Underage girls’ pregnancy during schooling in Niger: Socio-demographic aspect, causes, effect and control. A prospective cohort study

doi:10.21203/rs.3.rs-4867241/v1

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Underage girls’ pregnancy during schooling in Niger: Socio-demographic aspect, causes, effect and control. A prospective cohort study

https://doi.org/10.21203/rs.3.rs-4867241/v1

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Background

The aim of this study was to determine the frequency, the socio-demographic aspect, the consequences on the schooling of girls and the control measures of underage pregnancy in schooling in Niger.

Methods

This was a prospective cohort study over a 12-month period. The study concerned pregnant and parturient girls who were minors and in the process of attending school in the city of Niamey in the Republic of Niger.) The socio-demographic, obstetric and school data of 184 underage girls admitted to the Issaka Gazobi Maternity Hospital in Niamey during the study period were collected and analysed. At the same time, we conducted interviews in thirty (30) schools and educational inspection services in the city of Niamey, in order to gather qualitative data on the phenomenon of pregnancy and childbirth among minors in schools.

Results

The frequency of childbirth among under-age students was 3.06% in our maternity. The average age was 15.7 years. Nine out of ten minors (90.7%) had become mothers by the end of the study. School drop-out rates were high (53.8%). According to our interviews with school leaders, the factors at the root of pregnancy in Niamey schools are socio-cultural and religious (factors linked to the vulnerability of young girls, the lack of sex education within families and schools, and peer pressure, cultural and religious considerations which encourages early marriage and pregnancy, and the low contraceptive prevalence rate in Niger).

Conclusions

Pregnancy in the school environment is common in Niger and has repercussions on the normal progress of schooling. This study recommended adequate parental implication, eradication of street hawking and inculcation of moral values through religious bodies as ways of reducing underage girls’ pregnancy in schooling in Niger.

Pregnancy

Minor

Married student

Early school leaving

Young girls aged between 15 and 19 become pregnant every year in developing countries, and 12 millions of them give birth. At least 777,000 are under the age of 15 years old. East Asia and West Africa have the highest number of births [1]. In Niger, the 2017 Demographic and Health Survey (EDSN) revealed that adolescent girls make up 24.1% of all women of childbearing age [2]. They contribute almost 20% of total female fertility. The rate of teenage marriage in Niger is the highest in the world; 75% of girls are married before the age of 18 and 28% before the age of 15 years old [3]. The legal age of marriage is 15 years old in Niger. While pregnancy is an achievement in many cases, it can also be a major handicap in somme situations, such as when it occurs during a course of education or training [4]. Pregnancy in the school environment can be an obstacle to the development and education of young girls [4]. They can lead to early school dropout and exacerbate poverty [5]. In Niger, these pregnancies mainly occur in the context of marriage [6]. In Niger, despite the recurrent nature of early pregnancies in schools, it proves difficult to assess them quantitatively and qualitatively in schools due to the absence of a data collection and processing policy. Student pregnancies are not yet integrated into the system for collecting information relating to the school environment in Niger and in many African countries [3–5]. Thus, cases of dropouts and repetitions are attributed to these pregnancies without it being possible to measure their impact on academic performance.The phenomenon of early pregnancy in schools is a little explored area in Niger. We therefore undertook this study to analyse the frequency, the socio-demographic aspect, the consequences on the schooling of girls and the control measures of marriage and early pregnancy among minors attending school in Niger.

Type and period of study

This was a prospective cohort study over a 12-month period (January 2018 to 31 December 2018) on the phenomenon of marriage and early pregnancy in the school environment in Niamey in the Republic of Niger.

Study framework

The study had two components; a quantitative component carried out at the Issaka Gazoi Maternity Hospital in Niamey (National reference maternity hospital) and a qualitative component carried out in 25 general and secondary education establishments in the city of Niamey and the 5 secondary education inspections in the Niamey region. This part took place in the form of interviews with directors, principals or supervisors of schools and with secondary education inspectors.

Inclusion criteria

We included all married and pregnant students aged under 18 who agreed to participate in the study. Academic leaders from 30 educational institutions in the city of Niamey were also included in the study.

