
problems.
Considering this, HMG Nepal has adopted policies to provide
counseling services at different levels (community to district) under the National
Reproductive Health Strategy. However, detailed action plans pertaining to
providing counseling services have yet to be developed in the public sector. Some
of the NGOs are coming forward in this field. FRAN, for example, has strongly felt
the need for establishing counseling centers at some selected districts. Towards this
end sexual health modules are going to be developed for inclusion within the
counseling training curriculum and TOT on counseling will be organized for
counselors to be stationed in these centers.
3.3.3 Sex Education
i
>•
Adolescents needs are not fully met today in Nepal. Education authorities are not
prepared to introduce sex education courses for fears parents will disapprove.
Hence, formal and non-formal sex education is non-existent in Nepal. Of late,
government has adopted a soft attitude that NGOs and private sector could work in
the field of sexual and adolescent reproductive health services in Nepal. The family
life education program is one of the significant interventions in the field of sex
education. The family life education programs should aim at:
• providing family life education, sexual and reproductive health services and other
aspects of adolescent development.
• training adolescents/youth to become leaders and volunteers
The sex education could be provided through family life education centers and
secondary schools. The sex education should include:
• physical changes at puberty
• psychological changes in adolescence
33
Nepal Country Paper
• male and female reproductive system
• facts about menstruation, virginity, nocturnal emission, masturbation and
homosexuality
• evolution, fertilization and conception
For imparting sex education to adolescents through secondary schools, a curriculum
on sexual and other adolescent reproductive health education should be developed in
collaboration with school- teachers with the consensus of Ministry of Education.
For counseling and family life education centers, counselors should be provided
with TOT. This TOT should include male and female reproductive system; physical
emotional and psychological changes in puberty; the process of conception; STDs.
HIV/AIDS and population dynamics.
3.3.4 Information and Supply of Contraceptives
The adolescents have the right to complete and detailed knowledge and information
relating to their development, health and sensitive sexual issues. Hence,
Adolescents should be provided with information on sexual maturity, sexuality and
gender information and these information could be delivered through various
outlets, including counselling and family life education centers, health clinics, youth
and women clubs/groups, peer groups and so on.
Postponing the first birth or preventing unwanted pregnancies can be done through
the use of contraceptives. Some of the contraceptives suitable for young people like
condoms, oral pills, injectables, implants, emergency contraception should be
available within the reach of adolescents. However, at present unmarried
adolescents are either restricted to the free supply of contraceptives of their choice
or they are hesitant to seek supplies because of negative attitude of the society. Only
condom is freely available for everybody in Nepal because of its promotion for
HIV/AIDS prevention, while for the supply of other contraceptive methods meant
for adolescents, there is still a long way to go.
3.3.5 Youth-Friendly RH Services
It is evident from the foregoing section of the study that adolescents in Nepal
neither have access to, nor use the health services they need. One of the reasons for
this is that the young people in Nepal are virtually unaware that they need a service
or do not know that the services are available. Young people are likely to use the
services that are available if they are youth-friendly i.e. attractive, accessible,
affordable, confidential and able to meet a range of health needs.
It is unethical to provide education and counseling along without access to services
that will allow young people to take care of their health. Hence, in addition to the
supply of contraceptives, some young adolescents need diagnosis and treatment for
STDs, emergency post-coital contraception, prenatal care or safe abortion services
as far as possible and in this context we have to enlist overwhelming support from
the community leaders, parents and teachers. The diagnosis and treatment services
of STDs and HIV/AIDS have been provided to adolescents both by government and
NGOs and INGOs. However, in most of the cases, these are all too often geared
towards adults rather than young people. Moreover, the services are not youth.34
Nepal Country Paper
friendly, i.e. these services cannot meet the basic needs of accessibility,
confidentiality and low cost, and at the same time the services are not closely linked
or integrated with the essential health care needs of adolescents and youth.
3.3.6 STDs and HIV/AIDS
A major potential hazard of unprotected sexuality in adolescence is the danger of
contracting numerous sexually transmitted diseases. Adolescents are especially
vulnerable because of their high-risk behavior and greater biological susceptibility
to certain STDs. The younger the girl, the more the risk, especially if she is forced
into her first sexual intercourse.
Safer sex is strongly advocated. Safer sex is the term employed to mean any sexual
behavior or act which not only prevents pregnancy, but also protects against the
transmission of sexually transmitted infections, including HIV/AIDS. His Majesty’s
Government of Nepal adopted a national policy on AIDS and STD prevention in
1995. This is a major step in offering services to people with HIV/AIDS.. In 1996,
the Executive Committee of the National AIDS Prevention program has accepted
the guidelines for AIDS and STD prevention in a multi-sectoral basis.
