The state of adolescent reproductive and sexual health and health care in Burkina Faso

Backgrounder

Why is it important to talk about it?

Adolescence is a period of opportunities but also of risks.

• Behaviors during adolescence have repercussions for adult life.
• Talking about adolescent reproductive and sexual health helps to extend sexual education programs to adolescents and youth out of school, who make up the majority of this age group.
• Talking about it helps to inform adolescents about their choices and their sexual and reproductive lives. (6)
• Women who have their first baby in their teens are at higher risk of obstetric fistula than older women giving birth for the first time. Their babies are at risk of being born prematurely.
• An uneducated and untrained teenager is easy prey for people who want to take advantage of her.
• Talking about adolescent reproductive and sexual health enables parents to play a role in educating their teenagers about responsible sexuality. (1)
• Adolescents and young people sometimes express their need or desire to learn about family planning only after an experience of pregnancy.
• Early childbirth increases the risk of death among adolescent mothers.
• Adolescents and young people face many barriers in accessing sexual and reproductive health services.
• Early childbearing significantly reduces girls’ educational opportunities.
• Adolescents do not have the health education necessary to access information, about reproductive and sexual health, to understand it, and to use it effectively to stay healthy.
• Adolescents’ use of health services may be strongly influenced by the social values and attitudes (imagined or real) of their peers, parents, and other authoritative adults, including clinicians.
• Adolescents often find it difficult to accept regular primary care services because they feel that they are disrespected, that their privacy and confidentiality are not protected, that they may be stigmatized and discriminated against, and that health workers try to impose their moral values on them.
• Convenient opening hours (i.e., outside school hours) and flexible appointment procedures (e.g., walk-in clinics) are important factors in adolescents’ access to services, but are not always provided. In addition, adolescents may not visit facilities if they find them dirty, poorly equipped, or lacking essential drugs and supplies.

For more information, see documents 1 and 6.

Barriers to communication about reproductive health

• Some community leaders are afraid to support the promotion of reproductive health because they believe that it contributes to moral depravity.
• The abandonment of initiation rites where certain values that were taught (e.g., control of one’s body and sexuality, respect for elders) may contribute to premature sexual relations among young people.
• The negative influence of the media and ICTs on adolescents (especially pornographic sites).
• The reluctance of some religions to promote contraceptive methods (the focus on abstinence in
  family life education in schools the emphasis on sexual abstinence by religions).
• Adolescent girls are reluctant to be examined by men, and young men may find it difficult to discuss intimate symptoms with a female health care provider.
• In many societies, parents and other community members fear that the availability of information about sexuality is more harmful than beneficial.
• The persistence of certain traditional practices such as abduction, lito*, sororate*, and giving away girls are obstacles to the full development of girls.
• According to these norms and practices, a girl should marry as soon as she appears “well-formed” (after the onset of menstruation and the development of breasts) to prevent her from getting pregnant outside of marriage.
• Some parents and customary leaders do not understand why they should teach abstinence and contraception at the same time. (5)

Essential information

• Burkina Faso’s population is estimated at 20,244,079 s in 2018. More than half (58.3%) of the population is under 19 years of age and 67% under 24 years of age.
• The fertility rate is very high in young people, with 117 children per 1,000 women in the 15-19 age bracket.
• In 2010, more than 16% of young women aged 15-19 had already had a child.
• Early sexual activity coupled with a lack of reliable information makes adolescents vulnerable to STIs, HIV, and AIDS.
• In Burkina Faso, information on the practice of abortion is limited. A study showed that in 2008 the number of abortions was estimated at 25 per 1,000 women aged 15-49 years. The rate was 23 per 1,000 in the rural areas, and 28 per 1,000 in Ouagadougou. It is higher in the urban areas other than Ouagadougou (42 per 1,000).
• According to the same study, the women most likely to have recently terminated a pregnancy were those aged 15 to 24: 5.7 percent of them told a close friend or family member that they had had an abortion.
  43.6% of Burkinabe women aged 10-24 are vulnerable to venereal diseases because of low or poor use of contraceptive methods (condoms).
• From 2015 to 2016, 1,717 pregnancies were registered in schools, including more than 100 in primary schools. (4)
• The poverty and low social status of adolescents can make them vulnerable to highly unequal or coerced sex, especially girls, which leads some to fall into prostitution. (13) Most girls involved in prostitution say they had sexual intercourse at a young age with an older relative (uncle, cousin, etc.) Unfortunately, because of the influence of their family, they are unable to disclose what they are experiencing.

For more information, see documents 4 and 13.

Aspects of sexual and reproductive health for adolescents and young people

According to the National Health Development Plan 2011-2020, the sexual and reproductive health situation of adolescents and young people in Burkina Faso encompasses the following issues: (11)

• Unwanted pregnancies, early pregnancies.
• Intentionally-induced (voluntary) abortions.
• The spread of STI/HIV/AIDS.
• Caring for young people’s health, including risky behavior (alcoholism, drug addiction, and prostitution).
• Screening for cervical cancer.
• Young people with several sexual partners

The sexual and reproductive health challenges of adolescents and young people are aggravated by lack of literacy, low use of contraceptive methods, and few visits to health services.

