Written by Lana Chikhungu.
Image credit: World Vision Australia.
In both Taiwan and Malawi, adolescent pregnancy is associated with an increased risk of physical and mental health issues. According to the Ministry of the Interior (MoI) of Taiwan, the fertility rate of women between the ages of 15 and 19 years was 6.8% in 1951. The rate dropped by more than half to 3.1% in 1981, and it was further halved to 1.5% in 1997. Since 2009, it had remained at 0.4% until 2021 it further declined to 0.3% and stayed at 0.3% in the past two years. (The MoI does not provide fertility rate data of women below the age of 15.) The rate is higher than in South Korea. A study published in 2007 states that two-thirds of the fathers of children born to underage women were adults and argues that active use of contraception is ‘more important and practical’ to reduce underage pregnancy.
During the COVID-19 pandemic, both Taiwan and Malawi saw an increase in the risk of gender-based violence for women. In Taiwan, migrant domestic workers were also victims of gender-based violence during this period. Studies on pregnancy in Taiwan during the pandemic examined the effects of the disease on pregnancy and maternal care practices, as well as its impact on sex life. There does not seem to be any study conducted about teenage pregnancy during the pandemic in Taiwan. Dr Chikhungu’s research on Malawi provides a unique insight into how the pandemic not only had gender-specific implications but also had an age-specific impact. It remains to be seen as to whether a similar effect – increased adolescent pregnancy – also took place in Taiwan but has gone unnoticed and whether data collected by public health institutions and the National Health Insurance system can ascertain such incidences.
Teenage pregnancies are a global health concern because they increase complications during childbirth and are linked to poor maternal health outcomes. Teenage mothers are at an increased risk of experiencing conditions that put their lives at risk, such as eclampsia, puerperal endometritis, and systemic infections, and their babies face the risk of low birth weight, preterm birth, and severe neonatal conditions. Sub-Saharan African countries experience higher rates of unintended teenage pregnancies, particularly among those aged 10-14 years. This issue is exacerbated by the widespread acceptance of child marriage in many of these countries. For instance, in Malawi, one in every two girls marries before the age of 18, despite the existence of laws prohibiting such practices. A further complication is the hidden yet normalised issue of child sexual abuse within homes that came to light during the COVID-19 pandemic period. Malawi experienced an increase in defilement cases (sexual intercourse with a girl under the age of 16 years) and the number of girls attending antenatal services in public health facilities during the COVID-19 pandemic period. The close alignment between child marriages, teenage pregnancies, and child sexual abuse should be acknowledged and tackled as one problem if we are to make positive strides in achieving sustainable development goals related to maternal and newborn health.
The custom of child marriage obscures but, in some cases, illuminates girl-child sexual abuse within homes.
At 48%, the percentage of girls that marry before the age of 18 years in Malawi is one of the highest in the Sub-Saharan African region. It was only in 2017 that the Malawi government formalised the law, setting the age of 18 years as the minimum age of marriage following a parliamentary vote. Such a development is a source of hope for intensified efforts to ensure the observance of the minimum age and eventual reduction of child marriages and teenage pregnancies. Nevertheless, perceptions amongst married and unmarried women in Malawi are that the enforcement of child marriage laws, for example, through the issuing of fines and withdrawing girls from marriages, results in negative consequences. Addressing poverty is the needed long-term solution to reducing the prevalence of child marriages in Malawi. The practice of child marriage obscures child sexual abuse because girls who marry before the age of 18 years engage in sex within marriage and get pregnant as adolescents. Some communities undertake child marriages as a solution to unwanted pregnancies with parental support. In such situations, marriage is considered an act that makes good of a bad situation, and girls in these circumstances evade stigma. There is no system in place for recording such cases as child marriages or child sexual abuse.
Conversely, the high value placed on marriage provides unrecognised opportunities for monitoring child sexual abuse in Malawi. This is because cases of defilement are often reported to the police when a pregnancy occurs, and the one responsible refuses responsibility. In such cases, reporting to the police does not only serve to report the criminal act of child sexual abuse and have it recorded but obliges the man involved in marrying the impregnated girl or paying damages. Such patterns are confirmed in recent studies on girl child abuse in Malawi, which revealed that the Northern region has the highest likelihood of reporting cases of defilement compared to other regions. The Northern region differs from the Central and Southern regions by having the highest percentage of patrilineal communities, where lineage is traced through the father and the highest number of households headed by married couples. In contrast, the Central and Southern regions have the highest number of matrilineal communities, where lineage is traced through the mother. Additionally, the Southern region has the most female-headed or female single-parent households. The Northern region is also unique in the practice of polygyny, which further encourages child marriages. This geographical difference in marriage and lineage customs has a bearing on the practice of child sexual abuse and the tendency to report it to the police.
