CHAPTER ONE

BACKGROUND TO THE STUDY

INTRODUCTION

Over the last two decades, adolescents’ sexual and reproductive health has taken the center stage within the global discourse of reproductive health problems. Across the world today, adolescent sexuality has become an important social and medical topic because youths are known to be sexually active, often in situations of little reproductive health information or services (Alubo, 2001; Onifade, 1999; Sai, 1995).

Furthermore, adolescents have been considered to form a considerable at-risk group within the larger society. This is particularly evident in Nigeria where a lot of socio-economic factors put them at a greater risk given the challenges and opportunities they face daily in a rapidly changing world. In Nigeria and other low income countries, there are also several reproductive health problems such as unintended pregnancy, maternal mortality, and sexually transmitted infections (STIs) including HIV/AIDS, the transmission of which the youths are particularly disadvantaged, (Onifade, 1999; Lear, 1997).

The Population Reference Bureau (2011) has indicated that nearly one third of Nigeria’s total population of over 160 million is between the ages of 10 and 24. According to a report by Sampson Melodi of the Advocates for Youths, adolescent proportion of the population makes them integral to the country’s social, political and economic development. Nigeria’s development according to this report is compromised by the sexual and reproductive health issues afflicting her youth. Lack of sexual health information and services make young people vulnerable to sexually transmitted infections (STIs) and unintended pregnancy (Sampson,

Advocates for Youths, 2000). While intending to protect young people, some adults may limit young people’s access to information and health services in fear that information will promote sexual behaviour. Information however is the greatest tool young people need to protect themselves against reproductive and sexual ill-health.

Reproductive health has been viewed by scholars as a fundamental aspect of general well being, constituting a central feature of human development. It reflects one’s state of health during childhood, adolescence and adulthood, and sets the stage for health beyond the reproductive years for both women and men and also impacts on the health of the next generation (Kotwal, Gupta and Gupta, 2008). A probable unofficial working definition of reproductive health has been given as the state of complete physical, mental and social well-being, and not merely the absence of reproductive disease or infirmity. Reproductive health therefore deals with the reproductive processes, functions and system at all stages of life. Alubo (2001) in the African journal of Reproductive Health defined reproductive health as “the whole array of counsel, information and services required and necessary for safe and healthy sexual expression. It concerns health and illness in relation to the body's reproductive function”. A working definition of sexual health has been given as a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Thus, sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.

According to the late professor Olikoye Ransome-Kuti (2001), 30% (one and a half billion people) of the world’s population were between the ages of 5 and 19 years as at 1997. He therefore projected that, by 2025, the proportion of people in this age category would have become one quarter, that is, 2 billion, of a total population of 8 billion. To him therefore, in Nigeria, these age groups constitute about 30% of the population caught between the accepted constraints and order imposed by the traditions and customs of communities and the liberties of an emerging civilization. Adolescents in Nigeria are thus caught between tradition and changing cultures brought about by urbanization, globalized economies and a media saturated environment (AHI, 1999).

As stated in one of the monographs published by the Action Health Incorporated (2003), “adolescence is the transition period between childhood and adulthood. It extends roughly through the entire second decade of life. It is the period in which patterns of behaviour which have life-long consequences are formed and becomes established...”

From this statement we can easily deduce that the period of adolescence is a pretty precarious one and the behavioural patterns (which are usually risky) adopted at this period could result in far reaching consequences. The World Health Organization (1997) has this to say about adolescence – “adolescence is a time of learning which necessarily includes risk taking, but the conditions in which those risks are taken will often make the difference between constructive and destructive outcomes”.

The subject matter of adolescent sexuality can thus be seen as a reality as stated by the former Minister of health, late Professor Olikoye Ransome-Kuti. This is so because, in his opinion, today’s young people reach physical maturity earlier and marry later. Society has a responsibility therefore to ensure that they make responsible sexual choices.

A report by the UNFPA has revealed that adolescents aged 10-19 years comprise about one-fifth of the world’s population, which is equivalent to 1.2 billion young persons (UNFPA, 2003). Corroborating this revelation, Ipas (2004) submitted that about 87% of these young people live in developing countries. In fact, in many countries of Africa, young people make up to 33% of the population (Olukoya, 2004).