For more information, see document 11.

Early sexual activity

• The rate of women already having sex is 94 per cent among women aged 25. (18)
• According to the 2010 Burkina Faso Health Survey, half of young women and more than 25% of young men aged 15 to 19 have already had sexual relations. Sexual relations among young women generally occur within marriage, while they occur outside of marriage for young men. (2)
• 3.5% of adolescent girls aged 15-19 had their first sexual intercourse before the age of 15. (3)
• The proportion of adolescents who have had at least one child increases with age from 1 per cent at age 15-18 per cent at age 17, and 57 per cent at age 19, when 49 per cent of girls have already had at least one child.

Factors contributing to early sexuality

• The educational environment: Sexuality is a taboo subject among most Burkinabé. This is a handicap for young people in terms of sexual education.
• Dropping out of school: Adolescents are left to fend for themselves and self-educate sexually through the experiences of their peers. Parents lack the time to devote to their children.
• Poverty: For young girls, difficulty meeting financial needs can lead to risky sexual behaviors such as transactional sex (paying sex), or juvenile prostitution. (16)
• This early sexuality is associated with a lack of awareness of the risks of unprotected sex, limited access to sexual and reproductive health services, and insufficient sex education.
• Economic vulnerability, cultural practices such as early marriage and bride abduction, the influence of the media, and poor access to contraceptive products.

Early marriage

• Burkina Faso’s Code of Persons and the Family authorizes the marriage of girls from the age of 17.
• In Burkina Faso, one in two girls is married before the age of 18 and one in 10 before the age of 15. (8)
  1.6% of boys and 2.5% of girls aged 12-14 in the Sahel and Eastern regions are married. These are the two regions most affected by early marriage.

The harmful effects of early marriage and pregnancy include:

• Dropping out of school
• Maternal mortality
• Obstetrical fistulas*
• Physical and psychological violence
• Nearly 7,050 cases of pregnancy were registered in schools during the 2016-17 school year, of which more than 600 were at the primary level. (10)

Signs of responsible sexual behaviour in adolescents

• Being open to sex education.
• Refraining from or delaying sexual intercourse.
• Using a contraceptive method, especially condoms.
• Visiting health centres for information or treatment.
• Not being overly influenced by media (Internet, TV, etc.).
• Being less susceptible to the sexual influence of those around them (including sexual precociousness).
• Aware of the possible consequences of early sexuality.
• Ability to say no to attempts at sexual seduction.
• Avoids sexual “games” with or without penetration.
• Clearly refuses unwanted sexual intercourse.
• Requires condom use during sexual intercourse.
• Practices abstinence.

For more information, see documents 2, 3, 6, 8, 10, 18 and 23.

Abortion in Burkina Faso

Incidence of abortion

• According to a study conducted by the Higher Institute of Population Sciences of the University of Ouagadougou, the rate of clandestine abortions is 25 per 1,000 inhabitants per year. 41% of these are performed by traditional practitioners. (10)
• One of the main causes of clandestine abortions is the lengthy legal process to obtain a safe abortion before 14 weeks. Many people with high-risk pregnancies, women who become pregnant as a result of incest or rape, and women whose fetus has a genetic defect have had their applications rejected after the statutory deadline.
• The rate of abortions is 23 per 1,000 in rural areas and 28 per 1,000 in Ouagadougou. It is higher in urban areas other than Ouagadougou (42 per 1,000). The women most likely to have recently terminated a pregnancy are those aged 15 to 24: 5.7 per cent told a close friend or family member that they had had an abortion.

Types of abortions

From a legal perspective in Burkina Faso, there are four types of abortion:

• Spontaneous abortion, which is self-induced without outside intervention.
• Criminal abortion (voluntary termination of pregnancy or abortion).
• Induced abortion (performed in countries where the law allows it to remove any danger to the mother or when the fetus has a defect or malformation.)
• Social abortion, related to cases of incest or rape.

What does the law say about abortion in Burkina Faso?

In Burkina Faso, abortion is prohibited and punishable by imprisonment and fines.

• Any person of any age or position who encourages a woman to receive an illegal abortion is liable to a fine of 250,000 to one million CFA francs.
• Attempted abortion or complicity is punishable by a fine of one to two million CFA francs and one to five years’ imprisonment.
• Penalties increase depending on whether the perpetrators are accomplices or repeat offenders.
• In 2018, the penal code was revised to authorize abortion under certain conditions before the 14th week of fetal life in cases of incest, rape, serious malformation, and danger to the mother. (20)

In addition to requiring a doctor’s report to support a case for abortion, the law specifies that in cases of rape or incest, it is up to the prosecutor to establish that the victim’s distress requires an abortion. In all other cases, abortion is punishable by law.

