Economic Journal of Development Issues Vol. 11 & 12 No.

1-2 (2010) Combined Issue

SexualandReproductive...

SEXUALANDREPRODUCTIVEHEALTHOFLOW
INCOMEADOLESCENCEGIRLSINNEPAL:CAN
EDUCATIONBEACATALYST?

PrabhaKumariHamal,Ph.D.*

Abstract
Using data from five districts of MidWestern and FarWestern Development Region, this
paperreachestoconclusionthateducationhassignificantandinfluentialrolesindetermining
thesexualandreproductivehealthofadolescencegirls,particularlyofthosewhoarefromlow
incomefamilies.AroughUshapedrelationshipbetweeneducationandreportingofhealth
problemsandgenderbasedviolencewasobserved.

Key words:sexual and reproductive health, low income adolescence, girls, Nepal,
education,catalyst

INTRODUCTION
Within the unbinding arguments, sexual and reproductive health encompasses
developmentandmaintenanceofmeaningfulinterpersonalrelationships;appreciating
onesownbody;interactingwithbothmaleandfemaleinrespectfulandappropriate
ways;andexpressingaffection,loveandintimacyinwaysconsistentwithonesown
values (Tolman, Striepe and Harmon,2003). It is more concisely explained as the
experienceofongoingprocessofphysical,psychologicalandsocioculturalwellbeing
relatedtosexuality(PAHO;WHO;2000). Adolescencecomprisesbothbiologicaland
socialtransitioninalifecycle.Thisperiodhasseveralimportantmarksinthelifeof
girls in particular. The menarche alone brings several changes in psychological and
behaviouralaspectsofagirl,particularlyinsocietieswithconventionallifestyles.The
complexitiescontinueinthelaterstagesinnegotiationdynamicsonmarriage,fertility,
useofcontraceptionandotherpracticesofsafersex,particularlyduetogenderideals
(Varga2003).Sexualandreproductivehealthcanbeafunctionofarangeoffactors
including psychological, physical, societal, cultural, educational, economic and
spiritualfactors(Tolman,StriepeandHarmon2003).

Limitingthebroadtheoreticalspectrumofdeterminantsofsexualandreproductive
health,thispaperislittleselectiveinitsstructurefocusingontheeducationaldimension.
Sinceeducationisanimportantdeterminantofindividualbehaviourandperception,
itscontributionsarebothintrinsicandinstrumental.Evidencessupporttheexistenceof

* Ms. Hamal Associate Professor at the Central Department of Population Studies, Tribhuvan University

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Economic Journal of Development Issues Vol. 11 & 12 No. 1-2 (2010) Combined Issue

multipliereffectofeducationofferingchangesinadolescencereproductivebehaviour
including application of safe health practices. With an improvement in educational
status,girlstendtoexerciseliberalsocialandculturaltraits.

Access to resources determines the health status. A limited or shrunken access to

resourceimpliesshrinkingopportunitiesandreducedscopeincludingprematureexit
fromschool,reducedearningsprospects,reducedchancesofcommunityparticipation
and acquisition of social capital and fallen health opportunities, thereby increasing
riskinlivingpoverty(GreeneandMerrick,2005). Genderedpracticesandnormseven
increaseriskforadolescencegirlswhosufferfamilyhardshipatthefirst.Evidences
show girls from economically marginal households either do not enter school or
dropout early and begin family life early. Early initiation of reproductive activities
promotesaviciouscycleofpovertybyincreasingthehealthcarecostandlimitingthe
capabilityenhancementopportunities.

SCOPE,AIMANDDATA
Using the data from fivedistricts of Nepal Kailali, Dadeldhura, Bajhang, Jajarkot
and Salyan from field survey in January 2009, this article is entitled to discover
the reproductive health status of women aged 10 years and above at large and of
adolescencegirlsinparticular.Atotalof708womenaged10yearsandabovewere
interviewedfromfivedistrictsusingclustersamplingfromlowincomehouseholds.
However,thisarticleisbuiltonsampleof199femalesintheagegroup1019years
whichis29percentofthetotalsampledwomen. Usingeducationasoneofthemajor
determinants of individuals health, this article elucidates sexual and reproductive
health status of adolescents. Another contribution of the article would be to know
thesexualandreproductivehealthstatusofwomeninconflictaffectedareasinpost
conflictsituation.Thismayhelptodesignsomeinterventionstoprotectthesexualand
reproductiverightsofwomeninconflictsensitiveareasinthefuture.

