Sierra Leone: Innovative sexual health app to help prevent surge in teenage pregnancy due to COVID-19

Disruption due to COVID-19 in Sierra Leone could lead to 23,000 extra teenage pregnancies by the end of the year, according to new analysis from Save the Children^[i].

As part of programming to reduce teenage pregnancy, the organization has launched an innovative, interactive game app for boys and girls, which provides reliable information on sexual health as well as how to stay safe from the coronavirus.

For some, this information could be lifesaving. Pregnancy complications are number one killer of girls in Sierra Leone, accounting for a quarter of all deaths of girls age 15-19^[ii] and the teenage pregnancy rate is already one of the highest in the world^[iii]. In West Africa babies born to mothers under the age of 16 are twice as likely to die during the first month of their life.^[iv]

Heather Campbell, Save the Children’s Country Director in Sierra Leone, said:

“This pandemic threatens to be catastrophic for girls in Sierra Leone. During the Ebola outbreak, teenage pregnancy soared due to knock-on effects like school closures and increased poverty. Those same risks have returned, but we can’t let it happen again. Like all of us, children in Sierra Leone are scared of the virus and worried about the future. There has never been a more important time to empower teenagers to take control of their sexual health and stay safe.

“Young people in Sierra Leone led the app’s design, so we know it relates to their lives and works for them. And we quickly updated the content to include vital information about coronavirus as we saw it spreading across the world.”

The pandemic and its secondary impacts such as lockdowns, lack of school and economic hardship threaten to be hugely damaging for women and girls worldwide. Six months of lockdown could lead to seven million unintended pregnancies and 31 million additional cases of gender-based violence. As a result of COVID-19, there could also be an additional 13 million child marriages this decade.^[v]

Kadiatu*, 18, lives in a densely populated fishing community of makeshift homes built with mud and corrugated metal sheets. During the Ebola outbreak she became pregnant aged just 13 with a boy from a better off family.  She said: “My family and I were desperate, we hardly had enough money for food. I even got blurred vision from the hunger. When I asked my mother for food, she would tell me that I’m a big girl, so I should find ways of bringing in money to feed the family.”

“Some girls are going through the same thing [now]. There is no food. Girls need money. What they do not get at home they will likely get from the ‘big man’ on a corner.”

“For those coming up now, they should not make the same mistakes we made. And the parents who allowed us to make these mistakes, we need to tell them to stop it.

“I was lucky to give birth safely at such a young age. I worry for some of these children because they might not be so lucky.”

Save the Children provides food, cash and soap to girls facing hardship during the pandemic. The aid agency also gives teenage girls vocational training like tailoring, which they can use while still going to school to help boost family income.

But information is also key, according to Kadiatu*: “I was aware of it, but I did not know how to get prevention…… there was no money. I did not know that it [family planning] was free. I really did not have the understanding to take prevention at that time.”

Kadiatu* is determined not to let history repeat itself during the COVID-19 pandemic. After training from Save the Children she meets girls with similar backgrounds, to share her story and help them navigate the tough decisions they face.

In Sierra Leone, online misinformation on sex and sexuality contributes to high rates of teenage pregnancy and sexually transmitted diseases, especially in urban areas. Talking about sex is taboo in families and communities, and sexual education is not taught in schools.

The app aims to fill this gap by offering reliable information to help young people understand sexual health and make decisions that will protect them from infections and pregnancy, as well as the coronavirus. It also shows them where they can find support in their community.

The stigma attached to teenage pregnancy means it’s common for mothers to kick their daughters out of the family home when they become visibly pregnant, leaving them with nowhere to go. A vicious cycle that starts with a girl feeling pressured to support herself can end up with homelessness and motherhood.

Save the Children worked with young people and Limkokwing University in Sierra Leone, and software developers Lulu Lab in Denmark, to create an interactive game which takes teenagers through realistic challenges in their lives. As the threat of COVID-19 grew the team worked fast to incorporate vital information about hygiene and social distancing.

There have so far been 909 cases of COVID-19 and 47 deaths in Sierra Leone^[vi], with fears the virus could spread rapidly through densely populated slums.