Though certain areas for cooperation and coordination in AIDS and STD prevention
activities are weak in effective implementation, an indication of improvement has
been noticed. The National AIDS Coordination Committee, which is the highest
body to determine the policy on AIDS and STD carries out necessary AIDS and
STD prevention activities through National Center for AIDS and STD control.
Although government has been committed to the prevention and control of
AIDS/STDs in Nepal with multi-sectoral approach both from the government and
non-governmental sectors, yet the programs are limited more to awareness
generation and education than towards providing services. The regional and zonal
government hospitals in all the regions provide general services, including STDs
and HIV cases. The government has no specific programs of its own for the
prevention and control of STDs and AIDS.
At the central level government is also engaged in the production of IEC materials
and training through the establishment of National AIDS Prevention and Control
Center, while UNDP is supporting through technical support in 6 districts with
di versed economic and social settings. Moreover, CEC under the University of
Hidelburg is engaged in another set of 6 districts in both education and service
programs for STDs prevention and control.
There exists a considerable number of NGOs committed to AIDS awareness
programs, of which some have been working only occasionally, while 5 or 6 are
actively involved in AIDS awareness programs, including AIDSCAP and AmFAR
are actively contributing for AIDS prevention programs in Nepal.
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Nepal Country Paper
3.3.7 Barriers to Adolescents Program Implementation
There have been tremendous problems associated with (he implementation of
adolescents reproductive health programs in Nepal and these problems mainly relate
to the following issues:
•
•
•
•
•
•
limited access to food and health care for adolescent girls
unacceptably high maternal mortality rate due to too early and too frequent
pregnancies
high IMR due to low maternal age
low level of contraceptive prevalence among adolescents age groups
increasing tendency of STD cases among adolescents (15-19)
low level of literacy, especially among adolescent girls
Coupled with the above-mentioned problems or constraints, there exists significant
barriers to the promotion of adolescent reproductive health programs in Nepal.
These barriers could be summarized as follows:
3.4
•
Lack of effective policies and programs and failure to involve young people in
the existing promotional activities
•
There does not exist a coherent policy for protection and maintenance of
reproductive health in adolescent. Government decision makers are unaware of
the need for concerted actions in these field
•
Both young people and adults lack understanding of the dangerous of adolescent
pregnancies to the health of both mother and child
•
Educators, providers of health and social services, religious and youth leaders
and parents often lack awareness of, or sensitivity to special problems of young
people
•
There has been no involvement of young people in any educational programs or
services that are provided for their age groups.
•
There has a practice among the majority of rural population that young boys are
prepared for productive work and decision making while girls are trained to be
housewives, mothers and service providers.
Role of NGOs in Adolescent RH Interventions
3.4.1 Needs Assessment and Situation Analysis
The adolescents reproductive health program is of very recent origin in Nepal. The
RH activities addressing the needs of adolescents are mainly undertaken by non
governmental agencies. The bulk of the programs being carried out by government
relate to the awareness and prevention of STDs and HIV/AIDS There does not
exist any adolescent-specific agency at public, private and NGO sectors. However,
some of the national and international level NGOs are fully committed to the cause
of women. Their work area varied from providing a safe refuge for a single woman
36
Nepal Country Paper
to income-generating activities for communities. Moreover, there are about 16 other
NGOs and INGOs actively involved in reproductive health programs in Nepal. The
projects and programs being implemented by these agencies include, among other
things, general reproductive care, child survival, safe motherhood, family planning
and prevention education of HIV/AIDS and STDs, condom promotion and diagnosis
and treatment of STD/STI cases.
There are a few NGOs, which apart from engaging in the field of education and
services for the prevention of STDs and HIV/AIDS, are found to have been
committed towards addressing the needs of adolescents for the past few years,
especially after the 1994 ICPD.
In the process of designing and implementing programs for adolescents, needs
assessment surveys, research studies, focus group studies, situation analysis,
workshops/seminars, debate/ essay competitions, panel discussions, publications of
adolescent-specific literatures and IEC materials are being undertaken by NGOs
In this context it will be pertinent to mention here that FPAN conducted a needs
assessment through focus group studies and rapid surveys in urban areas of
Kathmandu, Sunsari and Chitwan. The area of study pertained to RH and sexuality
needs of adolescents by involving out-of-school and in-school students of secondary
level, youths, teenagers, community leaders, family planning acceptors etc. The
needs assessment studies and surveys revealed the positive indication about the need
for sex education among the adolescents which leads to the growth of responsible
parenthood, healthy children, increase in age at marriage.
