Adolescents Sexual and Reproductive Health and Rights in East and Southern Africa SADC Parliamentary Dialogue on Child Marriage Laws Maja Manzenski Hansen and Renata Tallarico UNFPA East and Southern Africa Regional Office

Outline 1. Overview of the situation of ASRHR in the East and Southern Africa region, including linkages between: Maternal mortality Early and unintended pregnancy Child marriage HIV Sexual and gender based violence 2. Key challenges 3. A framework for action 4. UNFPA response to ASRHR and child marriage Strategic plan & business model

Maternal Mortality and Morbidity among adolescents and young people Globally, 70,000 adolescents die annually from causes related to pregnancy and child birth – 1/3 of these occur in sub-Saharan Africa. Pregnancy related complications and HIV remain the leading causes of death among girls aged 15-19 in sub-Saharan Africa. 14 per cent of maternal deaths in Africa are the result of unsafe abortions. 5.5 million unsafe abortions in sub-Saharan Africa, including 2.52 million in East and Southern Africa. Women under the age of 25 account for 60 per cent of these. Up to 70 per cent of all women who receive treatment for complications of abortions are under 20 years old. Strategic plan & business model

Maternal Mortality and Morbidity among adolescents and young people (cont.) The risk of maternal death for mothers under 18 in low and middle-income countries is double that of older females. Girls under 14 years are five times more likely to die from complications in pregnancy and child birth. Young adolescents face significantly higher risk of maternal morbidity, including obstetric fistulae. Early pregnancy also put newborns at risk of morbidity and mortality Higher risks for the baby with younger mothers). Strategic plan & business model

Adolescent Pregnancy - Children giving birth to children Despite progress, adolescent pregnancy rates in East and Southern Africa remain among the world’s highest with a regional average of 108.2 births per 1,000 girls aged 15-19 years compared to the developing world average of 52.4 per 1,000 births. 1 in 4 women age 20 to 24 report a birth before age 18 in the ESA region and in 7 countries the proportion is even higher. Up to 9 of 10 pregnancies among adolescent girls take place within a union or marriage. Source: UNESCO diagnostic report, 2013 and UNFPA SWOP 2013 Mozambique (40%), Madagascar (36%), Malawi (35%), Zambia (34%), Uganda (33%), Tanzania (28%), DRC (25%), Kenya (25%), Eritrea (25%), Swaziland (22%), Ethiopia (22%) and Zimbabwe (21%) Source: UNFPA, State of World Population, 2013

Adolescent Pregnancy in the SADC region Strategic plan & business model Adolescent birth rates (Births per 1,000 girls aged 15-19) Source: Latest DHS, AIS or MICS Overall decline in a majority of countries, but recent increases in some countries, incl. Angola, DRC, Lesotho, Namibia, and Zimbabwe.

Maternal mortality and adolescent pregnancy - Underlying causes Direct factors: Age; Physical immaturity; Complications of unsafe abortion; Lack of access to routine and emergency obstetric care from skilled providers; HIV and AIDS. Other contributing/indirect factors: Poverty; Malnutrition; Lack of education; Child marriage Low status of girls and women; Sexual violence and coercion; Restricted access to contraception, information and age-appropriate sexuality education; Under investment in adolescent girl’s human capital. GPS, information dated 29 September 2014 Core and non-core resources combined

Access to contraception Despite some progress, most countries in sub-Saharan Africa are failing to meet the needs for family planning/contraception among women and especially adolescent girls. Strategic plan & business model Source: Two/three most recent DHS/MICs in the countries with highest adolescent pregnancy rates

Child Marriage - A global and regional challenge More than 1/3 of women aged 20-24 in the developing world were married or in union before age 18 in the period 2000 – 2011 12 per cent of them were married or in union before age 15 Regional: 28 of 41 countries worldwide with child marriage prevalence of 30 per cent or more are located in sub-Saharan Africa 40% of women in sub-Saharan Africa were married before aged 18 West and Central Africa: 41 per cent - 6.2 million young girls Ranges from 75 per cent (Niger) to 18 percent (Cape Verde) East and Southern Africa: 34 per cent - 7.0 million young girls Ranges from 50 per cent (Malawi) to 6 percent (South Africa) Child marriages are generally more frequent where poverty is extreme. Age differences within unions or marriages also influence adolescent pregnancy rates, the greater the age difference, the greater the chance that the girls will become pregnant before age 18. Source: UNFPA database using DHS, MICS and other household surveys.