DemographyofAdolescenceGirls

Theproportionofyoungpeople,atpresent,isthelargestintheworlddemographic
history(UNFPA2005).Nepalispredominantlyyoungcountrywherethemedianage
ofpopulationis20yearsmale19andfemale20years(PanthaandSharma2003).
Table1:Maritalstatusbylevelofeducation

Level of education
No education
Primary level
Some Secondary level
SLC and above
%
N

Never married
47.1
90.4
84.6
69.6

Currently Married
52.9
9.6
15.4
30.4

Total
100.0
100.0
100.0
100.0

82.4
164

17.6
35

100.00***
199

Source:FieldSurvey2009.
***2 valuesignificantatp<0.01level.

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The age structure favours adolescence girls (1019 years) with an increase of 2.23
percent point between 1991 and 2001, 21.08 and 23.21 percent respectively. The
adolescence girls make up more than one fifth in total female population (Central
Bureau of Statistics 2002). Within the adolescence girls, more than 50 percent are
in early adolescence, 1014 years, which is consistent to the study population. The
medianageat marriage for women aged 2024 is17.9 years, an improvement of 1.4
yearsoverthewomenofaged4549.Whilethemedianageatfirstsexualintercourseis
notsignificantlydifferentthanthatofageatmarriage.Bothindicatorsvaryalongwith
the improvement in the educational attainment(Ministry of Population and Health
(MoHP)[Nepal];NewERA;MacroInternationalInc.,2007).

In the sample population, 17.6 percent adolescent girls were ever married and the
percentageishighestforilliterateadolescents(52.9%)andleastforgirlsintheprimary
level of education (9.6%), implying that once a girl joins school her probability of
marryingatearlyagesignificantlydecreases(Table1). Ofthoseevermarried,more
than two thirds have had at least one live birth while 3 in 10 have had at least 2
pregnanciesduringthelateadolescence.Slightlymorethanonequarterevermarried
adolescencegirlswerepregnantatthetimeofsurvey.

FAMILYPLANNINGANDMATERNALHEALTH
Slightlymorethan4in10adolescencegirlswereusingcontraceptionandthosenot
havingeducationwerelesslikelytouse.Desireofachildwasamajorreasonforthose
notusingcontraception.Encouragingly,allpregnantadolescencegirlswerereceiving
antenatalcarevisitsandlessthan1in10reportedtohaveunwantedpregnancy.

ReproductiveHealthProblem
Fortheanalysis,fromalistofreported30sexualandreproductivehealthproblems
fivemajorcategorieswereconstructedpregnancyanddeliveryrelated,anemiaand
hemorrhagerelated,chroniccomplication,abortionrelatedandSTDsandtherestinto
Others. Nearly half of the adolescence girls have had at least a type of sexual and
reproductivehealth problem in the lastfiveyears, which indicates an emerging but
serioushealthconcernamongruraladolescencegirls.Although,noclearrelationship
between educational attainment and sexual and reproductive health problems of
adolescents,asmallproportionofNohealthproblemwithnoeducationleavesaroom
formakingaconclusionofsomepossiblerelationshipbetweeneducationandhealth
problem. A roughly U shaped relationship between education level and reported
reproductivehealthproblemisobserved(Figure1).Thishastwopossibleimplications.
First, adolescence girls with no education are more likely have reproductive health
problems.

This has an obvious reason includingpractice ofunsafe sexualbehavioursand lack

ofawarenessaboutpreventivemeasures.Second,withtheincreaseineducation,the
healthseekingbehaviourincreasesandadolescencegirlsaremorelikelytoreporttheir
health problems. For policy implication, the prevalence of sexual and reproductive
healthproblemsamonguneducatedadolescencegirlsshouldattractforintervention.
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Eight percent of adolescence girls reported to have experienced pregnancy and

deliveryrelatedproblems,followedbyanemiaandhemorrhage(7%)andSTDs(7%)
whereas four percent had abortion related problems and two percent had chronic
complicationslikeuterusprolapsedandobstetricfistula.

TreatmentSeekingBehaviour
Only half of the adolescence girls having reproductive health problem reported to
havevisitedhealthfacilitiesfortreatment.Theindicatorisfavourabletogirlswithno
education(68%)andthereasonsareunknown.Butonepossiblereasonmaybethat
theyhadalsoreportedhigherprevalenceofhealthproblems.

