Her eyes were yellow and drooping. She was obviously weak and tired. I touched her forehead and there was no obvious elevation of her temperature but I knew that she was seriously ill. I asked her when she first saw her period. She replied ‘About a year ago.’ As our conversation progressed, she confided in me that she was impregnated by a middle- aged man who gave her money.  She then left for home as she was not feeling well. The next day, I received a call from one of her counselors informing me that she had died overnight after being rushed to a hospital. This precious child was three months pregnant and only twelve years old.

Teenage Pregnancy – An Epidemic in Sierra Leone
The epidemic of teenage pregnancy in Sierra Leone is alarming and does not seem to be abating, despite legislation, wide media coverage, NGO activism and several meetings on the subject. A review of the numbers reveals a disturbing reality.  According to a report by UNFPA, the country’s rate of teenage motherhood ranked among the ten highest in the world, with 28% of girls aged 15-19 pregnant or already having given birth at least once. In terms of maternal mortality, Sierra Leone has the fourth highest rate in the world, and teenagers make up 40% of all its maternal deaths. The current rate of 1165 per 100,000 live births represents an increase from 800 per 100,000 live births in 2015. (UNFPA, 2017; OXFAM, 2017.)

The underlying cause is widespread and devastating poverty. According the UN threshold for poverty which is $2.00 a day, 70% of Sierra Leoneans live in poverty. Teenage pregnancy is a symptom of economic deprivation and imposes burdens on the girls and their economically-deprived families. It represents a waste of human resources as these future contributors and leaders of society become liabilities instead of assets. Teenage pregnancy is compounded by maternal mortality which are both the results of a deep socio-economic crisis fueled by chronic and intractable poverty.
 
Significantly, teenage pregnancy is extremely risky and dangerous, especially for poor girls. According to UNFPA, ‘tens of thousands of adolescents die annually of causes related to pregnancy and childbirth. In fact, these are the leading causes of death among adolescent girls, aged 15 to 19.’ (UNFPA, 2018.p.1) The babies are twice as likely to be stillborn or die as infants. Given the fact that their bodies are still developing, they are not physically equipped to deliver a baby without risks. In a number of cases, Caesarian sections become necessary due to their inability to push during labor. These major surgeries that can result in complications and even death and are contributory factors to the high maternal mortality rate, especially among teens.

Besides the potential and real threat of horrendous medical complications, being a pregnant teen or a teenage mother has social and economic consequences that are negative and long lasting. Although the direct medical causes of maternal mortality are fairly uniform all over the world and are well known, very little is known of the social and cultural determinants influencing maternal mortality or the impact of the political economy on health. In addition, there are personal costs which include dropping out of school; psychological trauma resulting from abandonment by the father of the baby; isolation, ostracism, low self-esteem and the likelihood of perpetuating inter-generational poverty. In addition, teenage pregnancy can result in social upheavals by disrupting family stability and household integrity, especially when some of these girls are thrown out of their homes by their parents.

As a result of poverty, many of these girls do not have adequate nutrition to sustain their own physical growth and development, let alone that of a fetus. Some are naïve and do not have a basic knowledge about their bodies, sexuality or how susceptible they are to becoming pregnant. Most of them do not protect themselves by using contraceptives, which they cannot afford, and are highly vulnerable to contacting venereal diseases and HIV/AIDS.

Causes of Maternal Mortality
Maternal Mortality is an oxymoron. Dying while in the process of reproducing new life, is a tragic contradiction! The direct causes of maternal deaths are the same all over the world in that the majority of maternal deaths are the result of complications arising during pregnancy and delivery. They include postpartum hemorrhage, a leading cause, sepsis, complications resulting from caesarian surgeries; unsafe abortion; prolonged or obstructed labor and hypertensive disorders, especially eclampsia. These complications can occur suddenly at any time during pregnancy or childbirth without forewarning. As a consequence of maternal deaths and disabilities, infants and children also suffer. Tragically, when a mother dies, her new-born child is at risk of dying. The older children, most often girls, have to leave school to take care of household chores. All of these risks are made worse by poverty due to lack of access to good health care services and timely intervention in situations of emergency.