Child Marriage and Adolescent Pregnancy Married girls are often under pressure to become pregnant immediately or soon after marriage, although they are still children themselves and know little about sex or reproduction. Adolescent birth rates are highest where child marriage is most prevalent Sources: UNFPA State of the World Population, 20013 using the latest DHS, MICS , UNICEF State of the World’s Children, 2013

National disparities and inequalities – the example of Mozambique Wide variations in the prevalence of child marriage are found within countries. Girls who are poor, have little or no education and live in rural areas are more likely to marry or enter into union before age 18. Child marriages are generally more frequent where poverty is extreme. Age differences within unions or marriages also influence adolescent pregnancy rates, the greater the age difference, the greater the chance that the girls will become pregnant before age 18. Source: Mozambique DHS 2011, Prepared by Population and Development Branch, Technical Division, UNFPA

Child marriage: Laws and policies Although 35 countries in Africa have adopted laws on the minimum legal age of marriage, many families and girls themselves may not know that these laws exists, and their enforcement is often lax. In many countries there are also loop holes that impede protection. Legal Age of Marriage for Women and Men, Selected Countries Without parental consent With parental consent Women Men DRC 17 20 15 18 Madagascar N/A Malawi Mozambique 16 Uganda United Republic of Tanzania 14 Zambia 21 Zimbabwe Strategic plan & business model Compiled by the United Nations Statistics Division (and supplemented by data from the periodic country reports to the Committee on the Elimination of All Forms of Discrimination against Women (CEDAW), and data published by United Nations, Department of Economic and Social Affairs, Population Division (2011). World Fertility Policies 2011

Projections What to expect if the current trends continue? If the current trends of child marriage are to continue, worldwide, 150 million girls will be married in the next decade. This translates into an average of 15.0 million girls who will marry every year or one girl every second. In East and Southern Africa, the number will increase from at least 7.0 million annually in 2010 to 7.4 million in 2020 and 8.0 million in 2030. Child marriages are generally more frequent where poverty is extreme. Age differences within unions or marriages also influence adolescent pregnancy rates, the greater the age difference, the greater the chance that the girls will become pregnant before age 18.

HIV remains a challenge, especially for adolescent girls Globally, there are about 380 000 new HIV infections among adolescent girls and young women (10–24) every year. Globally, 15% of women living with HIV are aged 15–24, of whom 80% live in sub-Saharan Africa. In some high-burden countries in East and Southern Africa, the HIV prevalence amongst adolescent girls is more than double that of adolescent men. Reasons: 1) (Younger) Women more likely than men to be infected with HIV; 2) imbalanced power relationship and violence between partners more prevalent in child marriages, which in turn increase the risk of HIV; 3) Higher risk of infection with older and more experienced husbands Last bullet: ICRW: TOO YOUNG TO WED: Education & Action Toward Ending Child Marriage: http://www.icrw.org/files/images/Child-Marriage-Fact-Sheet-Health.pdf. Supporting data from Kenya, Uganda and Zambia. Existing research suggests that one reason why married girls may be more vulnerable to HIV is because they have little option to change their sexual behavior in response to knowledge about HIV. For example, when asked how HIV knowledge changed their behavior, unmarried girls in Zambia and Kenya were much more likely than married girls to report that they stopped having sex in response to knowledge about HIV risk (18 percent in Kenya and 27 percent in Zambia). In contrast, married girls do not have the option of abstaining from sex. The Kenya and Zambia study found that unmarried girls were more likely to report condom use than married girls. This makes sense because research shows that men are more likely to use condoms outside of marriage than with their wives. Married girls responded to information about HIV by asking their husbands to be faithful — something that they have little or no power to enforce. Despite taking this action, 30 percent of married girls in the Zambia survey felt they were at “moderate” or “great” risk of contracting HIV, compared to 18 percent of sexually active unmarried girls.7 Young married girls can be at risk of contracting HIV and AIDS if their husbands are significantly older and therefore more likely to have contracted HIV or AIDS in their lifetime. Large age gaps between husband and wife are common in some regions of the world. In central and western Africa, one-third of young women in their first marriages report having a partner that is at least 11 years their senior.8 A large age difference between the spouses is particularly prevalent in polygamous unions, where adolescent girls can be the second or third wife of an older man. There is evidence that the earlier a girl marries, the more likely her husband is to be significantly older than her.9 Ending child marriage will elilminate a significant source of health risks for girls. Since older men tend to be more sexually experienced than young men, young girls are much more prone to HIV infection when marrying a much older man. Marriage to a much older husband also places a girl at higher risk of infection than her unmarried peers. The imbalance of power in a relationship like that also increases the chance that the bride will lack the authority to refuse sex or to insist on safer sex—all of which exposes her to the potential for infection. She may not even realize she’s in danger if she doesn’t have access to information about reproductive rights and sexually transmitted diseases, which is often the case in developing countries.