Exclusion criteria

The exclusion criteria were loss to follow-up and the desire expressed by the subject to no longer participate in the study. In this study no participants were excluded from the study.

Sample

One hundred and eighty-four (184) married minor students who presented to the Issaka Gozobi maternity hospital for childbirth or gravido-puerperal complications during the study period, which was from 1 January 2018 to 31 December 2018, were included in the study regardless of where the pregnancy was monitored.

For the qualitative aspect, 30 interviews were carried out with 30 academic managers working in the 25 general and secondary education establishments in the city of Niamey and the 5 secondary education inspections in the Niamey region selected for the study. For a total of 214 participants.

Variables studied

These were variables related to

-Maternal socio-demographic characteristics: maternal age (women under 18: underage), parity, husband’s profession,
-Clinical and obstetric data (quality of prenatal care, materno-fetal prognosis)
-Parameters related to schooling: factors leading to marriage, level of study, school absenteeism, underachievement, dropping out of school, perception of marriage and pregnancy among minors in the school environment.

Data collection method

Data was collected using an individual survey form was drawn up for this purpose. The survey form used was not validated but it was pilot tested with 20% of the population. The obstetrical records were searched for additional data. The obstetrical records were searched for additional data. For the qualitative study carried out in schools and educational institutions in Niamey, the grid for collecting data on marriages and pregnancies in schools was drawn up in order to compile data on marriages that had taken place in schools over the past year. The survey covered the five secondary education inspectorates in the city of Niamey. We carried out systematic sampling by reasoned choice, targeting 25 general and secondary schools, i.e. five establishments per commune, in order to obtain an exhaustive picture of the cases of pregnancy detected over the last two years in middle and secondary schools. To carry out this data collection work, we relied on the inspectors serving in the education inspectorates and the heads of the schools. A total of 30 interviews were carried out with 30 academic managers working in the 25 general and secondary education establishments in the city of Niamey and the 5 secondary education inspections. The duration of the interview was 30 minutes per participant. Data saturation was not considered for the qualitative outcome of this study. Also, the calculation and justification of the sample size was not done in this study.

Statistical analysis

Analyses were carried out using Epi Info 7.1 and Stata 12 software. Percentages were compared using Pearson's Chi2 test. For each test, the significance level (P) was calculated using a threshold of significance < 0.05.

Frequency

out of a total of 5807 births recorded during the study period, it had 178 of 184 minors attending school, i.e. a frequency of 3.06%.

Socio-demographic aspects and course of pregnancy: (Table 1) The mean age was 15.7 years, with extremes ranging from 14 to 17 years. The Zarma-Sonraî were the most common ethnic group (53.8%). The Kanouri and Arabs were the only ethnic groups spared the phenomenon of marriage and pregnancy among under-age girls in our study. Eighty-three point fifteen per cent (83.15%) of underage girls attended a state school. Thirteen point fifty-eight per cent (13.48%) of the underage patients had repeated at least two years of their schooling. More than 2/3 (73.34%) of minors were in secondary school. The sixth and second year classes were the most represented, with 36.41% and 22.82% respectively. The average age at marriage was 15.9 years, ranging from 13 to 17 years. Sixteen minors (8.7%) were married before the age of 15. The patients' husbands were civil servants in 26.08% of cases. Primigravida women were the most represented, accounting for 91.3% of cases. The average parity was 1.01. None of the patients smoked or drank alcohol before or during pregnancy. Pregnancy occurred within four months of marriage in 42.4% of patients. None of the women were on contraception before becoming pregnant. The proportion of minors referred by other centres was 72.8%. One hundred and five minors, i.e. 57%, came from the outlying maternity units of Niamey and twenty-nine (15.7%) came from other regions of the country. Forty-three percent (43%) of patients had at least one obstetric ultrasound scan. The average number of antenatal consultations (ANC) was 3.9, with 4.4% of pregnancies not attended. However, 46.7% of minors had attended at least four ANCs. Pregnancy outcome and fate of patients : The parameters relating to the educational consequences of gravido-puerperium are presented in Table 2. The pregnancy resulted in the birth of a healthy live child in 90.7% of cases. We recorded eleven cases of stillbirth (6%), three cases of spontaneous miscarriage (1.7%), one laparotomy for ectopic pregnancy (0.5%), one medical termination of pregnancy (0.5%) and two cases of molar pregnancy (1%). One patient had developed puerperal psychosis in the post-partum period, requiring hospitalisation in a psychiatric ward and temporary separation from the newborn.