Abortion is a troubling cause of maternal mortality because of its legal, religious and moral implications. Although abortion is illegal in Sierra Leone it is available through fairly safe medically-managed services as well as risky and dangerous underground operations, used by poor women. Some teenage girls have no option but to take their pregnancy to term because of the cost of abortion and lack of access to health care facilities. Globally, three million girls aged 15 to 19 in low income and middle income countries risk their lives and health through abortions. (UNFPA, 2018.)

Cultural Determinants of Teenage Pregnancy and Maternal Mortality
Culture can have both positive and negative effects on maternal mortality. Overall, poverty trumps culture in explaining the high rates of teenage pregnancy, maternal mortality and mortality rates in general. Poverty is responsible for the average life expectancy in Sierra Leone which is 51 years and poses a constant threat of morbidity and mortality. This results in a high degree of fatalism towards notions of life and death. Although maternal mortality is mourned by all ethnic groups, almost all of them attribute death to God’s will and in some ethnic groups, maternal mortality endows women with the glory of having ‘died in battle.’

A prevailing concern among medical professionals is that too much of the cultural management of pregnancy and childbirth is in the hands of Traditional Birth Attendants. Most are based in the rural areas of the Provinces of Sierra Leone but some of them operate in the urban Western area, where Freetown is located. Traditional Birth Attendants have the advantage of sharing the same cultural values and social norms with the pregnant girls and women and can provide support and comfort. They are also likely to have a long-term relationship of trust with the patient and her family. A number of the girls and women who are affected by maternal mortality have a rural background and some are recent migrants to Freetown. A large number have only rudimentary education and come from poor families that live in slums and unsafe neighborhoods.

Despite some cultural benefits of Traditional Birth Attendants in terms of providing a familiar environment which encourages the agency of women in the birthing process, the medical establishment is concerned that they may be unwittingly using techniques that are harmful to the mother or subscribing to harmful cultural practices. These could include female circumcision that can lead to infections; create complications during childbirth or undermine the health of women and teenagers. The Multiple Indicator Cluster Survey on Sierra Leone for 2017 reports that 80% of girls and women aged between 15 and 49 have undergone some form of female circumcision and 58% of women support the practice. It is also the case that traditional birth attendants tend to rush mothers to push too early, resulting in a difficult labor that can sometimes lead to fistula problems. There was a time when the World Health Organization encouraged the partnership of Traditional Birth Attendants in maternity health care. Now, they are being marginalized in Sierra Leone by the medical establishment in an effort to bring down the high rate of maternal mortality.

Other cultural factors influencing maternal mortality pertain to food taboos that require pregnant women to avoid eating certain foods like eggs, chicken and some vegetables that are rich in protein and other nutrients. There is also a taboo against giving blood among some ethnic groups, which can help save lives in situations of emergency where there is a shortage of blood in the hospitals. Furthermore, some cultural practices are related to gender inequality which endows men with decision-making authority, even in matters of pregnancy and childbirth. In many rural areas, it is men who decide the number of children a woman should have and have control over a woman’s body. In some instances, it is men who decide when a woman is ready to go to the birth center, clinic or hospital even though he is not the one in labor. All of these cultural factors are made worse by the lack of access to reproductive health care services by women in low socio-economic groups.

Case Study I: A Special Program for Teenage Pregnant Girls and Mothers
I was fortunate to spend some time with teenage pregnant girls and teenage mothers at one of the health centers in Freetown in the summer of 2018. The program is run by highly dedicated and knowledgeable counselors and teachers. It consists of lectures and discussions about the management of pregnancy, labor, delivery and infant care. The curriculum also includes lectures and video presentations about health, sanitation and diseases like malaria. cholera and other infectious diseases with emphasis on prevention. Other activities include counseling, arts and crafts, singing and dancing. Most of these girls are from very poor socio-economic backgrounds, a determining factor of their current situation.  Sexual encounters can be motivated by financial reasons, romantic relationships or coercion. Using their bodies for financial gain appears to be the only means of livelihood for some of these girls, even though romantic relationships do occur. The majority tend to become involved with men much older than they are who do not or would not use condoms, leaving the girls, who often cannot afford contraceptives, vulnerable to becoming pregnant. Many of these men are unscrupulous predators who prey on these girls.

