The effectiveness of a girl empowerment programme on early childbearing, marriage and school dropout in rural Zambia: A cluster trial

Adolescent pregnancies carry substantial risks of complications to young mothers and their babies. Complications of childbearing and abortion are estimated to be among the most common causes of death in girls aged 15-19 in poor countries, and newborn babies of mothers below 20 years of age have more than 50% higher risk of dying than those with 20-29 year old mothers. In Zambia, 35% of young rural girls aged 18 have given birth, and the percentage is particularly high among those who are out of school. Approximately 50% of girls never enroll in secondary school. Keeping girls in school is likely to protect them from becoming pregnant. Several studies have found that economic support to girls and their families can increase school enrolment and attendance, and a couple of experimental studies have found that girls who receive such support are more likely to delay marriage and pregnancy. However, the effects of economic support may differ in various settings. In preparation for this project, interviews were conducted with girls, parents, teachers, health workers, and community leaders in several Zambian districts about what leads adolescent girls to drop out of school, get married or pregnant at an early age. The interviews indicated that poverty is an important cause of all three. In addition, school dropout, social status related to fertility and marriage, and myths concerning use of contraceptives, are other factors leading to high adolescent pregnancy rates. In this trial, the effects of two different intervention packages are studied. Between March and July 2016 approximately 4900 girls enrolled in 157 schools in rural Zambia were recruited to the study. The schools were then randomly assigned to one of 3 groups: Group 1) Girls received writing materials; Group 2) Girls and their guardians received writing materials and economic support to cover school-related and other expenses; Group 3) Girls and their guardians received writing materals and economic support, and in addition youth club meetings were held with girls and boys to discuss reproductive health, and community meetings were organized to discuss issues of importance to the welfare of young girls, such as the benefits of education and risks of early pregnancy. The intervention programmes were run from September 2016 to the end of November 2018. The girls were followed-up until the second half of 2020. Follow-up interviews were conducted every six months, and 95.3% of the original participants were interviewed in the final follow-up round. The data analysis will start in March 2021, and rates of early childbearing will be compared between the three groups to evaluate whether the interventions were effective. If early pregnancy was reduced, this is likely to lead to better health and reduced mortality of young women and children. The project was run by the University of Bergen (CISMAC), the University of Zambia, Chr. Michelsen's Institute & the Norwegian School of Economics. The project is part of the project portfolio of the Centre for Intervention Science in Maternal and Child Health (CISMAC), which is a Norwegian Centre of Excellence in research led by the University of Bergen.

Research findings will be disseminated through scientific articles in peer-reviewed journals, reports and presentations at national and international academic- and policy-related conferences. So far we have published 14 articles. We expect to publish more than 15 additional papers from the trial. The Zambian government has shown great interest in the trial, and the findings will inform future policies for young people in Zambian and elsewhere. The trial has strengthened both the capacity of the two universities in implementing cluster randomized trials and the collaboration between different disciplines and institutions. The project has involved 23 master students and 4 PhD candidates. If the intervention packages lead to reduced early childbearing and marriage and increased completion of basic education, this is likely to lead to better health and reduced mortality of young women and children, and to higher welfare and improved economic conditions for families and society as a whole

Adolescent pregnancies carry substantial risks to young mothers and their babies. Complications of childbearing and abortion are estimated to be the most common causes of death in girls aged 15-19 in low and middle income countries, and neonatal mortality is >50% higher for babies born to mothers aged <20 years compared to mothers aged 20-29. In Zambia, 35% of young rural girls have given birth at the age of 18 years, and the pregnancy rates are particularly high among out-of-school girls. Approximately 50% of girls never enroll in secondary school. School dropout, poverty, myths and norms around adolescent girls? use of modern contraceptives, and norms regarding the importance of having children and being married, are some of the factors contributing to the high adolescent childbearing rates. Keeping girls in school is likely to protect girls from becoming pregnant. Several studies have found that economic support to girls and/or their families can increase school enrolment and attendance, and a couple of randomised trials have found that such support can lead to deferment of childbearing and marriage among adolescent girls in some settings. However, the effects may potentially differ in various contexts. This proposal describes a cluster randomized trial that will measure (1) the effectiveness of providing economic support to girls and their families that targets both the poverty and school drop-out dimensions of adolescent pregnancy in a Zambian context, and (2) whether economic support combined with a community approach targeting social norms and beliefs regarding sexual and reproductive health, can have an even stronger impact. If early pregnancy is reduced, this is likely to lead to better health and reduced mortality of young women and children. The partners are the University of Bergen(Centre for Intervention Science in Maternal and Child Health), University of Zambia, CMI and NHH.