Reaching Out to Teen Mothers in Malawi

This case study examines a communication initiative implemented by Save the Children (SC) to improve the health of Malawian women aged 10 to 24 and their children in the southern Mangochi district through increased voluntary use of family planning (FP) services. As explained here, in 1999, SC had launched a 5-year programme called Nchanda ni Nchanda (Youth to Youth) that used an array of approaches to improve the reproductive and sexual health of people aged 10 to 25. SC organised peer-to-peer education within youth clubs; established 39 youth resource centres; engaged health providers to increase their understanding of adolescent reproductive and sexual health (ARSH) needs and their ability to provide youth-friendly health services; and trained young community-based distribution (CBD) agents to counsel and provide FP services to fellow adolescents.

As part of Nchanda ni Nchanda, SC developed a large network of youth clubs in Mangochi; it initially used these clubs as a venue to link married girls and teen mothers with unmarried girls who were attending school. The rationale was that teen mothers would find the prospect of re-enrolling in school easier and more enticing if they socialised regularly with schoolgirls. At the same time, schoolgirls could learn valuable lessons from their peers who had become young mothers. But SC's situational analysis revealed that community members thought married girls and teen mothers should stay at home, attend to housework and child care, and learn from elderly women. To combat stigma, the project sensitised and mobilised communities to recognise the value of teen mothers' participation in club sessions. But teen mothers also reportedly felt alienated from the interests and concerns of their peers who were not parents.

At the end of Nchanda ni Nchanda, SC interviewed hundreds of young men and women, and found that those who had been exposed to Nchanda ni Nchanda reported later sexual debut, greater use of dual protection (condoms plus a second modern method) and positive changes vis-à-vis ABC messages (that is, abstinence, be faithful, and correct and consistent condom use). Use of modern contraceptives among participating women rose from 13% to 23%. Still, the birth rate among Malawian teens remained high and access to contraceptives remained low. The 2004 Demographic and Health Survey reported that women aged 15 to 19 still had one of the highest overall unmet needs for FP (26%), and that the greatest unmet need was in Mangochi district (33%).

SC decided to continue its work with adolescents and in 2006 attracted additional funding from United States Agency for International Development (USAID)'s Office of Population and Reproductive Health's Flexible Fund Program. In the 27-month project "Reaching Out to Teen Mothers in Malawi", SC built upon several interventions from Nchanda ni Nchanda and reached out to 35,000 youth in Chimwala, Mponda, and Namkumba in eastern Mangochi district. Even as the project continued to promote delayed marriage, delayed sexual debut, and use of modern contraceptives, SC specifically reached out to teen mothers.

SC chose to establish clubs for teen mothers only that could act as a stepping stone to general youth club participation. SC's 36 Teen Mothers Clubs (TMCs) provided a total of 2,035 young women with a venue in which to discuss their common concerns - openly and without stigma - and to get support from fellow teen mothers and friends. In the TMC, a participant noted, "We can talk about issues that really matter to us and are relevant to our lives, which we can't discuss during regular youth club meetings." One young mother commented that being a part of the TMC helped her be more independent, which she hoped "will lead to employment and a brighter future." Other teens expressed the value of learning how to take care of their children and the importance of birth spacing. One young woman, after learning how to negotiate FP and condom use with her partner, acknowledged, "If I knew then all that I know now, I wouldn't be a teen mother today." She credits her participation in the TMC with giving her the tools necessary to make positive life choices.

The TMC reportedly "created a convenient space for reaching teen mothers, who have higher unmet need for FP than their non-parent peers." One TMC member explained, "Sometimes we meet on the patio of a house or at the local school; but we need a private space where we can openly share the challenges of teen motherhood." Her group gathered supplies, mixed cement, and hand-molded bricks to build their own TMC clubhouse. TMC members in clubs like this one received health information on a variety of topics, and each club was linked to one or more local youth CBD agents who could provide FP advice and methods, including oral contraceptives and condoms. One young woman said, "Initially we were afraid to use contraceptives, but after learning about the benefits and side effects, we were able to choose a method to help us manage our fertility and return to school."

In 15 in-depth interviews with teen mothers at the end of the project, many reported improved knowledge about FP and greater ability to successfully negotiate contraceptive use with their partners. They also said that the male motivators helped their husbands become more supportive of FP. (Male outreach workers connected with the husbands in an effort to increase frequency of FP communication and FP use. The teens shared anecdotes about how husbands used their bicycles to bring their wives to the FP clinic, reminded them of their appointments, and encouraged them to visit the youth CBD agents or health centres for contraceptives.)