HIV Prevalence – Young women and adolescent girls are being left behind Adolescents (10–19 years) is the only age group in which AIDS deaths have risen between 2001 and 2013. Reasons: 1) (Younger) Women more likely than men to be infected with HIV; 2) imbalanced power relationship and violence between partners more prevalent in child marriages, which in turn increase the risk of HIV; 3) Higher risk of infection with older and more experienced husbands Last bullet: ICRW: TOO YOUNG TO WED: Education & Action Toward Ending Child Marriage: http://www.icrw.org/files/images/Child-Marriage-Fact-Sheet-Health.pdf. Supporting data from Kenya, Uganda and Zambia. Existing research suggests that one reason why married girls may be more vulnerable to HIV is because they have little option to change their sexual behavior in response to knowledge about HIV. For example, when asked how HIV knowledge changed their behavior, unmarried girls in Zambia and Kenya were much more likely than married girls to report that they stopped having sex in response to knowledge about HIV risk (18 percent in Kenya and 27 percent in Zambia). In contrast, married girls do not have the option of abstaining from sex. The Kenya and Zambia study found that unmarried girls were more likely to report condom use than married girls. This makes sense because research shows that men are more likely to use condoms outside of marriage than with their wives. Married girls responded to information about HIV by asking their husbands to be faithful — something that they have little or no power to enforce. Despite taking this action, 30 percent of married girls in the Zambia survey felt they were at “moderate” or “great” risk of contracting HIV, compared to 18 percent of sexually active unmarried girls.7 Young married girls can be at risk of contracting HIV and AIDS if their husbands are significantly older and therefore more likely to have contracted HIV or AIDS in their lifetime. Large age gaps between husband and wife are common in some regions of the world. In central and western Africa, one-third of young women in their first marriages report having a partner that is at least 11 years their senior.8 A large age difference between the spouses is particularly prevalent in polygamous unions, where adolescent girls can be the second or third wife of an older man. There is evidence that the earlier a girl marries, the more likely her husband is to be significantly older than her.9 Ending child marriage will elilminate a significant source of health risks for girls. Since older men tend to be more sexually experienced than young men, young girls are much more prone to HIV infection when marrying a much older man. Marriage to a much older husband also places a girl at higher risk of infection than her unmarried peers. The imbalance of power in a relationship like that also increases the chance that the bride will lack the authority to refuse sex or to insist on safer sex—all of which exposes her to the potential for infection. She may not even realize she’s in danger if she doesn’t have access to information about reproductive rights and sexually transmitted diseases, which is often the case in developing countries.