It is important for teenagers to understand the consequences of abortion. Even if it is allowed under certain conditions, abortion can have complications. These include:

• hemorrhages
• infections
• complications related to anesthesia
• complications related to undiagnosed extra-uterine pregnancies
• stress
• guilt after the act (20)

For more information, see documents 10 and 20.

The prevalence of HIV and AIDS

• In 2017, there were an estimated 94,000 people living with HIV in Burkina Faso. The HIV prevalence rate among adults aged 15-49 years was 0.8%. (17) It is 5.4% among sex workers, where many adolescents are found.
• Only 28 per cent [18-36 per cent] of children aged 14 or less who are HIV-positive have access to antiretrovirals. (12)
• In Burkina Faso, according to EDS IV (2010), HIV/AIDS prevalence is 0.3% for 15-19 year olds and 0.4% for 20-24 year olds. (14)

For more information, see documents 12, 14, and 17.

The use of alcohol

In Burkina Faso, the abuse of alcohol and drugs by young people is a reality that concerns both those in and out of school. (15)

• The major consequences of excessive alcohol consumption on sexual and reproductive health are the risks of early sexuality, recurrent cases of rape among young people, and the proliferation of sexually transmitted diseases. Young people under the influence of alcohol give little thought to protecting themselves before having sex.

To reduce alcohol consumption, the opening of drinking establishments close to schools could be banned, and parental education strengthened. (23)

For more information, see documents 15 and 23.

Female genital mutilation

• Female genital mutilation (FGM) is a harmful traditional practice that contributes to the degradation of the health of girls and women.
• In 2015, 67.6 per cent of Burkinabe women and girls aged 14 to 49 reported having undergone FGM. The proportion was highest in the Centre-Eastern (90%) and Northern (88%) regions. (21)
• The prevalence of this practice is still high despite a number of campaigns to combat it that targeted various populations.
• Often, FGM is carried out while the child is still breastfeeding, which allows the act to go unnoticed. Some women are subjected to the practice on the eve of their marriage, others from the age of 1 to 16.

The harmful effects of FGM include the following:

• Damage to the girl’s physical, mental, and social well-being.
• Vaginal problems (frigidity, irreversible damage to the genital tract).
• Heavy bleeding.
• Sexual infections (tetanus, pain during intercourse, and menstruation).
• Risks of incontinence (obstetric fistulas).
• Complications during childbirth.

Strategies for promoting sexual and reproductive health in adolescents (22)

• Using school clubs (so that young people’s sexuality is no longer taboo).
• Youth listening centres (to facilitate communication and confidentiality).
• Peer educators: Informed and responsible peer education builds adolescents’ confidence to protect themselves from risk.
• Introduction of new curricula on sexual and reproductive health for young people in school. (23)
• Expansion of sex education programs to unschooled young people, who make up the majority of this age group.
• Partnership with media for educational and informative programming for children and adolescents.
• Promotion of healthy recreational activities for adolescents and youth.
• Parents should develop age-appropriate tips for talking to their children about sexual and reproductive health (not limited to sexual penetration).
• When there is trust between parents and adolescents, they talk about their sexuality with confidence and parents have ample opportunity to provide guidance.
• Schooling can enable adolescents to delay the onset of sexual activity or give them enough information to protect themselves.

For more information, see documents 21, 22, and 23.

Effective health worker attitudes and strategies to promote sexual and reproductive health (21)

• When offering health services, ensures that services are readily available and accessible, acceptable to consumers, and that they respect confidentiality.
• Demonstrate to adolescents that health workers enjoy working with them.
• Do not look down on adolescents who come for sexual health counselling.
• Provide counselling to adolescents in private settings where they cannot be seen, heard, or recognized by others to ensure confidentiality.
• Ensure that a girl’s choice is her own and not subject to family or partner pressure.
• Agree to have the health establishment evaluated by its clients on the quality of services provided.
• Strengthen parents’ capacities to talk about sexuality.

For more information, see document 23.

Definitions

Adolescence: Period between the ages of 10 and 19.

Lito: The practice of giving girls away. For example, someone may promise to give their daughter in marriage to another as a sign of gratitude. Girls are sometimes given when still in infancy or even before they are born. In some cases, there is an exchange—one family gives a sister or daughter away in exchange for a young woman in another family. It’s a practice found in some regions of Burkina Faso, including Koulpéogo.

Sororate: The practice of widowers marrying the sister (in some cases specifically the younger sister) of their late wife, especially when the wife left very young children. Youth health: In Burkina Faso, this concerns young people of both sexes between the ages of 10 and 24, whether sexually active or not. The approach is referred to as Adolescent and Youth Reproductive Health (AYRH). This approach is meant to be comprehensive and takes into account the 6-9-year-old age group whose needs are not covered by ongoing health programs.

Reproductive health or sexual and reproductive health: The general physical, mental, and social well-being of the human person in all matters relating to the reproductive system and to its functions and functioning, and not merely the absence of disease or infirmity. It is based on the fundamental principle that everyone has the right to decide whether they want to have sex.