According to recent findings on adolescents’ sexual and reproductive health, unwanted pregnancies and abortions are increasing among adolescents with serious consequences on their health. Unsafe induced abortion has being identified as the number one cause of death among young adolescent mothers aged 13-19 years in developing countries. About 90 percent of adolescent births (12.8 million) occur each year in developing countries (World Health Organization, UNFPA, 2006). In sub-Saharan Africa and southern Asia, 28 to 29 percent of women give birth by age 18 (Population Reference Bureau, 2006).

The UNFPA (2004) has documented that pregnancy is the leading cause of death for young women ages 15 through 19. Maternal mortality statistics according to Graczyk (2007) underscore how societies have failed women, especially young women in developing countries. As many as 529,000 women die each year from complications of pregnancy and Childbirth (World Bank, 2006).

According to a recent USAID report, while maternal mortality figures vary widely by source and are highly controversial, the best estimates for Nigeria suggest that approximately 54,000 women and girls die each year due to pregnancy-related complications (USAID, 2011). It was also found out that, estimates of maternal deaths are under-reported by as much as 50 percent because maternal deaths are more often not counted at all. Additionally, another 1,080,000 to 1,620,000 Nigerian women and girls will suffer from disabilities caused by complications during pregnancy and childbirth ((USAID, 2011)) each year.

It has however been observed that correct and timely sexual and reproductive health information can make available the requisite knowledge and skill that is needed to make informed choices among adolescent girls. As reported by the late Professor Olikoye Ransome-Kuti (2001), “young people often complain about sexuality; that government and churches fail to convey the right messages about sexuality to them; that there is a lack of communication with their parents especially about sex and HIV and AIDS”. Professor Ransome-Kuti further asserted that these young people complain that they learn from their peers and suffer considerable peer pressure. It has also been observed by the World Health Organization (2011) that adolescent mothers often lack knowledge, education, experience, income and power relative to older mothers (WHO, 2011). A low level of reproductive health knowledge therefore could likely be the reason why there is high incidence of unplanned pregnancies among young adolescent girls which consequently often lead to the fatal decision to abort. Since abortion is not legalized in Nigeria except when a pregnancy poses a serious threat to the life of the woman, findings have revealed that most adolescents girls, in a desperate frenzy to get rid of an unwanted pregnancy, usually self-induce an abortion which poses a serious health risk to the adolescent in question. The decision to abort among adolescent girls also often generates fatal consequences because they lack the appropriate information and support they need especially from family members and the society at large. Pregnancy among adolescent girls is usually frowned upon by the society especially such society that places a high premium on moral values, chastity and education. An unfortunate pregnant adolescent girl usually finds herself alone in her dilemma to keep or terminate a pregnancy. Young pregnant girls in some societies in Nigeria often face the harsh consequence of being thrown out of the house by their parents. They are often subjected to rejection and denial by the person who impregnated them and they also face the risk of dropping out of school. Because of the fear of being subjected to shame and ridicule, and because of the family name which is at stake, pregnant adolescent girls may engage in unsafe induced abortion procedures which is usually inimical to their health and can lead to serious reproductive health outcomes, and ultimately, death.

This study therefore intends to assess the knowledge level of adolescent girls on sexual and reproductive health issues with particular focus on their awareness of family planning services and usage.

STATEMENT OF THE PROBLEM

The rate of unplanned pregnancies among adolescent girls around the world today is quite alarming. Cheng (2008), in his report has noted that, approximately 205 million pregnancies occur each year worldwide. Over a third are unintended and about a fifth end in induced abortion. Most abortions result from unintended pregnancies (Bankole et al, 1998), and it has been revealed that adolescents have the highest risks of suffering serious complications from unsafe abortions. Among women admitted to hospitals for treatment of unsafe abortion complications, those aged under 20 years account for 38-68% of cases in many developing countries (Olukoya et al., 2001). These complications include cervical or vaginal lacerations, sepsis, hemorrhage, bowel or uterine perforation, tetanus, pelvic infections or abscesses, chronic pelvic inflammatory disease and secondary infertility. According to a recent study, about 4.4million teenagers engage in abortion annually (Negedu, 2011). This is because, 60% of pregnancies are either mistimed or unwanted among adolescents.

