Let's talk about it
A Nepali Times survey shows adolescents want to know more about reproductive health, but don’t have anyone to turn to
Although Nepal has shown remarkable progress in child and maternal health, somehow not as much attention is paid to the needs of adolescents in the 10-19 age group who make up a quarter of Nepal’s population.
Adolescence is a critical developmental transition from childhood to adulthood in which an individual goes through changes at all levels: physical, emotional, psychological and social. These changes bring with them special health needs and risks.
Yet, the specific problems of this age group are overlooked by health care providers and the government. Surveys have shown that school-going adolescents do not get enough answers to questions about reproductive health, contraceptive use, sexually-transmitted diseases. Rarely do they get this information from parents, either.
“I have irregular periods, and my gynaecologist just gave me medicines without explaining what was wrong. After I stopped taking them, I am irregular again, but I don’t want to keep taking medicines. I don’t know what to do, who am I supposed to ask?” said 16-year-old Nisha Thapa who often misses school because of her condition.
All the girls interviewed for a recent Nepali Times focus group said it would have been much easier if there was a separate health facility for adolescents where they would feel comfortable and open to share problems, without feeling rushed or judged. Both girls and boys in the survey also said their schools did not explain puberty and reproductive health adequately.
"Our level of understanding is book-based. We know the definitions and basic concepts, but I cannot really apply that in real life," said 17-year-old Renu Adhikari. "I know what menstruation is, but I don’t know what is actually happening inside my body. I don’t know what causes cramps and how to ease it."
Even in Kathmandu, there isn’t any separate department for adolescents in hospitals or health posts. Teenagers are directed to adult doctors where they may be too shy to express what is happening to them. Unsatisfactory treatment and lack of privacy are other fears.
Many of the teenagers will be voting-age in less than ten years, and preparing them for life’s struggles should be a critical part of the education they get. But because of the lack of guidance from parents and teachers, they turn to peers or the internet for information, both of which give inadequate or inaccurate information.
All this leads to mental stress and anxiety in many adolescents. A survey showed that one in every five teens in Nepal suffers from some sort of mental disorder, and suicide is the leading cause of death among 15-19 year olds worldwide. Cultivating a safe and non-judgemental environment for adolescents is therefore of key importance, health experts say.
Investment in adolescents can be cost-effective, too. For example, safe motherhood is a top priority in Nepal’s public health. And if adolescent health had been given more importance, girls and boys would have had a more comprehensive understanding of reproduction – leading to fewer complications later in life.
Surveys have shown that many Nepali women are unaware that giving birth before age 20 is not safe. Adolescent reproductive health education is urgent in a country where more than half of women are married by age 18. Pregnancy related complications is the number one cause of death among girls aged 15-19 in Nepal.
The Nepali Times survey of boys and girls aged 14-19 showed girls were mostly concerned about abdominal and body pain during menstruation, or irregular periods. (See box) For boys it was mainly wet dreams and sexually-transmitted diseases, especially HIV/AIDS.
Sita Limbu, 19, is training to become a flight attendant. She has bad cramps and excessive bleeding. Instead of going to the gynaecologist, she takes pain killers. Like many others, she doesn’t know that sedatives are not the answer to painful periods.
Although 24-year-old Bina Gurung is not an adolescent anymore, she still has doubts about reproductive health: "I talk to my friends and older cousins, or go to Google to look up information, but I still cannot say that I know the pros and cons of various contraception methods. We never really had in-depth lessons in school, and we never spoke about it at home."
The Nepal government developed a National Adolescent Health and Development Strategy in 2000 and revised it in 2015. In 2011, a National ASRH (Adolescent Sexual Reproductive Health) Program Implementation Guidelines, and a National ASRH Communication Strategy was introduced. Adolescent health was also given priority in the National Health Policy 2014.
So Nepal seems to be well-placed in terms of plans and guidelines, but there are big gaps in implementation. The Family Health Division has set up over 1,000 Adolescent Friendly Service (AFS) centres throughout the country, with at least 13 in each district. But only 56 are certified. In a recent visit, one of the clinics in Kathmandu was understaffed and there was not enough information to the public, especially adolescents, about where it was located. None of the adolescents or school teachers interviewed for this article knew about the government AFS centres, or of any counselling organisation.
Birendra Pradhan at UNICEF says: "There are no controlled mechanisms for adolescent health care in urban areas. We need a multi-sectoral and coordinated effort. The government and development partners need to work closely."
Most girls, even in Kathmandu Valley, do not know much about menstruation prior to getting it. Nirvani Sharma, a teacher at Uma Maheswor School in Lalitpur, had to send a Grade 6 student home after she came to school without wearing a sanitary pad when her periods started.
“This situation could have been easily avoided if her parents had told her about periods,” Sharma said. Many school girls miss classes because of lack of awareness, or social and physical discomfort during menstruation. Some even drop out of school.
Pranisha Adhikari, 17, says that although she is comfortable talking about most things, learning about menstruation in school wasn’t easy, mainly because of the attitude of boys in her class.
“It is important for boys to also take interest in learning about menstruation, so that they are aware of what is happening to their classmates, instead of making it more uncomfortable for us,” Adhikari said.
This natural aspect of reproductive health is still largely viewed as something negative, shameful, dirty and embarrassing. All the adolescent girls interviewed for this story said that they were not satisfied with their knowledge of menstruation, and there was a lot they were still confused about. How to deal with period cramps, for example, was the top question everyone had. The second concerned menstrual hygiene.
They suggested that since students spend so much time every day in school, it would be most effective if schools had regular programs discussing these issues, normalising the talk and attitude towards menstruation.
Says Pranisha Adhikari, “What we learn through textbooks is helpful, but it still doesn’t equip us to deal with real life situations. For example menstrual hygiene is not discussed in depth, it is too important a matter for us not to know much about it. ”
Removing menstrual shame, Clara Hare-Grogg
That time of the month, Rubeena D Shrestha
Girl talk: period, Anjana Rajbhandari