Proportion of adolescence girls seeking treatment is the lowest among the primary
level education (42%) and then steadily increases along with the improvement in
education. This leads to a conclusion that low level of education is not enough to
motivateadolescencegirlsforhealthpromotion.

Reasons for not seeking treatment were economic and quality of service available
in the health institutions.An overwhelmingly large proportion of adolescence girls
who visited health institutions were encouraged by family members, friends and
relatives; followed by Female Community Health Volunteer (FCHV). Adolescence
girlswithlowleveleducationweremorelikelytodependonthesuggestionsoffamily
member, friends and relatives. Nearly half of the adolescence girls were still facing
theproblemstheyhadearlierandtheproportionishigherforadolescencegirlswith
lowereducation.

GenderBasedViolence
Gender basedviolence is considered as both cause and consequence of poor
reproductive health outcome. It has long lasting adverse consequences for womens
reproductive health (UNFPA; UNIFEM; 2005). Unwanted pregnancies, maternal
death, miscarriage, injury and STDs are a few of them. Studies have shown some
obvious relationship between education and genderbased violence. However, such
relationshipappearselusiveinmanydevelopingsocieties.

Figure3showsanelusiverelationshipbetweeneducationandgenderbasedviolence.
Atotal of nine percent adolescence girls reported to have experience gender based
violence.Interestingly,educatedadolescencegirlsaremorelikelytoreportthecases
ofviolenceagainstthem.Thehighestproportion(21.7%)ofgirlswithSLCandabove
levelofeducationreportinggenderbasedviolenceagainstthemimpliesthateducation
has broughtawareness to defy the injustice, which the low education girlsmay not
do. But figure does not approve that women with low education are less likely to
experience genderbased violence. In fact, they report less as in many cases they
internalize violence against them. Taking help in the cases of violence is extremely
lowasmorethanhalfofthoseexperiencingviolencedidnotseekhelp.Inwhichmore
werehavinglowlevelofeducation.
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DISCUSSIONANDCONCLUSION
Education benefits girls from different dimensions. It can be an important wealth
of those who lack other resources. Improvement in sexual and reproductive health
is one important dimension in which educational attainmentcan contribute. Sexual
andreproductivehealthismorecontextualized(Billy,BrewsterandGrady1994),in
which personal characteristics of adolescence girls may have visible influence. The
behaviourslikewhetherandwhentomarry,whetherandwhentohaveachild,how
manychildrentohave,whetherandwhentoapplycontraceptives,whethertoseek
treatmentincaseofillnessandwhethertoresistorreporttheviolenceareinfluenced
by the level of understanding and exposure a girl has.Adolescence girls with good
educationbackgroundfeelcomfortabletodealwiththeissuesdiscussedabove.

Thispaperasapartoflargeprojectapprovesthepositivecontributionofeducation
on sexual and reproductive status of adolescence girls. This paper also qualifiesthe
gendered sexual and reproductive health of adolescent girls (Tolman, Striepe and

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Harmon 2003). In countries like Nepal, where health service delivery is notoriously
difficult(Campbell,etal.2003),adolescencesexualandreproductivehealthgetslittle
attentioninthepolicydiscourse.

Investmentsineducationofgirlshavetangiblesocialandeconomicbenefitsreflected
in delayed marriage, reduced fertility, improved child survival and reduction in
healthcarecost.Schooleducationistheonlycatalystthatcanreducetheprobability
of marriage and birth at early age offering incalculable contribution in promotion
of sexual and reproductive health. Education has both intrinsic and instrumental
values.However,benefitsmayvaryconsiderablybysetting(MurphyandCarr2007),
includingtheeconomicstatus.

Poverty manifests the health consequences resulting deprivation of education and

other opportunities. In Nepal where female literacy is considerably low, increasing
investmentineducationofgirlsisanimportantmeasuretopromotethesexualand
reproductivehealthand contribute to reduce burden of povertyarising fromhealth
carecost.Targetinggirlsfromlowincomefamilyintheireducationhasgreaterstrategic
importancethananythingelse.Educationopenswindowofopportunities.

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Acknowledgements
The author is thankful to United Nations Population Fund, Nepal for providing
financialsupporttocarryouttheresearchproject.

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