Studies in the past have indicated that, lack of adequate sexual and reproductive health knowledge may possibly represent a key factor preventing the complete elimination of unwanted pregnancies, and unsafe induced abortion among adolescent girls in Nigeria. According to Ipas (2005) unplanned pregnancies are the result of various factors, including lack of knowledge about menstruation and pregnancy, lack of access to, and knowledge about how to use contraceptives; difficulties in using contraceptives because of a partner’s or family objections; contraceptive failure; and sexual assault. Also, adolescents may more often delay seeking care for abortion-related complications due to lack of transportation, lack of knowledge about where post-abortion care can be obtained, fears of censure from their parents and health-care providers, fear of legal repercussions, or lack of money to pay for services (Ipas, 2005). This may be particularly so in rural communities where access to basic infrastructural facilities remain low and inadequate.

As noted by Makinwa-Adebusoye (2006), policy and programming attention has turned towards adolescents’ sexual and reproductive health in the past decade but not much attention has been paid to the reproductive health needs of young adolescent girls, particularly in a developing country like Nigeria. Despite the activities of governmental and nongovernmental organizations (NGOs) in the areas of adolescent reproductive health, the need for accurate reproductive knowledge and skills especially among adolescent girls that reside in poor disadvantaged communities in Nigeria still remain largely unmet. Could the high level of unsafe induced abortion among adolescents be actually attributed to the limited reproductive health knowledge among them? This present study seeks to examine this problem.​

RESEARCH QUESTIONS

The guiding research questions for this study include the following:

• What is the knowledge level of adolescent girls about reproductive health issues generally?

• What is their level of awareness concerning the existence of family planning services?

• Is there a link between the knowledge level of adolescent girls about reproductive health issues and the incidence of unsafe induced abortion?

• Is there a connection between their level of awareness about family planning services and their usage of these services?

• Is there a link between their knowledge of family planning services and unsafe induced abortion?

GENERAL AIM OF STUDY

The general aim of this study is to assess the association between the sexual and reproductive health knowledge of adolescent girls and induced abortion in the study area.

​OBJECTIVES OF STUDY

This study therefore has as its objectives the following:

To investigate the general knowledge level of adolescent girls about reproductive health issues.

To assess their level of awareness concerning the existence of family planning services.

To find out the relationship (if any) between the knowledge level of adolescent girls on reproductive health issues and unsafe induced abortion

To establish the relationship between their level of awareness about family services and their usage of these services.

To ascertain the relationship between their knowledge of family planning services and unsafe induced abortion.

JUSTIFICATION FOR THE STUDY

Inspite of the wide array of literature on adolescent reproductive health, it has been observed albeit sadly that not much has been done in the area of reproductive health knowledge and the incidence of unsafe induced abortion particularly among female adolescents from disadvantaged communities in Nigeria.

The tendency for young people to indulge in premarital sex coupled with their poor access to reproductive health information and services has been viewed as increasing their risk of unplanned and too early pregnancy, HIV infection and other STDs, as well as unsafe induced

abortion (United Nations, 1995: para 95). It is believed that, an understanding of the extent of the sexual and reproductive health knowledge of adolescent girls and their usage of reproductive health services will help to better explain the reason for the prevalence of unsafe induced abortion among them in Nigeria. It will also help in reaching a logical conclusion about the depth of adolescents’ reproductive health knowledge that can help in improving public health intervention strategies that will assist in the formulation of feasible policies targeted at the improvement of the sexual and reproductive health status of adolescent girls in the country.

Past studies on the question of unsafe induced abortion have focused extensively on several issues ranging from the illegal status of abortion to poor access and quality of medical facilities to treat complications of abortion and the wide array of people who carry out unsafe abortion (Okonofua, 1993). Thus, Okonofua considers mainly service factors as responsible for the high abortion related mortality in Nigeria.