Some of these sexual encounters are technically ‘rapes’ since many of these girls are under 18, which is the age of consent. In fact, coercion is often deliberate and can take the form of entrapment. A number of these girls are petty traders and can be lured into a man’s dwelling under the guise of a trading transaction, only to be raped in the end. Others are lured away unwillingly when they go out at night to fetch water from public taps. Hence the public spaces of the city become sexual traps for these girls by men who use their tender and developing bodies as sites of rampant exploitation. Most of the men deny the pregnancies and those that accept usually become withdrawn and may move away from the area altogether to avoid further contact with the mother and demands for child support.

Profiles of teenage pregnant girls and teenage mothers
The following are representations of the pregnant teenage girls in their own words.

Pregnant Teen 1 – 15 years old and four months pregnant said the following in tears:
‘My mother and father threw me out of the house when I became pregnant. They are very poor and so are my relatives. My parents could not pay my school fees so I had sex with a man who paid my fees and I was able to go on with my schooling. When I got pregnant I stopped going to school. I am now staying with a friend. The friend also lives with relatives and the house is crowded. It is very hard and sometimes we do not have enough to eat. The man never denied the pregnancy but he says he is not going to be able to help me with the expenses for the baby.’

Pregnant Teen II – 16 years old and eight months pregnant.
‘The father of the baby in my belly is a 25 years old mechanic and is my boyfriend.  However, since I got pregnant, he has not been coming to see me as frequently as he did before, even though he did not deny the pregnancy. I was told that he has another girl friend. My parents cannot afford to have me stay with them so I am staying with my sister, her husband and their two children. When I stayed with my mother, I used to help her in selling cooked ‘cow kanda’ (cow skin.) We do not make much money from that and my parents can barely make enough to feed themselves let alone having another mouth to feed when my baby is born. My father works in security and is not paid much. I do not see how I can take care of the baby once it is born. I am thinking of giving the baby up for adoption.

Pregnant Teen III – 14 years old and three months pregnant said the following in tears:
‘My parents threw me out of the house when I got pregnant. I had sex with a man for money because my people are very poor. The man denied the pregnancy. I am staying with friends and have no other person to help me. I do not know how I am going to be able to take care of the baby.’

Pregnant Teen IV. Age 14 and six months pregnant. ‘I got pregnant by a man who made friends with me soon after I came to Freetown from up country. I had just come out of Bondo society and he was after me until he impregnated me. I thought he would marry me since I have been through society but he denied the pregnancy. I am with my parents who now live in Freetown and they are helping me but the family is poor and is having a hard time.’

Pregnant Teen V. Age 16 said the following in tears. ‘I was staying with a friend of the family and her husband. My parents are up country and sent me to them to help them and for them to take care of me. The woman cannot have children. She told me to sleep with her husband so that I can get pregnant and have a child for them. I got pregnant by her husband but now she hates me and treats me badly. She wants me to leave the house and I have nowhere else to go. I am afraid.’


Case Study II: Teenage Mothers
The following are profiles of teen mothers who also attend this special program at a health center in Sierra Leone.
There are usually about 10 -20 young mothers and their children at the special weekly program held for them at the health center just outside of Freetown. Most of the babies sleep on the floor during the meetings. There are usually one or two children that are older and roam about the hall where the meetings are being held.  The babies always seemed healthy but are often overdressed, even on hot days.  All the young mothers are having financial and other challenges but for now seem to have help looking after the babies. They are often given lectures and demonstrations on how to bathe, feed and change the babies and generally how to look after them. Other topics covered include hygiene, prevention of diseases and nutritional guidelines. At the end of the lectures, they usually resume their handicraft work, making knitted or crocheted clothes and blankets for their babies followed by some refreshments before being dismissed after about four hours at these meetings.
 
