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Preventing teen pregnancies and supporting pregnant teenagers in Ecuador

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By Sara Bernardini, Geraldine Honton, Laura Irizarry, Jesús Sanz, Estefanía Castillo, Carmen Guevara and Lorena Andrade

Sara Bernardini has more than 12 years of experience working in humanitarian nutrition in numerous locations. Since 2012, she has supported the World Food Programme (WFP) headquarters as a nutrition specialist in the Nutrition Division. She holds a Master’s degree in biology and a Master’s degree in clinical nutrition and dietetics. 

Geraldine Honton is a nutritionist with a Master’s degree in public health and another in political sciences. She has 15 years’ work experience in an extensive range of humanitarian and development programmes in many different settings. She joined WFP in Rome five years ago to support the nutrition integration work stream.

Laura Irizarry has 13 years of experience working in international nutrition. She holds a Master’s degree in food and nutrition policy and programmes from the Friedman School of Nutrition Science and Policy at Tufts University. Since 2015, she has supported WFP as a nutrition specialist.

Jesus Sanz is a sociologist with a Master’s degree in youth studies and policies from the University of Lleida (Spain). He was involved in the design of an adolescent pregnancy prevention and care project implemented by PMA-Ecuador in 2019 and now works as a COVID-19 emergency coordinator.

Estefanía Castillo joined WFP Ecuador in 2017 after working in public service. She holds a Bachelor’s degree in nutrition from the Universidade Federal do Rio Grande do Sul (Brazil) and a Specialist’s degree in public policies for equality. She works to support food and nutritional security for the vulnerable population and migrants in Ecuador.

Carmen Guevara has more than 10 years of experience working in the humanitarian field and since 2021 has served as the focal point at WFP Ecuador for gender and protection for the vulnerable population and human mobility . She graduated as a clinical psychologist from the Universidad de Central del Ecuador and is a specialist in the facilitation of synergic processes.

Lorena Andrade has a PhD in nutrition and dietetics and a Master's degree in health management for local development. She currently works for the Undersecretary of Integral Child Development at the Ministry of Economic and Social Inclusion, Ecuador. 

We would like to offer our special thanks to Jessica Bourdaire and Carla Mejia, Regional Advisors WFP RBP, for their valuable and constructive suggestions during the development of this paper. We would also like to thank our colleagues, Rocío Vaca, Valentina Virdis and Sébastien Paque, who were involved in the implementation of the programme and Soledad Vela, Juan Pablo Bustamante y Tatiana León of the Ministry of Economic and Social Inclusion of Ecuador who supported WFP in its design and implementation. Special thanks to the Government of Denmark for financially supporting the programme in Ecuador and a special mention to Soledad Guayasamín, UNFPA-Ecuador Programme Officer, who actively participated in the development of the project and who, unfortunately, left us in May 2020 (RIP).

Location: Ecuador

What this article is about: A pilot project demonstrated that a cash-based transfer (CBT) accompanied by nutrition education had the potential to increase the dietary diversity of and attendance to antenatal care by pregnant adolescent girls.

Key messages:

  • The findings from this project suggest that a comprehensive CBT package can improve dietary diversity and promote the use of health services among pregnant adolescents.
  • WFP could not fully leverage the existing government platforms for cash transfers as targeted participants were below 18 years of age, preventing a potential scale-up of the project.  
  • The findings from this case study will serve as an advocacy tool to continue work with the government of Ecuador to improve the comprehensive policy of prevention and care of pregnancy in girls and adolescents and its implementation on the ground.

Background 

Ecuador has the second-highest rate of adolescent pregnancy in the Latin America and Caribbean region, with 19.6% of births being among mothers below 20 years of age (INEC, 2018). Babies born to young mothers face a higher risk of preterm birth, low birth weight and short stature (INEC, 2018). The risk of adolescent pregnancy is greater for those living in very poor households, not enrolled in school or who experience sexual abuse during childhood and adolescence (Espinel-Flores et al, 2020). Girls from indigenous communities are also disproportionately affected1

The double burden of malnutrition is a common phenomenon in Ecuador. Nationally, 17.9% of adolescents aged between 12 and 14 years and 20.8% of adolescents between 15 and 19 years are stunted. Simultaneously, overweight and obesity are high, with 26% of adolescents affected (INEC, 2012). While stunting rates are higher in the poorest quintile, overweight is more common in the richest quintile. 