Emma Kargbo, 16, from Freetown said: “I came to know about coronavirus through Facebook and What’s App. This app is good because it teaches us about contraceptives and other ways we can be protected. The app will protect me and my family from the virus. By using it we will learn more about social distancing, washing of hands frequently and using a face mask, no hugging or shaking of hands.”

Teenagers identified scenarios and came up with options and solutions that felt real to them. The result is a tool that talks frankly about sexual reproductive health in a way that resonates with the people it aims to reach.

The game application can be accessed online or offline through smartphone or tablet. Mobile phone subscriptions in Sierra Leone more than doubled from 2012 to 2016^[vii]  – and usage is growing among urban teenagers. More than half of mobile connections in the country are now broadband^[viii]. For children without tablets or smartphones Save the Children holds facilitated sessions with the app.

Worldwide, pregnancy and childbirth complications are the leading cause of death among girls aged 15–19. Adolescent mothers aged 10–19 years face higher risks of eclampsia and infections. Each year there are 3.9 million unsafe abortions among girls aged 15–19 contributing to maternal mortality and lasting health problems.^[ix] Many health facilities are over-burdened with responding to COVID-19 and are unable to provide essential health services, including for sexual and reproductive health. Save the Children Canada has recently launched a 3-year, Global Affairs Canada-funded project on preventing child, early and forced marriage (CEFM) in two districts of Sierra Leone. This project also focuses on adolescent sexual and reproductive health and rights (SRHR) and gender equality, and will benefit from this use of this interactive app particularly during time of physical distancing due to the Coronavirus can make accessing this information limited.

In Sierra Leone there are many parallels between the measures brought in to curb the Ebola outbreak in 2014-15 and the current COVID-19 pandemic, such as school closures and curfews. Meanwhile the health system suffered and jobs were lost leading to economic hardship^[x] and food insecurity. As a result of a combination of these factors teenage pregnancy surged by up to 65%. Save the Children Canada supports the commitment made by Global Affairs Canada this week towards improving SRHR (sexual and reproductive health and rights), highlighting that these needs are heightened by the pandemic, with support being needed now, more than ever.

ENDS

*Name changed to protect identity.

^[i] Save the children analysed a range of studies into the impact of the Ebola crisis in Sierra Leone, which recorded surges in teenage pregnancies of 11% (Bandera et al, 2018),  25% (Elston et al, 2015) and 65% (UNDP, 2015). Applying these spikes to the analogous situation today, the aid agency concluded that in 2020, the pandemic could result in between 9 and 60 thousand additional adolescent pregnancies in Sierra Leone. The intermediate scenario predicts a 25% increase in the rate of adolescent pregnancy, or 23,000 additional pregnancies by the end of the year.

^[ii] Maternal disorders are the primary cause of death for girls age 15-19 in Sierra Leone, accounting for 24.8% of deaths in this age group (Institute for Health Metrics and Evaluation. Global Burden of Disease 2017)

^[iii] According to World Bank data Sierra Leone’s teenage pregnancy rate is 17^th highest in the world, placing it in the top 10% globally: https://data.worldbank.org/indicator/SP.ADO.TFRT?most_recent_value_desc=true

^[iv] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5965834/

^[v]https://news.un.org/en/story/2020/04/1062742

^[vi] WHO figures as of 4 June 2020: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200604-covid-19-sitrep-136.pdf?sfvrsn=fd36550b_2

^[vii] https://www.itu.int/en/ITU-D/Statistics/Pages/stat/default.aspx

^[viii] https://datareportal.com/reports/digital-2020-sierra-leone – slide 34

^[ix] https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy

^[x] In August 2014 Sierra Leone’s Agriculture Minister said “The economy has been deflated by 30% because of Ebola” – https://www.bbc.co.uk/news/business-28865434 ; A 2015 census in Sierra Leone found that more than half of people who were working at the time of the survey said their income had deteriorated during the Ebola outbreak – https://sierraleone.unfpa.org/sites/default/files/pub-pdf/EVD%20report.pdf ; The World Bank found that employment in Freetown fell from a baseline of 71% to a 63% at the peak of the Ebola outbreak – http://documents.worldbank.org/curated/en/873321467999676330/pdf/97392-WP-P151624-Box391466B-PUBLIC-Socio-Economic-Impacts-of-Ebola-in-Sierra-Leone-June-2015-final.pdf