HIV knowledge and behaviour amongst adolescent girls and women In sub-Saharan Africa: Women acquire HIV five to seven years earlier than men Only 15% of young women aged 15–24 are aware of their HIV status Only 26% of adolescent girls possess comprehensive and correct knowledge about HIV, compared with 36% of adolescent boys. Among girls aged 15–19 who reported having multiple sexual partners in the past 12 months, only 36% reported that they used a condom the last time they had sex. Relationships between young women and older male partners are common and associated with unsafe sexual behaviour and low condom use. Increasing evidence to establish linkages between child marriage and HIV, including from Zambia, Uganda and Kenya.

Physical, emotional and sexual violence Percentage of ever-married women who have experienced spousal physical or sexual violence by their current or most recent husband or partner in the past 12 months, by age. Source: Demographic and Health Survey data, countries with available data in sub-Saharan Africa.

Violence, abuse and exploitation: Increasing risk and vulnerability In some settings in sub-Saharan Africa, up to 45% of adolescent girls report that their first sexual experience was forced. Over half of adolescent girls and young women who are married in sub-Saharan countries with available data do not have the final say regarding their own health care. Girls who marry before 18 are more likely to experience domestic violence than their peers who marry later.  Young women who experience intimate partner violence are 50% more likely to acquire HIV than women who have not. The available data suggest that ever-married adolescent girls and young women aged 15–24 years are the most affected by spousal physical or sexual violence, often due to low empowerment and negotiation power resulting from lack/low education, low status and decision-making power within the family and in the relationship Reasons: 1) (Younger) Women more likely than men to be infected with HIV; 2) imbalanced power relationship and violence between partners more prevalent in child marriages, which in turn increase the risk of HIV; 3) Higher risk of infection with older and more experienced husbands For example, in Kenya, 36 percent of girls married before 18 believe that a man is sometimes justified in beating his wife, compared to 20 percent of married women; UNICEF (2005). Sex between child brides—many of whom are prepubescent—and their older husbands is often violent. According to UNAIDS, violent sex increases HIV transmission because vaginal abrasions make it easier for the virus to enter the body. Source: Multi-country study on women’s health and domestic violence against women. Geneva: World Health Organization

Key challenges Laws and policies Financial Contradictions between constitutional and customary laws, especially in relation to child marriage. Laws and policies that govern the age of consent for HIV testing, treatment and access to sexual and reproductive health services. Enforcement of laws protecting young girls from child marriage, gender based violence, FGM and other harmful traditional practices. Financial Resources available for implementation of national adolescent reproductive health or related policies. Efforts - and resources – to prevent adolescent pregnancy typically focus on girls aged 15-19. Yet, the girls with the greatest vulnerabilities, and who face the greatest risk of complications and deaths from pregnancy and child birth are 14 or younger.

Key challenges (cont.) Institutional/service level Institutionalization of comprehensive sexuality education, including for marginalized and vulnerable adolescents (out-of-school youth, YPLHIV, adolescent living in slums, disabled people, LGBTI etc.). Access to integrated, safe, effective, affordable and quality SRH/HIV services, incl. prevention, contraception, HCT, counseling, and HIV treatment for youth. Availability and access to comprehensive MNCH services, including antenatal, postnatal and neonatal care for adolescent mothers and their newborns. Social protection mechanisms, mentorship and livelihood programmes for young mothers and vulnerable adolescents.

Key challenges (cont.) Community /individual Data and evidence Traditional beliefs, values and norms. Harmful practices. Knowledge and condom use/contraceptive use Multiple sexual partners and other risk behaviors. Data and evidence Documentation of best practices and evidence generation. Availability of data, especially for unmarried youth and very young adolescent aged 10-14. Civil, marriage and birth registration systems Participation in planning, implementation and M&E Involvement and engagement of adolescents and young people, including adolescents girls, in policy making, planning and M&E M&E and accountability systems

