“Our mothers do not tell us”: a qualitative study of adolescent girls’ perspectives on sexual and reproductive health in rural Nepal

Abstract

Adolescent girls in low- and middle-income countries continue to face poor sexual and reproductive health (SRH). In Nepal, early marriage and motherhood, gender-based violence, and unmet need for contraception remain pervasive. Adolescent girls in rural areas bear a disproportionate burden of poor reproductive health outcomes, but there are limited context-specific data. This is a qualitative study to identify factors that impact adolescent girls’ utilisation of and access to SRH services in a rural district of Nepal. We conducted 21 individual interviews with adolescent girls aged 15–19 years, and three focus group discussions with community health workers. We used an inductive analytic approach to identify emergent and recurrent themes and present the themes using the social ecological model. Individual-level factors that contribute to low uptake of services among adolescent girls include lack of knowledge, self-perceived lack of need, low decision-making autonomy, and shyness. Interpersonal factors that impact access include unsupportive family norms, absence of open communication, and need for permission from family members to access care. At the community level, disparate gender norms, son preference, and judgment by community members affect adolescent SRH. Inadequate sex education, far travel distance to facilities, lack of female healthcare providers and teachers, and inability to access abortion services were identified as organisational and systems barriers. Stigma was a factor cross-cutting several levels. Our findings suggest the need for multi-level strategies to address these factors to improve adolescent girls’ SRH.

Parental knowledge and communication with their adolescent on sexual and reproductive health issues in Nepal

“…More than half adolescents had never communicated on SRH topics with their parents [ 12 ]. In addition, similar to the previous studies [ 9 , 12 , 13 , 15 ], most parents in this study perceived difficulty in explaining SRH issues. Social stigma or fear of social disapproval and feelings of lack of sexual health information were seen as barriers to limited parental-adolescent communication on sexual health matters.…”

“…context, including the practice of parental and adolescent communication about sexual health issues [12,13]. This study showed that parents from Brahmin/Chhetri ethnic group were more likely to communicate about sexual health matters with their adolescent children compared to the Newar ethnic group.…”

“…These results are supported by the study conducted in Iran, where despite the parent’s negative attitude toward teenage pregnancy among their daughter, they had a low level of knowledge about the health consequences of pregnancy at an early age [ 22 ]. Likewise, a similar study from Nepal also disclosed that adolescents felt unsupported by their parents and family in accessing reproductive health information and services [ 13 ]. Women’s poor knowledge about safe abortion services, cultural attitudes, religious beliefs, cultural norms, and stigma were key barriers to seeking SRH services and information among Nepalese women [ 23 , 24 ].…”

“…Nepal, one of the resource-poor countries in South Asia, has approximately six million adolescent population, which accounts for 24% of the total population of Nepal [ 11 ]. Despite the progress in implementing a range of adolescent-friendly sexual health policies and interventions in Nepal, adolescents still lack access to adequate SRH information and services [ 12 , 13 ]. The most recent nationally representative survey of Nepal showed a 17% prevalence of teenage pregnancy, a 32% unmet need for child spacing which is highest among married women aged 15–19, less than half (40%) of females aged 15−19 knew about legal provisions for safe abortion, 20% of teenage female have comprehensive knowledge of HIV/AIDS and 42% of married female aged 15−19 were already a mother [ 14 ].…”

“…In Nepalese culture, adolescent children usually stay with their parents, and they are expected to take permission from their parents for most of their decisions, including decision-making towards SRH issues. However, social stigma and deep-rooted cultural values restrict adolescent-parent communication and open conversations about SRH, even with close family members [ 12 , 13 , 15 ]. Adolescents in Nepal mainly discuss their SRH issues with their peers in the community and school due to the unfavourable familial environment to discuss such matters with their parents [ 12 , 16 ].…”