An Assessment of Sexual Networking in Five Urban Areas in Nepal was undertaken
by Valley Research Group in 1994, revealed that there was high prevalence of
sexually transmitted diseases among the commercial sex workers and low rates of
condom use facilitates HIV transmission. In addition, lack of public awareness
resulting from the country's low rates of literacy, a shortage of appropriate AIDS
education messages, and strong cultural prohibitions against the public discussion of
sex led to further aggravate the problems among commercial sex workers in
Kathmandu. Likewise, various institutions and individuals have undertaken similar
studies relating to flesh trade and girls trafficking. All of these literatures and
research papers deal with the magnitude of problems associated with girls
trafficking and recommend various measures for the eradication of problems created
by such issues in the country in the future. These studies also recommend that
interventions should be made by various levels, including family, community,
general public, media, and the government.
Another survey, under the caption Rapid Needs Assessment on Reproductive Health
was undertaken by Dr V.L. Gurubacharya in Kathmandu, Chitwan and Makwanpur
in 1995. The findings of the study report revealed that the adolescent reproductive
health and sexuality has been the need of the time for providing sex education to
adolescents in Nepal.
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Nepal Country Paper
3.4.2 Advocacy initiatives In Support of Adolescents
In the process of creating environment in favor of addressing the needs of
adolescents, various NGOs, especially FPAN, are engaged in organizing
workshops/seminars are being organized for parliamentarians, the media, women
leaders and social workers on advocating the RH sexuality needs of adolescents.
Debate and essay competitions among secondary level school students on the needs
of adolescents have been an on-going process of FPAN. It published and distributed
reproductive health and teenager booklets meant for providing information to
adolescents. A radio program was also organized by it through BBC Nepali
program on Be Wise Sex Wise. This program resulted in a great interest/curiosity
among the Nepalese teenagers and adolescents.
Soon after the Cairo Conference in 1994, FPAN organized workshops in all the
developments with the involvement of local government authorities and social
workers. The workshops strongly recommended for the need of introducing sex
education at district levels.
Prevention of unwanted pregnancy through counseling, emergency contraception
and use of family planning services is the key to preventing abortion. In the wake of
forestalling the consequences of unwanted pregnancies, various NGO and private
sectors have organized advocacy programs. In this context, FPAN has been playing
a significant role towards creating pressure groups in the parliament, in the media
forum and in the society to influence the government, policy makers and political
leaders to bring favorable policy changes. As continuing efforts, workshops on
FP/RH as basic human right, the need for introduction of sexual education and
favorable policies on abortion are being organized on various occasions. The
workshops recommended that while unrestricted abortion is neither desirable nor
right for Nepal, abortion of first trimester of pregnancy should be made legal if
performed by registered and trained medical professionals, and if the pregnancy is
unwanted. The recommendation also included the legalization of abortion of more
advanced pregnancies, if resulted by rape, incest, contraceptive failure. Eventually,
a private bill was tabled by Hon'ble Mr Sunil Bhandari, MP in 1996. The bill seeks
to modify the existing abortion laws to give access to safe abortion services under
certain conditions affecting the health of women. The bill does not propose to make
abortion a method of family planning. The move towards this end is consistent with
the action plans of both ICPD 1994 and Beijing conference 1995.
In this context, some of the NGOs and INGOs like ABC Nepal, Asia Foundation,
Shtrii Shakti, SHATHI, WOREC and WICOM are all working in advocating for the
cause of women, violence against women and girls, girls trafficking, eradicating the
social barriers like son preference etc. Mothers Clubs
Marriage in adolescence often leads to early pregnancies. Hence, delaying the age at
marriage beyond 20 years through effective advocacy and social and legal action
can prevent adolescent pregnancies with associated risks. Although there has been
significant progress in delaying the age at marriage in Nepal, yet there is still a long
way to way in this regard since bulk of the rural adolescent girls get married in
their early years. To do away this problem education, both formal and non-formal is
the only way out. However, it is pity to say female literacy is one of the lowest in
38
Nepal Country Paper
the world. Marriage in adolescence often leads to early pregnancies. Hence,
delaying the age at marriage beyond 20 years through effective advocacy and social
and legal action can prevent adolescent pregnancies with associated risks.
39
Nepal Country Paper
REFERENCES
1.
Adolescent, The Critical Phase, The Challenges and Potential, WHO, Regional Office
for South East Asia, 1997.
2.
Adolescent Reproductive Health in Asia. Current Needs and Status, paper presented
by Hari Khanal, UNFPA, 1997.