Advancing ASRHR - A multi sectoral framework for action

Key strategies and recommendations Reduce marriage before age 18 Harmonize and enforce laws, protocols and policies related to ASRHR/HIV and child marriage Inform and empower girls Keep girls in school Influence cultural norms that support child marriage and harmful practices through sensitization of communities and religious leaders Reduce HIV and early and unintended pregnancies Provide Comprehensive Sexuality Education to adolescent girls and boys - in and out of school /key populations Enhance access and quality of HIV and early pregnancy prevention programmes Build community and education sector support for prevention of HIV and early pregnancies Improve access to youth friendly, integrated SRH/HIV services Increase use of contraception Legislate access to contraceptive information and commodities Reduce the cost of contraceptives to adolescents Educate adolescents about contraceptive use Build community support for contraceptive provision to adolescents Improve access to contraceptive services Skills for adolescents to obtain contraceptive services

Key strategies and recommendations Reduce sexual and gender based violence and harmful practices Put in place and enforce laws that prohibit sexual and gender based violence and harmful practices Empower girls to resist coerced sex and gender based violence Influence social norms that condone coerced sex and gender based violence Engage men and boys to critically assess gender norms Reduce unsafe abortion Enable access to safe abortion and post-abortion services for adolescents Inform adolescents about dangers of unsafe abortion Increase community awareness of the dangers of unsafe abortion Increase use of skilled antenatal, childbirth, and postpartum care Be sensitive and responsive to the needs of young mothers and mothers-to-be Inform adolescents and community members about the importance of skilled antenatal and childbirth care Expand access to skilled antenatal, childbirth, and postnatal care, including Basic and Comprehensive Emergency Obstetric Care

UNFPA regional response – ASRHR and child marriage Advocacy and support for implementation of the AU and national campaigns to end child marriage (ongoing) Regional assessment of ASRHR laws and policies (ongoing) Data for development, incl. secondary analysis of census, DHS,MICS etc. to identify and target geographic “hotspots” – areas with high proportions and numbers of girls at risk of child marriage (ongoing) Support for implementation of multi-sectoral adolescent girls and child marriage programmes in high-prevalence countries (community engagement, CSE, health services/commodities, information, social protection and asset building) (ongoing) Capacity building for REC parliamentarians and national partners/member states (2015) Intervention/operational research for evidence generation (planned for 2015/2016)

A Regional assessment of laws and policies UNFPA will undertake a comprehensive assessment with compilation, review and analysis of national laws and policy provisions related to ASRHR in the Eastern and Southern Africa Region; The study will inform the development of a standardized regional framework/protocol for harmonized AYP national laws and policies and support national partners in realizing enabling legal and health system environments for adolescents sexual and reproductive health and rights, including HIV-prevention.

A Regional assessment of laws and policies The study will be undertaken by Business Enterprises at University of Pretoria (Pty) The objectives of the study are the following: To compile a full synopsis of laws and policy provisions relating to adolescents’ and young people’s SRH Rights, including HIV-prevention; To undertake an exhaustive analysis of the information obtained, including status of implementation, monitoring and evaluation of the relevant laws and policies in the East and Southern Africa Region; To document good practices, lessons learned at the national and/or regional level and the development of recommendations for SADC and EAC; To compile short case studies of young people’s experiences on how policies and laws are affecting their access to SRH and HIV services in select countries in the East and Southern Africa Region; and Finally, to develop a draft regional framework /protocol that takes into consideration regional and global commitments, and which is to be presented to SADC, EAC, IGAD and their member states for validation and endorsement.

A Regional assessment of laws and policies The study will be mainly focus on the following areas: Ages of consent to sexual activity; Ages of consent to marriage; Criminalization of consensual sexual activity among children; Ages of consent to medical treatment, including treatment for HIV and access to contraceptive aids; Reproductive health services including termination of pregnancy; Provision of education on sexuality and sexual health; Sexual diversity; National AIDS plans with focus on addressing stigma and discrimination; Criminalization of HIV/AIDS transmission; Forced sterilization; Harmful cultural practices; Protection for victims of sexual abuse; Gender specific legal protection; Sexual offences framework, including sexual abuse in schools and laws criminalizing consensual sex.

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