Pregnant adolescents have an increased risk of nutritional shortfalls as their own requirements for optimal height and pelvic growth interfere with those of their children’s development. In turn, undernourished mothers are more likely to give birth to infants with low birth weight, micronutrient deficiency and who – if they survive childhood – experience poor health throughout their life, perpetuating a cycle of poverty, deprivation and malnutrition. At the same time, maternal overweight and obesity result in increased maternal morbidity and infant mortality (Black et al, 2013). Adolescent pregnancy also derails the development trajectory of girls, affecting their physical, cognitive and mental health. This forces them out of school which reduces their chances of accessing stable jobs, livelihoods and incomes. 

Addressing the problems associated with adolescent pregnancy requires the application of a comprehensive, multi-sector and inter-institutional perspective that considers different dimensions, including that of food and nutritional security. To generate evidence that contributes to strengthening public policies for the prevention and care of adolescent pregnancy, the World Food Programme (WFP), together with the United Nations Population Fund (UNFPA) and the Ministry of Economic and Social Inclusion (MIES) led a pilot project in 2019 in the provinces of the northern Ecuadorian border. This article summarises the main results, findings and lessons learned. 

Project description 

Project rationale

In 2018, the government of Ecuador launched Misión Ternura2,  a multi-stakeholder strategy that aimed to promote early childhood development across the health, education and protection sectors. To address the issue of early pregnancy, the government formulated an intersectoral policy document3  which offers a platform for the development of national solutions to address the social, economic and cultural drivers of early pregnancy – including improvements to the judicial system for the protection of girls and adolescents against sexual and gender-based violence.  

During the same year, 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 (39% of the total cost). The analysis also indicated that, by providing micronutrient supplements (iron and folic acid) to adolescent girls, the gap in the cost of a nutritious diet could be reduced by 53% from USD3.50 to USD1.65 per day. 

In 2019, WFP worked in close collaboration with the MIES, the Ministry of Public Health (MoPH), the Ministry of Education (MoE), UNFPA and the international non-government organisation, Plan International, to design a cash-based transfer (CBT) pilot project that aimed to contribute to the promotion of food security, nutrition and sexual and reproductive rights among adolescents. The CBT project was implemented from July to December 2019 and incorporated into the Misión Ternura framework and the 2018-2025 Intersectoral Policy.

Project design

The objectives of the project were to increase national awareness and to 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 in the northern provinces of Carchi, Imbabura, Sucumbíos and Esmeraldas where adolescent pregnancy and gender-based violence are of concern. WFP coordinated with the MIES to identify the most economically vulnerable (poor or extremely poor) pregnant girls up to 19 years of age, prioritising those who were up to six months pregnant. Among the girls targeted, 11% were aged 14 years or younger and 59% were from the Esmeraldas province. Most of these adolescents lived in rural or peri-urban areas with no or low access to communication methods and with limited access to transportation. 

Project interventions

The pregnant adolescents enrolled received monthly unconditional and unrestricted CBTs (USD50) over the six-month period of the pilot project. The value of the transfer was intended to cover the gap in accessing a nutritious diet based on the FNG analysis recommendations. The amount of the transfer was the same as the one provided as part of the national social protection programme to the most vulnerable households4.  Pregnant adolescents also received a birth kit that included diapers, baby clothing, a carrier blanket and a booklet that contained key messages on food security, nutrition and feeding practices (including the benefits of breastfeeding) and on sexual and gender-based violence. Pregnant adolescents were consulted to define the content of this birth kit.

WFP opted to provide assistance in the form of cash to enable adolescents to make critical decisions and to purchase locally grown foods. An agreement with a financial provider (Banco del Pichincha) was put in place to deliver the monthly CBT to the beneficiaries. Those under 18 years of age had to assign an elder (usually their mother) to be able to withdraw the cash. 

