Dr. Manal M. M. Darwish Dr. Wafaa S Hamza Mirette M. W. Aziz

1. Exploratory Study of Reproductive Health Behaviors and Sexual Problems among married Adolescent Girls in Egypt Dr. Manal M. M. Darwish Dr. Wafaa S Hamza Mirette M. W. Aziz Amira F. EL-Gazzar

2. Introduction • Early marriage of girls is a violation of human rights as it deprives them of freedom, opportunity for personal development, and negatively impacts other rights. • Early marriage is generally associated with early childbearing and high fertility, both of which pose health risks to women and their children. • Married adolescent girls are often are socially isolated, have little or no autonomous decision-making power, lack accurate knowledge related to sexual and reproductive health, and lack basic life skills and economic opportunities. • Among Egyptian women, 13 percent of 15-19 years old are married (El-Zanaty&Way, 2008).

3. Objectives of the study: • To understand the SRH behaviors and experience of MAGs in Egypt by investigating three key areas: • Marriage experience of MAGs • Husband-wife communication • Utilization of reproductive health services among MAGs. • To understand the role of mothers/mothers-in-law in influencing the experience of MAGs in Egypt.

4. Methodology: • The target populations were: • Married adolescent girls (16-19 ys.) who have been married for 1-3 years • Mothers /mothers-in-law of married adolescent girls. • In-depth interviews were conducted with MAGs (n=20) while focus group discussions were conducted with mothers / mothers in law (n=4) • Data collection was done in three villages in Assiut Governorate.

5. Methodology • Both IDIs and FGDs took place at the health units. • Participation in the research study was completely voluntary and informed consents were obtained from all subjects. For MAGs, both her consent and that of her guardian were obtained (if she is <18).

6. Study results • Background characteristics of MAGs: • The average age of participants : 18.4 years • Education • Illiterate : n= 4 • Primary: n= 6 • Intermediate: n=3 • Secondary: n=7 • None of the MAGs were working for cash. • Two of the girlshad more than 35 years of age gap with their husbands.

7. Study Results Engagement • There was no clear pattern for length of engagement. Engagement duration ranged from 0-30 months with average engagement duration of 9.5 months Engagement periods varied from couple of days to couple of years with no direct relation with degree of feeling that she knew her husband well by the time they got married. ” متعرفتش عليه، انا بصراحة كنت بسرح قطن، هوه جه اتكلم على وجاب الدهب، وانا معرفتش، انا اتفاجئت بالدهب بعدها بـ3 أيام كتب ودخل“ (MAG)

8. Study results Wedding night Both MAGs & mothers / mothers-in-law agreed on disappearance of traditional i.e. manual type of defloration. However, almost always a kind of dissemination was required to prove virginity of the girl and potency of the husband. which lead to fear, worries, pressure& force and Bleeding, injury, fear, embarrassment were the main problems at the wedding night. In one case there was violence to get defloration done in time. ”احساس غريب، حاسه انى داخلة بيت غريب، بيت مش بيتى، وتعبت أكتر لما شفت الداية، وأخته، ومرت أخوى، وأخت مرت أخوى.حسيت بحاجة غريبة، حسيت ان أنا هدبح فى اليوم ده...5 انفاروهوه، يعنى 6 انفار واقفين جوه. يبقى اكيد فى حاجة هتحصل..وهوه لا اتكلم ولا قال حاجة... قلعونى الفستان وقعدونى فى الأرض، وخلاص، حصل اللى حصل...“ (MAG 18)

9. Study results Sexual relations Most of MAGs didn’t have any information about sexual relations before marriage which was explained by being a taboo to talk about this subject even with mothers. Mothers' advice is only about husband obedience and house chores. ”انا لما حاولت اسأل ايه اللي هيحصل مالقتش حد يشجعني حسسوني اني بسأل سؤال غلط، طيب اللي خالاكوا قدرتوا تجوزوني طيب فهموني “ MAG, 17 ) ) About half of MAGs (9 out 20) reported dissatisfaction sometimes or most of the time. In most cases dissatisfaction was mainly due to H/W miscommunication, physical violence, age gap, lack of knowledge or painful intercourse. ”...انا البت بتبقي جنبي، اول ما تنام ينام عليا، يخلص مصلحته بسرعة وبعدين يديني ظهره، وينام ما بحسش بأي حاجة ....“

10. Study results • Husband-wife communication Communication between MAGs and their husbands was limited especially when there was large age difference or the girl is not educated. ”...هو برضه معزور انا ملياش خبرة في الحياة كتير فالتاني برضه مابياخدش رائي في حاجات كتير.... " (MAG, 18 years old)

11. Study results Information needs • All MAGs requested information about details of wedding night and communication skills, not just house chores. Most of MAGs do not have enough information about their body, health, pregnancy, child birth, family planning, sexual relations. They all wanted to know more about all these topics. ”...كان مفروض -الله وكيلي- يقولوا حاجات كتير، يقوللولي اول يوم تدخلي البيت يحصل كذا وكذا، ده أنا لما جم الصبح قعدت ابكي ومسكت في خالتي قلتلها مش مفروض تفهميني انه هينام معايا وكده، انا مكنتش عارفة الحاجة دي ايه، ولا بيعملوها ليه، البيت مش اكل وشرب بس، ولا ان الواحدة تنظف بيتها المفروض انه يشاركني في كل حاجة معاه...“(MAG, 17)