Table 1

Socio-demographic characteristics, pregnancy monitoring and the concept of referral of minors in Niamey.
Variables
Variables	Number	Percentage (%)
Materna age (years)
Mean	15,7 -
(Extrêmes)	14–17 -
age of mariage (years)
Mean	15,9 -
(Extremes)	13–17 -
Time between marriage to pregnancy (month)
Mean	4 -
(Extremes)	1–15 -
Parity
Mean	1,1 -
(Extremes)	0–3 -
0	1	0,5
1	169	91,8
2–3	14	7,7
≥ 4	0	0
Marital status
Single	0	0
Maried	184	100
Level of study
Primary school	2	1,08
College	133	73,34
high school	49	26,66
Husband's occupation
public servant/liberal	176	95,66
Student	8	4,34
Without occupation	0	0
Reference of patients
Refered	134	72,8
Not refered	50	27,2
Nomber de prenatal monitoring
Mean	3,9
(Extremes)	0–8
0	8	4,4
1–3	90	48,9
≥ 4 Total	86 184	46,7 100

Table 2

Pregnancy outcome and educational consequences of gravido-puerperal disease
Variables
Variables	Number	Percentage (%)
Pregnancy outcome
Live newborns	166	90,7
Stillborn	11	6
Medical Termination of pregnancy	1	0,5
Abortion	3	1,7
Ectopic pregnancy	1	0,5
Molar pregnancy	2	1
educational effects of pregnancy
School dropouts	99	53,8
Bad performance	49	26,6
Nond Total	36 184	19,6 100

Consequences on schooling

We observed that, 53.8% of minors had dropped out of school. Poor performance was noted in 26.6% of patients, while 19.6% reported no negative consequences of pregnancy on their studies. The average duration of absence from school due to pregnancy was 5.8 weeks. The risk of dropping out of school was higher for 3rd and 2nd year classes (P < 0.05).

Results of the interview in 25 general and secondary schools ant five secondary education inspectorates in the city of Niamey :

Perception of girls' marriages and pregnancies during schooling

In most of the sites surveyed, underage girls’ marriages and pregnancies were seen as a major concern. Early pregnancy is an obstacle to girls' education. However, there was no systematic system for collecting data on the marriage and pregnancy of girls in schools. Indeed in Niger, student pregnancies are not recorded or notified to school inspections and to the Ministry of Education, hence the lack of documentation. Every year, some minors leave school for good or interrupt their studies temporarily. According to school heads, it is usually at the beginning of the school year that the absence of girls is noted. Very often, after enquiries, it turns out that this is due to pregnancy. The school authorities are often informed of cases of marriages and pregnancies of girls during their schooling by their husbands, other students, parents and especially when requests are made for exemption from physical education and sports lessons. Absenteeism from school and physical changes in the body due to pregnancy are often the circumstances in which the pregnancy is discovered.

Factors at the root of early marriage and pregnancy in schools

The survey of various target groups showed that the factors at the root of early marriage and pregnancy in Niamey schools can be grouped into four main categories according to the respondents. Firstly, factors linked to the vulnerability of young girls. Secondly, the lack of sex education within families and schools, and peer pressure. Thirdly, cultural and religious considerations. Fourthly, the low contraceptive prevalence rate in Niger.