Teen Mother I is 17 years old with a ten months old baby. She said the following:  ‘I became pregnant as a result of rape by an older man who lured me into his house. The man denied the charge of rape and the pregnancy and we don’t know where he is. I have a hard time raising my baby but my mother is helping me.’

Teen Mother II is 17 years old and her baby is two months old. She recounted the following to me: ‘The father of my baby is much older than me. He is 25 years old and is a driver. He does not earn much and he does not have work all the time. He did not deny the pregnancy because he was my boyfriend. I think he would like to help me more but is not able to do so. My mother helps me to take care of the baby. She does not have much money and is a trader of foodstuff.’

Teen Mother III is 18 years old and her baby is 7 months old. In an emotional and shaky voice, she said the following to me: ‘The father of my baby is 27 years old. We live together with the baby but he has no job. I would like to give my child up for adoption if my boyfriend agrees but the people who adopt the baby have to promise to provide money for me regularly. I do not like the idea though of never seeing my baby if I give her up for adoption.’

Teen Mother IV is 17 years old and her baby is 2 months old. According to her: ‘The father of my baby is the same age as me but he was not my boyfriend. I could not push the baby out by myself because they said that my body was too small. I was delivered by operation. The father does not care about the baby and denied the baby. It was a result of rape and the police was informed but the father cannot be found. I live with my parents but they have no jobs. Life is hard. Sometimes we do not have enough to eat and have to ask the neighbors for food.’

Teen Mother V is 16 years old and her baby is four months old. Speaking with tears in her eyes, she said: ‘The father of my baby is 25 years old and has no job. He denied being the father. My parents threw me out of the house. My baby and I live with my uncle who is a security worker at Waterloo. I get some help in the form of food and clothes for the baby from a group called ‘Girls’ Initiative,’ an NGO that works in Sierra Leone.’

General Observations regarding the Case Studies
My interaction with the teenage pregnant girls and mothers leaves me with a lot of concern for them and for their wellbeing as well as that of their babies. Their situation is almost surreal in that they are ‘misfits’ in a society that does not make sufficient provisions for them in term of protecting them from early pregnancies or supporting their educational development and well- being. To make matters worse, a number of them are thrown out of the house by their parents, which leaves them in even more precarious positions. Some live with other relatives or friends, many of whom are poor.

During my interaction with the teens, I conducted a discussion in which I asked them what they would like for their babies. In their response, they gave priority to good education and good health. They also said that they would hope that their girls would not disappoint them by getting pregnant like they disappointed their parents. It was clear to me that that these girls are sensitive, caring and have good values. Those that have already given birth love their babies, even when they were having a difficult time taking care of them.

I grew very fond of these special young women and referred to them collectively as ‘ladies’ and their babies as ‘precious ones.’ I often wished the pregnant ones good luck in their pending deliveries and hope they will have ‘nice babies.’ These words tended to lift their spirits and morale. They referred to me as ‘Professor’ and showed respect, good manners and kindness to me, their counselors and other adults. In turn I valued the opportunity to get to know them as people with dreams and abilities and as potential contributors to society, rather than victims of their special situations. I tried not to pass judgment on them but was fully aware that abstention from sexual activity was not an option for them.  Instead, I tried to encourage them to get safe and proper counseling about contraceptives to avoid having a second child, which would simply add to their already difficult lives. Many wanted to go to school or return to school, finish their education, get a job or become self-employed.