12. Study results Health services utilization • All MAGs had variable number of ANC visits regardless of their socioeconomic, demographic and husband wife communication factors. • Hospitals and private clinics were the main sites for provision of ANC while the role of health unit was confined to TT vaccine. - Hospital delivery was found in most of the cases. Only one MAG refused to deliver in a hospital and insisted to deliver at home and to be attended by Daya due to her bad experience with a relative. ” اصلى كنت رحت المستشفى مع واحدة تعتبر أختى يعنى، فى الوقت اللى كانت عتموت فيه، الدكتور ضربها قلمين أو تلاتة...والله العظيم. أنا حاجة شفتها بعينى... ومنظرها كده وهما شاحطين رجليها كده وشاحطين رجليها كده، حاجة صعبة خالص... من ساعتها عاد انا قلت لو كنت هموت انا مش هروح المستشفى.“(MAG, 19)

13. Study results Delaying first pregnancy None of our MAGs intended to delay the 1st pregnancy because either they wanted to, misconceptions, social pressure & husband refusal, not enough time/knowledge or feeling lonely. ” انا معاى حماتى. .. عشنا مأساة الفترة اللى مخلفتش فيها(3 شهور)، هى بالنسبة لها، أصل هوه مفيش غيره واحد بس، هيه كانت عايزة تشوف ولده بسرعة، وهيه كل شوية تقوللى، اكشفى، تعالى نروح عند الشيوخ وكده...“(MAG,18)

14. Study results Birth spacing • Most of our participants accepted FP for spacing after the 1st baby except for those seeking a boy, lacking knowledge about FP, social security, misconceptions and husbands’ refusal. • Only two MAGs (with relatively high education, SES and good H/W communication) consistently used FP. Others either did not use at all or used inconsistently.

15. Study results Mothers / mothers in law Socio-demographic characteristics • Forty (40) mothers and mothers-in-law participated in FGDs. • Their age ranged from 35-70 years • The majority of them (67.5%) had never been to school, about 20% had completed their 2ry technical education. • The majority (82.5%) were not working for cash.

16. Study results • Reasons for early marriage • Ensuring her virginity, the concept of “El Sotra” and social security • Appearance of the suitable person • The younger the better • To protect the girl’s reputation • Fear of losing fertility • Social pressure • “ .البت بعدالـ30 سنة خلاص خلفتها ماتت..لواحدة مننا لامؤاخذة صندوقهابيكش“ • .”(Mother( "النغم اللى برة يهوس البيت و يهوس البت ذات نفسها, البت تيجى باكية من كلام الناس“ (Mother-in- law(

17. Study results Opinions about delaying of first pregnancy Nearly all mothers and mothers-in-law totally refused the delay of the 1st pregnancy either for assurance of couples fertility or for fear of method induced infertility. "...أحنا نحبهم يحملوا على طول, أنا جوزت بتى, ومن ثانى شهر، أسأل, قلقانه, الدوره جت ولا لأ, نفسى تجيب أول عيل, وبعديها براحتها ان شاالله تستنى 5 سنين, عشر سنين, نفسى فى أول عيل, أشوف بتى حتخلف ولا مش حتخلف...." (Mother- El-Shaghba) • According to almost all mothers and mothers-in-law opinion, all husbands will refuse to delay 1st pregnancy. In a few cases it was acceptable for economic reasons only. "... لو مش عايزه تخلف, ما يخليهاش, يخلصها ويجيب غيرها.... يزعطها.....طالما مش عايزه تخلف منه, تبقى مش عايزاه...”(Mother- in -law)

18. Study results Mother daughter communication about marriage Most of mothers and mothers-in-law do not talk about sexual issues with their daughters before marriage as they think girls know all about sexual life from media and friends. Mothers and mothers in law were not mentioned as a source for such information. The recommended sources were other relatives, older sister and friends. ”لأإحنا منقولش للبنات،البنت تخش وتعرف طباع جوزها،هى وجوزها حرين ملناش دعوة“

19. Challenges • Distributing consents forms by the nurse/raeda on invitation and orientation day increased the possibility of withdrawal due to husband refusal • The need for guardians’ consents (if MAG is <18) • The need for signed consent with high rate of illiteracy in rural communities • Meeting selection criteria for MAGs. • Determining MAG current age and age at marriage

20. Recommendations • Support delaying marriage of adolescents through ensuring school attendance • Enforce laws concerning minimum age of marriage and marriage registration • Counseling services for married and unmarried young females about sexual relations, life skills and H/W communication. • Awareness raising campaigns for parents about risks of early age at marriage and about benefits of birth spacing • Training doctors and nurses to be able to handle sexual problems of married couples.