Frequency

In this work, we report data from a study of 184 married underage student patients; managed for pregnancy and childbirth in 2018 in the Issaka Gazobi maternity hospital in Niamey, Niger. This study reports a frequency of 3.06%. This frequency varies from 0.65–6.2% depending on the author [7, 8]. In France, the overseas departments and regions continue to have the highest percentages of underage pregnancies, with figures of 6.2% in French Guiana and 3.8% in Réunion [7]. Guiot O et al [7] in Guadeloupe reported a frequency of 4.2% of cases. This difference can be explained by the fact that our study population was made up entirely of married schoolgirls. Our rate is higher than that of Alouini S et al [8] in France, who reported 2.38% of cases. This frequency (3.06%) can be explained by the fact that in Niger, as in other developing countries, women are subject to social and religious rules that force them to marry and start a family when they are still very young. Schoolchildren are no exception to these constraints. Niger is one of the countries where child marriage is most common in the world [4, 7, 9, 10]. Many adolescent girls are subjected to their parents' choice and to social pressure. They are suddenly thrust into the adult world with the responsibilities of wife and mother. They are exposed to the risks of early pregnancy. Marriage is also seen as a way of avoiding early pregnancies outside marriage. To a certain extent, fertility determines a woman's status in society. Whatever a woman's desire to seek social advancement through school, she is always caught up in her expected role as mother [1, 10]. This could also be explained by the fact that the majority of Niger's population is very young, with 48.8% aged between 15 and 19. The average total fertility rate is one of the highest in the world, at six children per woman, and is 5.3 children per woman in Niamey [2].

Academic and socio-demographic aspects and progress of pregnancy

The average age of under-age mothers was 15.7 years, with an average parity of 1.01. This value is higher than the national average for first births in Niger, which is 18.1 years [11]. However, this applies to all girls attending school, regardless of age or marital status. The high prevalence of early pregnancy and motherhood has been observed in several African and European studies. Guiot et al [7] reported an average age of 16.01 years. Ndayizeye J et al [12] reported an age range of between 14 and 22 years, more than half of whom were aged between 14 and 18. Gbaguidi T [13] reported that 54.19% of pregnant schoolgirls were aged between 15 and 17, while Ka A et al [14] reported 69% of cases in the 16–19 age group. Goguoa R [13] reported 40% of pregnant students between the ages of 15 and 18. Concerning the level of education, in our series 73.34% of cases of pregnancy concerned secondary school pupils. Our results are much better than those of Ka A et al [14], Gbaguidi T [13] and Ndayizeye J et al [12], who reported 71.9%, 73.6% and 49% of cases respectively. With regard to marriage, the average age of marriage in our study was 15.9 years. This rate is similar to the national average age of first marriage in Niger, which is 15.7 years [2]. This can be explained by the policies to keep girls in school put in place by the State of Niger, with the support of partners, to delay the age of marriage among girls attending school. Concerning antenatal care, 53.3% of patients did not have ANC that was properly monitored. The role of well-conducted ANC is essential. This would significantly reduce the various complications arising during pregnancy and childbirth. Antenatal follow-up is the ideal time to identify high-risk pregnancies so that they can be managed [7].

Pregnancy outcome and fate of patients

In our series, 90.7% of minors became mothers. This rate is much higher than that of Dagnogo GB [16] who reported 72.42%, and that of Gbaguidi T [13] with 44.52% of cases. This difference can be explained by the fact that in our study all the girls were married. One minor student had developed puerperal psychosis in the post-partum period, requiring hospitalisation in a psychiatric ward and temporary separation from the newborn. The psychiatric outcome was favourable. In terms of school prognosis, more than one out of two minors dropped out of school. Our results corroborate the literature on the subject. Indeed, Ka A et al [14] reported 54.43% of school dropouts, Gbaguidi T [13] found 70% of cases and Sekine K et al [17] reported 40% of cases of premature school dropout. However, in our series, 19.6% of minors reported no negative consequences of pregnancy on their studies. This rate is higher than that of Dagnogo GB [16] who found 17.24%.

