Preventing teen pregnancies and supporting pregnant teenagers in Ecuador

This is a summary of a Field Exchange field article that was included in issue 66. The original article was authored by Sara Bernardini, Geraldine Honton, Laura Irizarry, Jesús Sanz, Estefanía Castillo, Carmen Guevara and Lorena Andrade.

Sara Bernardini is a Nutrition Specialist at the World Food Programme (WFP).

Geraldine Honton is a Nutritionist at the WFP.

Laura Irizarry is a Nutrition Specialist at the WFP.

Jesus Sanz is a sociologist and was involved in the design of an adolescent pregnancy prevention and care project implemented by PMA-Ecuador in 2019.

Estefanía Castillo is a Nutritionist at the WFP.

Carmen Guevara serves as the focal point at WFP Ecuador for gender and protection for the vulnerable population and human mobility.

Lorena Andrade works for the Undersecretary of Integral Child Development at the Ministry of Economic and Social Inclusion, Ecuador.

Background

Ecuador has the second-highest adolescent pregnancy rate in the Latin America and Caribbean region. In 2018, the government of Ecuador launched Misión Ternura,¹ a multi-stakeholder strategy that aimed to promote early childhood development. To address the issue of early pregnancy, the government formulated an intersectoral policy document² that offered a platform for the development of national solutions to address the social, economic and cultural drivers of early pregnancy. During the same year, the World Food Programme (WFP) conducted a ‘Fill the Nutrient Gap’ (FNG) analysis which revealed that, among all household members, the cost of a nutritious diet for adolescent girls was the highest.

In 2019, WFP, together with the United Nations Population Fund (UNFPA) and the Ministry of Economic and Social Inclusion (MIES) and in close collaboration with the Ministry of Public Health (MoPH), the Ministry of Education (MoE) and the international non-government organisation, Plan International, designed a cash-based transfer (CBT) pilot project in four provinces in Ecuador. The project's objectives were to increase national awareness and generate evidence to inform interventions and public policies for pregnant adolescent girls by improving access to healthy diets while preventing other early pregnancies. The project was implemented from July to December 2019 and incorporated into the Misión Ternura framework and the 2018-2025 Intersectoral Policy.

Project

Project interventions

WFP coordinated with MIES to identify the most economically vulnerable pregnant girls up to 19 years of age, prioritising those who were up to six months pregnant. The pregnant adolescents who enrolled received monthly unconditional CBTs (USD50) over the six-month period. The value of the transfer was intended to cover the gap in accessing a nutritious diet based on the FNG analysis recommendations. Pregnant adolescents also received a birth kit that included diapers, baby clothing, a carrier blanket and a booklet containing key messages on food security, nutrition and feeding practices and sexual and gender-based violence.

The WFP provided assistance in cash to enable adolescents to make critical decisions and purchase locally grown foods. Nutrition education sessions for pregnant adolescents and their families were organised to complement the cash distribution and to facilitate social and behaviour change communication (SBCC). Educators from MIES carried out monthly home visits to encourage the beneficiaries to use the cash transfers to purchase and consume nutritious local foods and to attend regular nutrition education sessions. Educators also shared standardised messages to promote responsible reproductive health behaviours and rights.

The WFP partnered with UNFPA and Plan International to complement the cash distributions with other activities such as workshops and information sessions that promoted capacity-building and skills development related to food security, nutrition and sexual reproductive health. Other workshops in the form of training of trainers that targeted school staff, health counsellors and youth and community leaders were also conducted using a customised Rurankapak toolkit.³

Monitoring and evaluation

The bank provided weekly reports of cash withdrawals. A project educator visited the homes of those adolescents who had not received the transfers to enquire why the transfer had not been collected and to encourage them to do so.

The WFP implemented a baseline survey in July 2019 with all 776 project beneficiaries and an endline project evaluation in December 2019 with 191 randomly selected beneficiaries from all four intervention provinces. There was no control group. The surveyed individuals were interviewed on questions related to food consumption and attendance at antenatal check-ups.

The endline survey was complemented with focus group discussions with 87 randomly selected participants. The participants were divided into three groups: pregnant children (10-14 years) and adolescents (15-19 years) and students who participated in the prevention workshops. Informative interviews with 24 key informants from the MIES, the MoPH, the MoE and WFP staff were also undertaken.

Results

• Overall, 3,086 students and 458 community leaders were trained on food, nutrition and sexual reproductive health rights.
• A total of 468 technicians from the MIES, the MoE and the MoPH were trained in the Rurankapak toolkit methodology.
• During the six months, 776 pregnant adolescents received monthly CBTs and birth kits, while 34% of these adolescents participated in workshops and information sessions.
• Adolescents reported that they felt empowered by receiving unconditional cash transfers.
• Most beneficiaries reported that they spent the cash transfer mainly on food followed by sanitary supplies and transport costs for attending medical services, savings, clothes and items for their newborns.
• Between baseline and endline, women's minimum dietary diversity increased among pregnant adolescents from 34% to 60%.
• The beneficiaries increased their consumption of foods from animal sources such as meat (18%), dairy products (17%) and eggs (13%). The consumption of fruits and vegetables also increased substantially.
• Overall, 70% of adolescents attended at least five antenatal check-ups.

Successes, challenges and lessons learned

Successes

• The MIES showed high interest in collaborating with the WFP and partners given the magnitude of the issue and the necessity to develop an approach to break the traditional silos between sectors.
• The pilot demonstrated how a cash-based strategy to promote dietary diversification can be successful with adolescent girls, even within a short period.
• The combination of SBCC activities with improved access to diverse and nutrient-rich foods was effective in triggering change.

Challenges

• Due to the short duration of the project and limited staff availability, no formal formative research was conducted; hence a formal evidence-based SBCC plan was lacking.
• Most adolescents had no access to a phone, making it challenging to disseminate information.
• The lack of transportation from remote areas limited the participation of some adolescents.
• Although cash was identified as the best modality to promote autonomy, it could not be directly transferred to adolescents below 18 years of age and had to be collected by an adult. Hence, the WFP could not fully leverage the MIES transactional platform⁴ as initially envisioned. This was an obstacle to the potential scale-up of the project. However, the evaluation showed parental control did not prevent adolescent girls from accessing and using the cash as they wanted.

Lessons learned

Early childbearing and teenage pregnancy are complex issues and addressing these requires a multi-dimensional and multi-sector approach. Although important results and learning were achieved, commitment to preventing pregnancy in adolescent girls still requires advocacy efforts, resources and mobilisation. Furthermore, most pregnancies in girls under the age of 14 are the result of sexual violence. A specific strategy needs to be in place to address this reality.

Conclusion

The findings from the pilot project suggest that a comprehensive CBT package can improve dietary diversity and promote the use of health services among pregnant adolescents.

For more information, please contact Sara Bernardini at sbernardini@gmail.com.