3.
Asia Pacific Population Journal, ESCAP, Vol 12, No.l, March, 1997.
4.
A Survey of KABP in Relation to Risk of HIV and HIV Prevalence Among Injecting
Drug Users in Kathmandu , Nepal, S.H. Maharjan, Manisha Singh, Aaran Peak &
Nick Crofts, Life Saving and Life giving Society (LALS), Nepal, 1994
5.
Adolescent Reproductive Health, Approach to Planning Health Services Research,
WHO, Geneva.
6.
Children and Women of Nepal, A Situation Analysis, NPC, HMG/Nepal, UNICEF
1996
7.
CHOICES, Journal of IPPF (European Network), Vol.26, No.l, 1997
8.
CREHPA, Reproductive Health Care Knowledge, Attitude and Practice Among
Adolescent in Program Areas of PLAN International, Makwanpur, 1996.
9.
CREHPA, A study on Perception and Attitudes of Parents and Grand Parents
Towards Adolescents Reproductive Health Program, 1997.
10.
CREHPA, Providing Adolescents health Services, The Nepalese Experience, 1998.
11.
Educational Statistics of Nepal, HMG/Nepal, Ministry of Education, Planning
Division, 1995.
12.
Family Health Survey, 1996, Family Health Division, Department of Health Services,
Ministry of Health, HMG, Nepal
13.
Fertility, Family Planning and Health Survey, 1991, Ministry of Health, FP/MCH
Division, Nepal, 1993
14.
FORUM, What Our Adolescent Need, Journal, IPPF, Western Hemisphere Region
Inc. Vol. XIII, No. 2,1998
15.
Gender Equality & Empowerment of Women, A Status Report submitted to UNFPA,
Dr. M. Acharya, UNFPA, 1997
16.
Guidelines for Preparing Plan of Action in Family and Reproductive Health Program
at Country Level: Dr Peter Patta Sunbung, WHO/STC.
17.
Impact of Rapid Population Growth on Development in Nepal, Population Division,
NPC Secretariat, FP/MCH Division, Ministry of Health, New ERA, 1995.
40
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18.
JNMA, Journal of the Nepal Medical Association, Vol. 32, No. Ill, 1994.
’9.
JNMA. Journal of the Nepal Medical Association, Vol. 34, No. 118 & 119, 1996
20.
Nepal Population and Development Journal, HMG, Ministry of Population and
Environment, 1997.
21.
National Reproductive Health Strategy of Nepal (Draft), Family Health Division,
Department of Health Services, Ministry of Health, 1997
22.
National STD Case Management Guideline, Second Revised Edition, 1997, Ministry
of Health, Department of Health Services, National Center for AIDS and STD
Control, Nepal, 1997
23.
Nepal Contraceptive Prevalence Survey Report, 1981, MOH, NFP/MCH Project
24.
Population Monograph of Nepal, CBS, HMG, Nepal, 1995
25.
Profile of Ministry of Education, Ministry of Education, HMG/Nepal, 1996.
26.
Report on Mid-term External Review of National AIDS Program of Nepal, Ministry
of Health, Department of Health Services, National Center for AIDS and STD
Control, Nepal, 1997.
27.
Regional Reproductive Health Strategy, WHO, South-East Region.
28.
Report on Rapid Need Assessment of Reproductive health and Sex Education in three
urban cities of Nepal, Dr V.L. Gurubacharya, FPAN, 1995.
29.
Sexual & Reproductive Health, Family Planning puts promises into practice, IPPF,
1995.
30.
Statistical Year Book, CBS, HMG, Nepal, 1991
31.
Statistical Year Book, CBS, HMG, Nepal, 1997
32.
Sexual Harassment in Public Places in the Kathmandu Valley, Result of a Survey, C.
Thapa & A. Rana, SATHI, Nepal, 1994.
33.
The World’s Youth, Population Reference Bureau, Inc. Washington, DC, USA, 1996
34.
Towards Equal Political Power, South Asian Women's Voice, Regional Seminar
Report. ABC/Nepal and Women's Awareness Center, Nepal, 1995.
35.
The Right to Choose: Reproductive Rights and Reproductive Health, UNFPA
36.
Understanding Adolescents, An IPPF Report on Young People's Sexual &
Reproductive Health Needs: IPPF.
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37.
Women Development Democracy, A Study of the Socio-economic Changes in the
Profile of Women in Nepal, SHTRII SHAKTI, 1995.
38.
Youth Health - For A Change. A UNICEF Notebook on Programming for Young
People's Health and Development. UNICEF. 1997.
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