Adolescent Pregnancy and Barriers to Zika Prevention
By: Elga Salvador
The maternity hospital, Nuestra Señora de la Altagracia, holds the record of the first birth of 2019 in the Dominican Republic for the sixth consecutive year. On the same day, the same hospital also holds another record: this is the third year in which the first baby was born to an adolescent mother [1,2]. This is no longer a surprise in a country where the percentage of pregnancy in adolescents has never been lower than 20% in the last 23 years .
Article 396 of Law 136-03 of the Dominican Republic defines any sexual relationship between children or adolescents with partners who exceed their age by five years or more as sexual abuse . However, the first baby of the year was born to 16-year-old girl and a man six years older than her. While the legal framework to reduce adolescent pregnancy is in place, implementation of the law remains a widespread issue.
According to the Dominican Republic National Statistics Office, this is not an isolated case. Thirty-five percent of adolescents in a relationship have partners five to nine years older than them and 23.4% have partners ten or more years older than them . Adolescents with significantly older partners are in relationships characterized by a strong imbalance of power. In many cases this increases their risk of being victims of violence and controlling behaviors. This can limit their decision-making power over their sexual and reproductive health, increasing the risk of unplanned pregnancy .
According to a gender analysis carried out in the Dominican Republic by the WI-HER team, adolescents face many barriers to prevent pregnancy, especially lack of information and sexual education, limited power to negotiate methods with their partners, and stigma about the use of contraceptives . The following quotes from focus groups and interviews highlight many of these issues:
“Adolescents lack of proper information and orientation, it is important to introduce sexual education in the schools.” (Female health provider, Barahona)
“In the suburbs, teenagers don’t use condoms. Girls don’t ask for it and men take advantage of them. [..] Both teenagers and adult men.” (Young man, Santiago)
“I give condoms to sexually active girls and tell them not to have sex without them. Most of them have adult partners who look for sex but not responsibilities and they use condoms, they finish the condoms quickly. I tell them “you go fast!” […] Some others say their partners don’t want to use condoms because they say they don’t feel the same.” (Female community health promoter, Santo Domingo)
“Adolescents don’t use condoms because they are afraid of parents, especially girls, they don’t run the risk to carry condoms in their bags.” (Adult man, Santiago)
In the Dominican Republic, current legislation guarantees adolescents the right to comprehensive healthcare, including access to preconception counseling and contraceptive methods [3,7,8]. Nevertheless, according to information collected through key informants and focus group discussions, some health workers are not aware of these laws. In fact, many providers have biases against offering adolescent sexual and reproductive health services. For example, a community health promoter recounts how she had reservations about giving condoms to a young boy:
“Once a boy aged 13 or 14 came looking for condoms, I told him: ‘Don’t do this, you are just 14.’ He went away and while leaving told me: ‘If I get sick it's your fault!’ Can you imagine?” (Grandmother and community health promoter, Barahona).
It was also found that some health personnel believe that condoms should not be distributed to adolescents due to the disagreement of the Catholic Church and that they mistakenly believe that families of adolescents can take legal action against medical and nursing staff that distribute condoms to them.
In the context of Zika prevention, there is another key barrier that adolescents face: late entry into antenatal care. According to key informants who work in antenatal care, the biased behavior of health personnel, along with social stigma, fear of the reactions of fathers and mothers when informed about the pregnancy, and lack of knowledge about the reproductive process, are some of the reasons for which many adolescents attend prenatal care consultations at very advanced stages of pregnancy. This could contribute to the already high statistics of maternal morbidity and mortality among adolescents. Likewise, late access to counseling limits the possibilities for adolescents to receive information on how to prevent the sexual transmission of Zika and other STIs and, therefore, increases the risk of their children to be born with health problems, such as microcephaly or other symptoms of Congenital Syndrome associated with Zika.
WI-HER’s gender analysis highlights how the intersection of gender, socioeconomic level and age, among other characteristics, limits the capacity and power of adolescents to avoid unplanned pregnancy, prevent Zika and other sexually transmitted infections and exercise their right to a quality integral health.
WI-HER is working with USAID’s Applying Science to Strengthen and Improve Health Systems (ASSIST) Project in 13 countries in Latin America and the Caribbean, conducting gender analyses to identify gender issues that limit the results of the project response to Zika in the health sector, and offering training and ongoing technical assistance to ensure the integration of gender in the project.
As of December 2018, in the Dominican Republic, ASSIST and WI-HER have built the capacity of 210 people, including health personnel, authorities and facilitation teams, to identify and address gender gaps in their facilities. These trainings are structured in two essential components, the first raises awareness about the importance of addressing gender issues in the health sector, and the second builds skills and tools to identify, analyze and implement initiatives to address gender gaps and issues that limit the reach of their Zika response programming. Five months out from their training, the team at Nuestra Señora de la Altagracia, renewed their interest in sensitizing more professionals in the health system on gender.
Recognizing the importance of this initiative to achieve better results in health, the ASSIST team of the Dominican Republic will continue to carry out these trainings in 2019, highlighting the importance of addressing the intersection between gender and age, to prevent cases of sexual transmission of Zika among adolescents.
 (1 enero, 2019). Primer bebé dominicano del 2019 es hijo de una adolescente de 16 años. El Día.Recuperado de http://eldia.com.do/primer-bebe-dominicano-del-2019-es-hijo-de-una-adole...
 (2 enero, 2019). Dos niñas y un niño son los primeros bebés del nuevo año. Listín Diario. Recuperado de https://listindiario.com/economia/2019/01/02/547853/dos-ninas-y-un-nino-...
 CESDEM. (2014). Demographic and health survey Dominican Republic 2013. Santo Domingo, Dominican Republic.
 National Congress of the Dominican Republic (2003). Code for the System of Protection and Fundamental Rights of Children and Adolescents (Law 136-03). Santo Domingo.
 ONE (2016). National Survey of Households of Multiple Purposes ENHOGAR- MICS 2014 - Final Report. Santo Domingo.
 UNICEF Dominican Republic (2017). Reasons to end child marriage in the Dominican Republic. Press center https://www.unicef.org/republicadominicana/media_36232.html.
 Salvador E, Faramand TH, Barrios Wilson T. 2018. Technical Report. Gender issues that influence the improvement of quality in health care compared to Zika in the Dominican Republic. Published by the USAID ASSIST Project. Chevy Chase, MD: University Research Co., LLC (URC).
 Ministry of Public Health (2010). National standards for comprehensive adolescent care. Santo Domingo https://www.unicef.org/republicadominicana/Plan_Estrategico_Salud_Integr....
 Ministry of Public Health (2017). Protocol of Attention for Management of Counseling and Counseling in Contraception for Adolescents.