SC learned that teen mothers must be linked with youth CBD agents and youth-friendly health providers, with specific approaches for teen mothers and married adolescents needed to address their needs, which "differ greatly from those of girls who are not married or do not have children." SC claims that "Youth CBD agents were widely successful in increasing contraceptive uptake among this group. Unfortunately, the project's monitoring framework did not disaggregate contraceptive acceptance by type of acceptor; that is, it did not differentiate between teen mothers and other users. Therefore, it is not possible to examine numeric evidence of FP use and changes in FP use among this group."

The TMCs reportedly became a springboard for outreach to other teenagers. Club members went door to door; performed music, dance, and drama; and participated in community meetings. "The main focus of our community outreach is to educate other adolescents about unwanted pregnancy and the difficulties of being a teen mother," stated one TMC member. "Not only was this a clear shift in attitude from community members' initial opinion that young mothers should remain at home, it also marked adults' new acceptance of discussing FP and related topics with young people."

SC's situation analysis had revealed that parents, community leaders, teachers, and chiefs believed that access to and knowledge of FP would increase youth promiscuity. So, the project continuously involved these individuals - whom it calls "gatekeepers" to mark their important role in youths' lives - in its activities. In one such activity, a team of 4 gatekeepers, plus 2 in-school teen mothers and one teacher, raised awareness among community members and schoolgirls about the benefits of FP, the dangers of teen pregnancies, and so on. In one event, a Traditional Authority Chief stood in the presence of 5 village chiefs and more than 200 community members and advocated that parents should delay marrying off their daughters and instead keep them in school.

SC also invited initiation counsellors - the women and men who guide children's initiation into adulthood - to participate in the project. Overall, 150 such counsellors attended an ARSH workshop where FP messages were developed and incorporated, along with HIV prevention practices, into messages passed on to initiates. The counsellors discussed the importance of FP, as well as the dangers and merits of certain traditional practices, such as those that lead to early pregnancy and young motherhood, thereby possibly compromising the health of young girls.

A key focus of the project was creating awareness about the Ministry of Education (MoE) policy on teen mothers' re-enrollment in school and empowering young women to exercise their right to re-enroll. Community members and parents were encouraged to support mothers' education and learned of the benefits to the women, their children, and communities as a whole. Teachers and school officials also learned of the readmission policy and the importance of supporting teen mothers' return to and retention in school. Youth CBD agents also promoted a return to school. SC staff visited and counselled some of the teen mothers, preparing them to be assertive and prevent pregnancies before achieving their educational goals. Further, SC worked with local non-governmental organisations (NGOs), the District Education Office, and secondary schools to locate financial assistance for young mothers wishing to re-enroll. Finally, project staff encouraged teens who had returned to school to participate actively in TMCs alongside those who had not, so that members could learn from each others' experience.

In the project's first year, 53 teen mothers returned to school; 10 more returned in year two. "Remaining in school was an ongoing challenge....The young women clearly expressed, however, that they saw FP as one means of delaying their next pregnancy to improve their options in life."

Key findings related to the project's re-enrollment focus:

• The societal norms surrounding teen motherhood were deeply entrenched, including the belief that a young mother must forgo her education to raise her child and take care of her husband. Even after discussion and evidence of changing social support, some parents refused to provide money or child care to a daughter, or daughter-in-law, wishing to return to school.
• Teen mothers who did return to school often struggled to remain there. Major obstacles at home were financial resources, time, and child care. As one teen explained, "When I get home from school my parents hand me my child. I had no time in the afternoon to study and no money to buy candles for studying in the evening. I eventually had to drop out of school because the challenges became too great."
• Stigma and harassment in school were further obstacles. "Some teen mothers are laughed at by their peers...others face discrimination from teachers who believe getting pregnant is a disciplinary issue."
• And yet, teen mothers who did return to school were often as successful in their studies as they were before dropping out. The District Education Officer estimated that 75% of returnees graduated from secondary school.
• Getting just one young woman back into to school requires extensive outreach: with the teen herself, with her family, and with her community. SC's essential allies in this outreach included local schools and NGOs that provided school fees. But for every girl who received funding to return to her studies, at least 5 did not. Remaining in school means that money is also needed for uniforms, school supplies, and transportation. Teen mothers may also need help to pay for child care. "Community support and awareness is key, not only to achieving improved financial support for these girls but also to breaking the vicious cycle in which young women have few real options except early marriage or exchanging sex for money, both of which lead to early pregnancy and dropout."
• "Malawi's MoE was instrumental in educating staff to roll out the teen mother policy. In Mangochi, it was the District Education Officer who sensitized staff and encouraged a welcoming environment for returning teen mothers. A strong policy environment paired with community mobilization proved to be the correct formula for a successful program."