Sex initiation practices amongst girls promote child sexual abuse in Malawi.
In addition to the practice of child marriage, another harmful cultural practice that influences girl child sexual abuse in Malawi is initiation ceremonies that groom young girls on how to please men sexually. In some initiation practices, girls are encouraged to identify a boy or professional man (referred to as hyena, fisi in Chichewa, the national language) to have sex with them to put into practice what they learned at the initiation ceremonies which puts them at risk of unwanted pregnancies or contracting sexually transmitted diseases. While in most cases, such initiation ceremonies are conducted in private, in some cases, girls have to dance in public, and people in attendance can touch their breasts at a small fee. Such a practice violates human rights and sows a mentality of disrespect towards girls and women in Malawi. It is no wonder that the percentage of teenage pregnancies is relatively higher in the Southern region, where such type of initiation practices are more prevalent.
Can Public Health facilities’ data on Girls’ utilisation of Antenatal and Postnatal Services be used to monitor girl-child sexual abuse in Malawi?
Girl child sexual abuse in Malawi is monitored through reports of defilement made to the Malawi Police. In 2021, the Northern region recorded the highest rate of defilement per 100,000 population, followed by the Southern (second highest) and Eastern region (third) and the Central region had the lowest. Nevertheless, it is expected that a majority of cases were not reported to the police due to the custom of child marriages and sex initiation practices earlier described. As mentioned earlier, most defilement cases get reported when the man who made a girl pregnant refuses responsibility. With this in mind, data on the number of girls accessing antenatal, postnatal, and post-abortion care services that is recorded in Malawi public health facilities compiled through the district health information (DHIS2) offers an opportunity to monitor the trends and patterns of girl child sexual abuse in Malawi. The DHIS2 was developed collaboratively by the HISP Centre at the University of Oslo (UiO) and the global HISP network and is provided free of charge as a global public good. More than 80 countries worldwide use DHIS2 for collecting and analysing health data. According to the study by Chikhungu that used DHIS2 data, the rate of recorded antenatal cases per 100,000 population was highest in the Eastern region, second highest in the Southern region, third highest in the Northern region, and lowest in the Central region.
Confidence in using public health facility data on antenatal care accessed by adolescents as a proxy for girl-child sexual can be achieved if we are to establish an alignment between the geographical patterns observed from the DHIS2 data with survey data on adolescent sexual and reproductive health. The following variables from the 2015 Malawi Demographic and Health Survey data; population aged between 12 to 14 years that are married, the median age at first sexual intercourse, the median age at first marriage, and the median age at first birth are best placed for such a purpose. By performing the Mann Whitney U Statistical test, Chikhungu found that the number of girls that were ever married was significantly higher amongst girls from populations where the rate of reported defilement per 100,000 women was 30.50 or higher compared to girls from populations where the rate of reported defilements was 28.50 or less (P value 0.029.) The median age at first intercourse was significantly higher for girls from populations whose rate for antenatal attendance was 22.60 or less compared to girls from populations with an antenatal attendance rate of 25.80 or higher (P value 0.044). The number of girls attending antenatal and postnatal services was higher in the Eastern region compared to other regions. The same study also found that the Northern region has a higher number of girls aged 14 years or less that reported to have been ever married compared to other regions (P value 0.012), the central region has significantly lower number of girls aged 14 years or less that reported to have been ever married compared to other regions (P value <0.001) and that there were no significant differences between the Southern nor Eastern regions and the rest of the regions in the number girls that reported to have been ever married. The median age at first sexual intercourse and first birth is significantly lower in the Eastern region, with P values <0.001 and 0.024, respectively, compared to the rest of the regions, but significantly higher in the Central region compared to the rest of the regions, P value <0.001 for both.
Conclusion
The close alignment between Malawi Police defilement data, Public health facilities data on the number of girls accessing antenatal services, and survey data on child marriage and sexual debut gives confidence that Public health facility data can be relied on for the monitoring of girl child sexual abuse in Malawi. It is important for programmes designed to tackle girl child sexual abuse in Malawi to recognise and use this data due to underreporting of girl child sexual abuse to the Malawi Police.
Dr Lana Chikhungu is Senior Lecturer in International Development Studies at the School of Area Studies, Sociology, History, Politics and Literature of the University of Portsmouth. She is an Associate Editor of the International Journal for Equity in Health and a Member of the Editorial Board of Plos Global Public Health.
This article was published as part of a special issue on ‘In the Name of Birth: Technology, Care and Circumstances‘.
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