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 beneficiaries to use the cash transfers to purchase and consume seasonal, nutritious local and fresh foods and to attend regular nutrition education sessions. During their visits, educators also shared standardised messages to promote responsible reproductive health behaviours and rights. 

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, knowledge acquisition and skills development related to food security, nutrition and sexual reproductive health. Other workshops in the form of the training of trainers that targeted school staff, health counsellors as well as youth and community leaders were also conducted using a customised Rurankapak toolkit5.  

Monitoring and evaluation data 

The bank provided WFP project coordinators with weekly reports of cash withdrawals. The list of pending withdrawals was then shared with MIES and a project educator visited the homes of adolescents to enquire why the transfer had not been collected and to encourage them to do so.

WFP carried out a baseline survey (July 2019) and an endline project evaluation (December 2019) to generate critical evidence from the six-month pilot and to provide learning to the authorities of Ecuador. 

The surveyed individuals were interviewed on questions related to food consumption and attendance at antenatal check-ups. The variables of interest were: 

The baseline survey was conducted among 776 adolescent girls (all participants of the project) while the endline project evaluation was conducted among 191 beneficiaries who had been enrolled in the project. Beneficiaries from the four provinces included in the project were randomly selected. There was no control group. 

The endline survey was complemented by 11 focus group discussions that included 87 randomly selected participants from the four provinces. The participants were divided into three groups: two groups were pregnant children (10-14 years) and adolescents (15-19 years) and one was made of students who participated in the prevention workshops organised by UNFPA and the MoE. Informative interviews with 24 key informants from the MIES, the MoPH, the MoE and WFP staff were also undertaken across all the provinces.

Results/outcomes 

During the six months of the pilot, 776 pregnant teenagers received monthly CBTs and birth kits. Among these, 89% were in the vulnerable and extremely vulnerable category and 34% participated in workshops, received information on sexual and reproductive health, food and nutrition and built a life projection plan. In addition, 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. 

The results of the endline survey revealed that adolescents felt empowered by receiving unconditional cash transfers that allowed them to make their own decisions on how to spend the money. Most beneficiaries across the four provinces responded that they spent this cash 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, MDD-W increased among pregnant adolescents from 34% to 60%. The average number of food groups consumed increased by 29%, from an average consumption of 3.89 food groups to 5.03 food groups. Specifically, beneficiaries increased their consumption of foods from animal sources such as meat (18%), dairy products (17%) and eggs (13%) (Figure 1). The consumption of fruits and vegetables also increased substantially. 

Figure 1: Prevalence of pregnant teenagers who consumed each of 10 food groups: baseline and endline results

Although the transfer of cash was not linked to any conditionality, the project promoted health check-ups during pregnancy. It was found that 70% of adolescents attended at least five antenatal check-ups. Qualitative data revealed that they understood the importance of using medical services during pregnancy and spent the cash provided to cover transportation costs. The high participation in antenatal check-ups is considered a positive project achievement. 

Successes, challenges and lessons learned 

What went well

The high rate of teenage pregnancies, alongside the findings from the FNG analysis, prompted the implementation of this pilot project. The MIES showed high interest in collaborating with WFP and partners given the magnitude of the issue and the necessity to develop an approach to break the traditional silos between sectors, both at policy and programmatic levels. 

This pilot demonstrated how a cash-based strategy to promote dietary diversification can be successful with adolescent girls, even within a short period of time. The combination of SBCC activities with improved access to diverse and nutrient-rich foods was effective in triggering the change. 

Challenges faced

Due to the short duration of the project and limited staff availability, no formal formative research was conducted prior to the start of the intervention. Hence, a formal evidence-based SBCC plan was lacking. Consulting with participants ahead of project implementation would have enabled barriers to behaviour change to be better addressed during sensitisation activities.

Because most adolescents belonged to low-income households and had no access to a phone, reaching them to disseminate information was a challenge. Transportation from remote areas also limited participation from adolescents, either for cash withdrawals or to attend workshops.  

Although cash was identified as the best modality to promote autonomy, it could not be directly transferred to adolescents below the age of 18 and hence had to be collected by an adult. The evaluation showed parental control did not prevent adolescent girls from accessing and using the cash as they wanted. However, because the national government cannot provide bonuses or pensions to minors, WFP could not fully leverage the MIES transactional platform6  as initially envisioned. This was an obstacle to the potential scale-up of the project. 