Factors at the root of early marriages and pregnancies in schools and accompanying measures: Firstly, there are factors linked to the vulnerability of young girls. Some girls are in particularly vulnerable situations, which encourages early marriage and pregnancy. However, several actions have been undertaken by the Nigerien authorities alongside development partners. These include the project to promote the enrolment of girls in school (PROSEF) run by the Ministry of Primary Education, the adoption of Decree No. 2017 − 935 on the protection, support and accompaniment of young girls in the course of their schooling, and the project for the empowerment of women and the demographic dividend in the Sahel through its "all girls to school and husband’s school" components. Early marriage and pregnancy are more common among girls from disadvantaged backgrounds. It emerged from our interviews that poverty is a factor that is very often invoked to explain the phenomenon of early marriage. Poor parents find it difficult to ensure that girls go to school normally. Secondly, low levels of sex education within families and at school, and peer pressure : Our surveys show that the early pregnancies observed in schools are also the result of low levels of education within families and at school, and peer pressure. Within families, sexuality remains a taboo subject. Schools do not take sufficient account of the sexuality of adolescents. Within schools, there are no specific programmes or strategies aimed at preventing or managing pregnancies among girls during their school years. The inadequacy of sex education provided by families and schools exacerbates the vulnerability of girls. Thirdly, cultural and religious phenomena: Niger is one of the countries where child marriage is most common in the world. Early marriages occur in all parts of the country, including the city of Niamey. Many teenage girls are subjected to their parents' choice and social pressure. They are suddenly thrust into the adult world with the responsibilities of wives and mothers. They are exposed to the risks of early pregnancy [1, 10]. Marriage is also seen as a way of avoiding early pregnancies outside marriage. The social pressure exerted on these young girls can lead to complications [14]. Fourthly, low contraceptive prevalence in Niger: In our study, none of the underage girls used contraception before becoming pregnant. The taboo nature of sexuality in Niger makes minors reluctant to use reproductive health services. These risk factors for early pregnancy in schools have been reported in several African and Asian studies [12–24]. Concerning the management of pregnancies in girls at school: At school level, there is no specific framework for the management of pregnancies in women at school. Once a pregnancy has been diagnosed, school heads often allow pregnant girls to continue their studies as normal by exempting them from physical education and sports classes. In some schools, they are allowed to make up missed lessons and exams. Sometimes headteachers ask students to suspend their studies. Depending on the circumstances, students may be able to resume their studies after childbirth or, in some cases, the following year. Our interviews with the school authorities revealed that neither the schools nor the secondary education inspectorates have a system for collecting data on the marriages and pregnancies of girls at school. One positive development is that pregnant girls are no longer subject to expulsion from school. Some regions of the country, with the support of UNICEF and UNFPA, have developed a system of coaching by mentors, godmothers, whistleblowers or negotiators whose role is to delay or cancel an early marriage. The hope is that, with time and education, it will be the parents themselves who keep their daughters at school. They will benefit a little more from what they learn at school, and that will be good for their home. In Canada, there are schools reserved for pregnant students with programmes adapted to their circumstances [25]. In Africa, some countries have made remarkable efforts to support young girls after they have given birth: These include Rwanda, which has abolished primary and secondary school fees for young girls; South Africa, which has provided financial support for teenage mothers; Senegal, which has chosen to adapt school hours to allow mothers to breastfeed or take time off when the baby is sick; Gabon, which has set up crèches and early childhood centres close to schools; and Ivory Cost, which facilitates access to sexual and reproductive health services [26].

Implications of the results and recommendations:

The themes generated out of the qualitative data obtained in this study were the folliwing :

Early pregnancy is an obstacle to girls' education and increases poverty in countries,
Child marriage and early pregnancy are undervalued phenomena in Nigerien schools,
The poverty of families, the lack of knowledge about sexual and reproductive health, cultural considerations and misinterpretation of religious texts are the causes of child marriage and early pregnancy in schools.

To reduce early marriage and pregnancy we make the following recommendations:

Encourage the development of the “husband school” initiative which has shown its effectiveness in preventing early pregnancies in certain regions of Niger,
Keep girls in school through political and social involvement,
Delay the age of marriage among students through legal texts,
Guarantee the availability of contraceptive methods for students,
Initiate zero pregnancy campaigns at school
Create educational establishments reserved for pregnant pupils/students with programs adapted to their conditions in order to avoid school dropouts,
Create nurseries and early childhood centers near schools for student mothers,
Aid to return to school would be necessary for cases of school dropouts due to pregnancy and childbirth.
Create a register for collecting and reporting data on early pregnancies in schools. Indeed, it is appropriate at all levels (school, education inspectorate, ministry of education) to have data collection tools for the documentation of early pregnancies at school.