Similarly, a number of studies have concentrated on the older members of the society, thereby giving little attention to adolescents, particularly adolescent girl who constitute a a serious at-risk group within the society. Quite a number of studies have also focused extensively on married adolescents in the Northern part of Nigeria while little attention has been given to adolescent girls from less privileged areas, particularly poor communities that are usually subjected to neglect in terms of infrastructural facilities in the South-west region of the country. This research work therefore seeks to address this gap.

​STUDY AREA

This study was conducted in the Badagry local government area of Lagos State, Nigeria. Lagos state is the smallest state in Nigeria with an area of 356,861 hectares of which 75,755 hectares are wetlands, yet it has the highest population, which is over five per cent of the national estimate. The state has a population of 17 million out of a national estimate of 150 million. The UN estimates that at its present growth rate, Lagos state will be the third largest mega city in the world by the year 2015 after Tokyo in Japan and Bombay in India. Of this population, Metropolitan Lagos, an area covering 37% of the land area of Lagos State is home to over 85% of the State population.

The rate of population growth is about 600,000 per annum with a population density of about 4,193 persons per sq. km. In the built-up areas of Metropolitan Lagos, the average density is over 20,000 persons per square km. Current demographic trend analysis revealed that the State population growth rate of 8% has resulted in its capturing of 36.8% of Nigeria’s urban population (World Bank, 1996) estimate at 49.8 million people of the nation’s million population. The implication is that, whereas country population growth is 4/5% and global 2%, Lagos population is growing ten times faster than New York and Los Angeles with grave implication for urban sustainability.

Badagry is a coastal town and Local Government Area (LGA) in Lagos State, Nigeria. Badagry is situated between Metropolitan Lagos, and the border with Benin at Seme. The ancient town of Badagry was founded around l425 A.D. However, before its existence, people lived along the coast of Gberefu and this area later gave birth to the town of Badagry. It is the second largest commercial town in Lagos State, located an hour from Lagos and half hour from the Republic du

Benin. The Town of Badgry is bordered on the south by the Gulf of Guinea and surrounded by creeks, islands and a lake. The ancient town served mainly the Oyo Empire which was comprised of Yoruba and Ogu people. Today, the Aworis and Egun are mainly the people who reside in the town of Badagry as well as in Ogun State in Nigeria and in the neighboring Republic du Benin.

In the early 1500's, slaves were transported from West Africa to America through Badagry. It is reported that Badagry exported no fewer than 550,000 African slaves to America during the period of the American Independence in l787. In addition, slaves were transported to Europe, South America and the Caribbean. The slaves came mainly from West Africa and the neighboring countries of Benin and Togo as well as others parts of Nigeria. The slave trade became the major source of income for the Europeans in Badagry.

As of the preliminary 2006 census results, the municipality had a population of 241,093. In 1863, the town was annexed by the United Kingdom and incorporated into the Lagos colony. In 1901, it became a part of Nigeria.

Badagry subsists largely on fishing and agriculture, and maintains a small museum of slavery. Places of interest include the Palace of the Akran of Badagry and its mini ethnographic museum, the early missionaries cemetery, the District Officer's Office and Residence, the First Storey Building in Nigeria constructed by the Anglican missionaries, relics of slave chains in the mini museum of slave trade, cannons of war, the Vlekte slave Market, and the Slave Port established for the shipment of slaves.

The Badagry local government has been divided into three Development Areas namely: Badagry West, Badagry central and Olorunda. The study population for this research was thus selected from two out of these three development areas and they are: Badagry West and Olorunda.

​SCOPE AND LIMITATION OF STUDY

The major scope of interest for this study basically revolves around issues surrounding the depth of knowledge about sexual and reproductive health among female adolescents in selected communities in the Badagry local government area of Lagos state. This study therefore intends to assess the knowledge level of female adolescents in selected disadvantaged communities in Badagry in order to identify the link between their knowledge of reproductive health, service availability and awareness, and the usage of these services. An understanding of this link is believed will help to better explain the prevalence of unsafe induced abortion among adolescent girls who constitute a significant at-risk group in the population. The study therefore is limited to in-school and out of school female adolescents in the selected study area.