Lessons learned

Early childbearing and teenage pregnancy are complex issues with multiple causes and diverse consequences. Addressing these requires a multi-dimensional and multi-sector approach that includes sexual reproductive health, child protection, economic, social as well as nutrition considerations, among others. This pilot project was an attempt to contribute to the national intersectoral policy, to generate evidence and to expand coverage. Although important results and learning were achieved, and the conceptual and methodological basis established with the national authorities, commitment to the prevention of pregnancy in adolescent girls still requires advocacy efforts, resources and mobilisation.

Most pregnancies in girls under the age of 14 are the result of sexual violence, including domestic sexual violence. A specific strategy needs to be in place to address this reality. With 11% of beneficiaries in this age group, this pilot project confirms the need to adapt strategies, guidelines and activities to include a strong child protection component and offer specialised assistance to children up to 14 years of age. 

Conclusion 

The findings from our pilot suggest that a comprehensive CBT package can improve dietary diversity and promote the use of health services among pregnant adolescents. The nutrition-sensitive cash transfer provided helped adolescent girls to meet their elevated nutrient requirements while stimulating demand for nutritious food. The need for strong linkages between food and social protection systems to support healthy diets for all, and particularly adolescents, is increasingly evident. Better alignment between social protection and food systems would mean that cash can be spent on nutritious foods that are available and affordable. 

The implementation of the project ended a few months before the start of the COVID-19 pandemic and general elections were held early 2021. Both events delayed the dissemination of the results until mid-2021 which compelled the government to revisit policy priorities.

The findings derived from this case study will serve as an advocacy tool to pursue the engagement with the MIES and other ministries to improve the comprehensive policy of prevention and care of pregnancy in girls and adolescents and its implementation on the ground.

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


1 In 2019, 13.7% of mothers below the age of 20 years were identified as “white”. This rate increased to 23.4% amongst “indigenous”, 23.9% among “black” and 18.3% among “mixed-race”.

2 https://www.todaunavida.gob.ec/politica-mision-ternura/

3Política Intersectorial de Prevención del Embarazo en niñas y adolescentes 2018-2025 (Intersectoral Policy for the Prevention of Pregnancy in Girls and Adolescents 2018-2025”)

4 Bono de Desarrollo Humano (Human Development Bonus) is a cash transfer worth USD50 per month that is delivered to households living in poverty and extreme poverty, as part of the national social protection system. At present, 842,000 families receive this.

Rurankapak is an interactive methodology composed of six modules around sexual reproductive health and the prevention of teenage pregnancy. Two additional modules were developed, one on nutrition and one on the prevention of sexual violence. 

6The MIES is the institution that provides unconditional cash transfers that are delivered based on criteria of social vulnerability. For this, the MIES has a "transactional platform" which is a technical tool in which the data of the beneficiaries is included and they can then withdraw the cash at different bank offices, credit unions (“Cooperativas”) or associated non-bank establishments. 


References

Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M et al and Maternal and Child Nutrition Study Group (2013) Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet (London, England)382(9890), 427–451. https://doi.org/10.1016/S0140-6736(13)60937-X

Espinel-Flores V, Gotsens M, Puig-Barrachina V, León-Gómez BB, Peralta A and Pérez G (2020) Trends in teenage motherhood in Ecuador: challenges and inequalities. International journal of public health, 65(9), 1647–1655. https://doi.org/10.1007/s00038-020-01517-w

INEC (2012) Encuesta Nacional de salud y nutrición, 2012.  https://www.ecuadorencifras.gob.ec/encuesta-nacional-de-salud-salud-reproductiva-y-nutricion-ensanut-2012/

INEC (2018) Registro estadístico de nacidos vivos.

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Sara Bernardini, Geraldine Honton, Laura Irizarry, Jesús Sanz, Estefanía Castillo, Carmen Guevara and Lorena Andrade (). Preventing teen pregnancies and supporting pregnant teenagers in Ecuador. Field Exchange 66, November 2021. p33. www.ennonline.net/fex/66/preventingteenpregnancies

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