Limitations

This study did not include parents, teachers and other students from Niamey schools, which did not allow us to have broader views on the phenomenon of early pregnancy in school environment in Niamey. Qualitative interviews with parents, teachers and other students would make it possible to better understand and describe the effects of pregnancy and/or marriage on schooling in the experience of minors. Verification of school grades with educational establishments would be necessary. In fact, the collection of data concerning the consequences of pregnancy on schooling was based solely on the personal stories of the patients. Other limit of this study wa the absence of the calculation and justification of the sample size for in the study.

This study show that pregnancy in underage school girls is a public health problem in Niger. Pregnancy at school has an impact on the normal course of schooling. Effective contraception can be offered to students in exam classes and awareness-raising for better attendance at antenatal services. Emphasis should be placed on getting young girls into school, and on informing and educating parents about the risks of early pregnancy and childbirth, both medically and academically. Help with returning to school should be promoted.

ANC

antenatal care

PROSEF

Project to promote the enrolment of girls in school

UNICEF

United Nation funding for children

UNFPA

United Nation funding for population

-Ethics approval and consent to participate:

Ethics approval was obtained by the ethics committee of Abdou Moumouni University of Niamey and Niamey City Hall (approval number 000761/2AUA/FSS/SS, date 15/11/2017 and approval number 0346/MSP, date 29/01/2018, and authorization of research letter of 28/11/2018).

Written informed consent was obtained from the legally authorized representative of the minor subjects and all persons involved in this study.The study was conducted according to the principles of the World Medical Association Declaration of Helsinki. The reporting of the study conforms to the STROBE guidelines.[27]

-Consent for publication

Not Applicable

-Availability of data and materials

The data will be made available by the corresponding author upon reasonable request.

-Competing interests

The authors declare that there is no conflict of interest.

-Funding

This research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

-Authors’ contributions

HSD: concept, design, data collection and analysis, discussion, writing and revision of the manuscript. MCY, MO, M.M.S.A, RMG, NI: statistics, results, data analysis, and writing. MN: analysis, discussion, and writing of the manuscript.

-Acknowledgement

Author grateful to colleagues, secondary school teachers, resident doctors and the patient who made writing this manuscript possible.

-Author’ information

HSD : MD, Obstetrician gynaecologist, Abdou Moumouni University ; Department of obstetrics and gynecology ; Issaka Gazobi Maternity Hospital, Niamey.

MCY : Medecin Doctor, Obstetrician gynaecologist. Abdou Moumouni University ; Department of obstetrics and gynecology ; Issaka Gazobi Maternity Hospital, Niamey.

MO : Medecin Doctor, Obstetrician gynaecologist. Abdou Moumouni University ; Department of obstetrics and gynecology ; General referal hospital in Niamey.

MMSA: Medecin Doctor, Abdou Moumouni University ; Psychiatrist, Department of Psychiatry, Niamey National Hospital, Niger.

RMG : Full Professor of Obstetrics and Gynaecology; Abdou Moumouni University ; Department of obstetrics and gynecology ; Issaka Gazobi Maternity Hospital, Niamey.

IN : Associate Professor of Obstetrics and Gynaecology; Abdou Moumouni University ; Department of obstetrics and gynecology ; Niamey Regional Hospital Maternity Unit.

NM : Full Professor of Obstetrics and Gynaecology; Abdou Moumouni University ; Department of obstetrics and gynecology ; Issaka Gazobi Maternity Hospital, Niamey.

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No competing interests reported.

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Underage girls’ pregnancy during schooling in Niger: Socio-demographic aspect, causes, effect and control. A prospective cohort study

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Background

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Discussion

Implications of the results and recommendations:

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