IMAGINE a World Where Girls Decide

“In the past, we would be amazed at the decision of a married girl who is considering delaying her first birth, because it would seem foolish for her to do so. Today, we see that it is very well-founded for her to do so. Suppose it is a girl who studies at school – she will need time to assimilate her studies.” – Female community member, exposed to intervention, Djeda

Globally, around 13 million girls under the age of 20 give birth annually. Child marriage is linked with early pregnancy and birth, especially in the developing world where 90% of adolescent pregnancies happen in girls that are already married. Niger and Bangladesh are not the exception. Niger has the highest fertility rate worldwide with 7.6 children per woman. Bangladesh has a legal marriage age of 18 but the enforcement of this law is low, leading to a median age of marriage of 15.8 years old. This makes IMAGINE a vital project to address contraceptive use and pregnancy choices among adolescents.

IMAGINE was a CARE and Bill & Melinda Gates Foundation (2017-2022) program. Overall, the program took place from 2017 to 2022 in Niger and Bangladesh, it was a 3-year intervention period but the program in a whole was over seven years.

In 2017, CARE embarked on formative research, consisting of a qualitative study and a market analysis in both countries to:

1. Understand the barriers and facilitators that influence a married girl’s ability to delay pregnancy.
2. Identify alternative futures that could motivate girls, families, and communities to support this pregnancy delay.

Following these aims and guided by a human-centered design, a multi-disciplinary team of CARE staff identified, polished, and prototyped potential solutions through building a holistic intervention package for each country. After the baseline study, the project launched in January 2019 and ended its implementation in October 2021.

What changed?

• Saving money and making family planning decisions. For example, in the treatment group in Bangladesh, 99% of adolescents knew where to access family planning (97% control). And 62% of participants in both groups have savings.
• Adolescent girls use contraceptives. In Niger, 34.1% subscribed to contraceptive use in the treatment group, in comparison to the control group (19.1%). Also, the treatment group had higher knowledge of places to access family planning (FP) and visits to community health workers (CHWs) to discuss FP, in comparison to the control group.
• Giving birth and using contraception goes hand in hand. Adolescents who gave birth have a higher percentage of contraceptive usage in both treatment and control group. For example, in Niger the modern contraceptive use among adolescents who gave birth from the treatment group was 33% (20% control) versus 13% (4% control) among the ones that have not gave birth.
• But in both countries, there is a still unmet family planning need among adolescents who gave birth. The unmet needs among this population in Bangladesh’s treatment group is 22% (26% control). And among the ones that have not given birth is 8% in the treatment group (13% control group).
• Let’s talk. The knowledge on key issues like early pregnancy risks, delaying childbirth, and/or income generation increased from baseline to endline among the treatment group. At the same time, the belief of myths related to FP decreased.
• Economic reasons were an incentive for delaying becoming parents. In Bangladesh, respondents reported financial stability as a key factor in delaying birth. Also, the treatment group showed improvement in family planning perceptions and reproductive health knowledge.
• Social norms are changing. There was an increase in respondents supporting delayed birth compared to previous years. And at the same time a positive change in supporting girls when wanting to engage in income-generating activities outside of the home.
• People live longer, healthier lives. More contraceptive access = less Disability-Adjusted Life Year (DALYs). In Niger the increment in contraceptive use prevented 1548 DALYs. DALYs are the sum of the years of life lost to due to early mortality (YLLs) and the years lived with a disability (YLDs) due to a disease or health condition.
• The IMAGINE program is cost-effective. The GDP per capita in Niger is $594. Yet the IMAGINE program had a cost per DALY of $552. According to the threshold recommended by the WHO, any cost per DALY lower than 3 times the GDP in a country is cost effective. Therefore, the program would still have been cost effective even if it were 3 times more expensive.

How did we get there?

• Girls’ collectives addressing sexual and reproductive health and rights (SRHR) topics, decision-making, basic financial literacy communication skills, gender and social norms, collective action, and leadership with 15-25 girls per village. These collectives linked girls with community health workers (CHWs) and women role models. With the additional option of joining Village Savings and Loan Associations (VSLA) groups.
• Vocational training. CARE worked with the private and public sector to provide training for adolescent girls in a variety of key market systems. For example, in Niger these were on cowpea processing and refinement, goat breeding and management. In Bangladesh, enterprises included cotton and jute handicraft production, and mobile phone retail and repair, for example. After the training was completed, CARE worked with partners to create market linkages for girls through internship opportunities, craft fairs, professional associations, and ongoing mentorship.
• Health worker transformation activities not only addressed key gaps in health workers skills such as FP methods and counseling skills, but also promoted reflexivity on how their biases can impact the way they provide SRHR services to adolescent girls. In both countries, health care workers reported a greater sense of ownership and motivation of their work, which led them to see their role from “simple” service providers to girls’ health advocates.
• With the aim of empowering couples in planning their future family, couples’ counseling in Bangladesh was established. This addressed many goal settings like family and financial planning, communication, and negotiation, SRHR, and social norms reflection, to empower couples to create a shared vision for their family.
• Fada Groups in Niger worked with trained local male facilitators to address the health and economic benefits of delayed first birth, communication skills, and gender and social norm transformation with young men and husbands from the villages.
• In Niger, because of the Social Analysis and Action (SAA), CARE led community stakeholders to challenge social norms related to early birth through self-reflection and action planning. This to build norms encouraging married adolescents to access essential health services like family planning.

What did we learn? Providing adolescent girls with contraceptive information and access can lead to decreasing the nationwide DALYs, while at the same time being cost-effective for the country. In Niger, it showed an investment of $552 per DALY achieved. This is considerably better than the WHO standard.

More key lessons are:

• Being a mother and wanting to plan? Yes. Being a mother and accessing FP methods is still a high unmet need that needs to be addressed among health programming so women and couples can plan birth spacing properly.
• Discussing sexual and reproductive health is still a challenge. For example, in Niger the self-efficacy to use and discuss family planning showed a negative change among treatment and control group from baseline to endline. The discussion around family planning is still challenging due to reasons such as prevailing social norms, health workers attitudes etc.
• Re-think and adapt your Theory of Change (ToC) to the population targeted based on the context’s realities and needs. For example, in the scenario of Bangladesh, the ToC needed to change from targeting married adolescent to targeting unmarried ones.
• Since changes, especially in relation to gender and social norms, do not happen overnight, the timespan of a program like this one need to be increased.
• Change the focus of the outcome, from delaying birth to birth spacing, which is more commonly supported: in Niger, girls almost unanimously declared that taking part in income generating activities and being young mothers were not mutually exclusive facts. The reproductive burden girls seemed to feel was related to infrequent or too many births.

Where do we go next? IMAGINE enable us to believe of a world where contraceptive use can support female empowerment. This being translated into female economic participation, birth spacing, but mostly on women deciding when to become mothers. This program also brings a novel approach of including men and couples in the interventions to challenge and exercise the re-thinking of social and gender norms to achieve gender equality for girls and women. 
Overall, IMAGINE provides a gender and social lens, but also a cost-effectiveness one, that should be analyzed and took in future programs and projects. This shows how sexual and reproductive health is extremely linked to the different social, cultural, and economic spheres running any country. 
Want to learn more? Click here to learn more from the reports, CARE Shares page, and here for the technical resources.