Causes of Teenage Pregnancy
Poverty is clearly a major determinant and driving force behind teenage pregnancy and maternal mortality. Economic deprivation operates at the national, household and individual levels and creates a vicious cycle of poverty. According the United Nations Development Programme:

‘Sierra Leone remains among the world’s poorest countries, ranking 180th out of 187 countries in the Human Development Index in 2011. Decades of economic decline and 11 years of armed conflict had dramatic consequences on the economy. Poverty remains widespread with more than 60% of the population living on less than US$ 1.25 a day and unemployment and illiteracy levels remain high, particularly among youth.’   (UNDP, 2017 p.1)
 
The country is currently implementing Structural Adjustment Programs to achieve what the International Monetary Fund refers to as ‘macro-economic stability.’ intended to correct deficiencies in the economy. Despite its ‘wealth’ in natural resources, Sierra Leone is one of the Least Developed Countries, according to the United Nations. Unemployment is widespread, leading to alternative means of generating income, including prostitution. Most of the pregnant girls and mothers live in poor areas and households that are located in remote parts in the city as well as major slum areas like Kroo Bay, Susan’s Bay, Red Pump, and so forth. These neighborhoods are renowned for poor sanitation, dilapidated and crumbling shacks and a large percentage of poor inhabitants.  As many as ten people could be living in a dwelling of about 1000 square feet. Latrines are usually of the pit variety and are in dilapidated structures that are weakened by heavy rains during the rainy season.

Water is scarce and many have to go out to fetch water from the public taps which open about two or three times a week. They live in run down houses, known locally as ‘pan bodies’ with little or no electricity and inadequate furnishings. Some of the girls I interviewed sleep on mats on the floor with as many as four to five other people. One of them reported that when it rains, the water comes into her room up to the level of her bed soaking her and making it very difficult for her to get any sleep at night.

The second cause of teenage pregnancy is teenage prostitution which is primarily a result of poverty and lack of other income-generating options. Prostitution can be both formal and informal in the sense that girls may use sex to get material things from men without formally being regarded as prostitutes. In addition, it is believed that in some homes, girls are encouraged to go into prostitution informally to earn a living for the family in the absence of any other options.
Teenage prostitution is a major problem in the urban areas and is tolerated by the population at large, even though prostitution as a commercial activity is technically illegal in Sierra Leone.

Teenage prostitution generally takes place along the main thoroughfares and beaches. Some of these girls act on their own, but a number have pimps or madams that operate small brothel-like services. Although the actual numbers are difficult to obtain, teen prostitutes are visible at night along the main roads in Freetown, such as Wilkinson Road, Beach Road, Lumley Beach, The Light Bus Stop, around Youyi Building in Brookfields, Bode Ose , Lamsat, Fowl Cop and so forth. (Concord Times, 2015.) Prostitution is also high in mining areas in Sierra Leone and in other commercial towns in the Provinces.

Prostitutes in their teen years 20s and above regularly exchange sex for very little money, ranging from Le. 30,000 ($4.00) for brief encounters to Le.100,000 ($12) for the whole night. Demand is high and male customers come from all works of life. (Concord Times, 2015.) There is risk of contracting venereal and other infectious diseases and the incidence of HIV/AIDS infection which is given as 1.7% for adults is probably higher among prostitutes. Nonetheless, HIV/AIDS and other sexually-transmitted diseases do not serve as deterrents to teenage prostitution. In addition, the influence of the internet and pornography is likely to be a contributing factor as well as X-rated movies that are shown in Freetown without any form of regulation.

The third cause of teenage pregnancy is the tradition of child marriage. According to the UNFPA, 9 out of 10 births to adolescent girls occur within a marriage or a union. (UNFPA, 2018.) Although the legal age for marriage in Sierra Leone is 18, in many rural areas and among some ethnic groups, girls can be married off as young as 13 years old. In mining areas, a survey found that some parents forcefully give their girls in marriage to rich miners and in some cases to men old enough to be their fathers. (Awareness Times, 2018)

Usually initiation into the Bondo/Sande society as adolescents signals the transformation of a girl from childhood to adulthood, i.e. womanhood and readiness for marriage. Marriage is an institution that functions partly for reproduction and partly to regulate sexual behavior and contain female sexual activity within marriage. Female circumcision is usually performed as a prerequisite and prelude to marriage, which marks the beginning of a woman’s childbearing destiny. This legacy of child marriage and early motherhood accounts in part for the high tolerance of teenage pregnancy as it tends to blur the distinctions between childhood and womanhood. In other words, a teenager can bear a child in the traditional rural setting where there is a social and cultural infrastructure to support it. In the urban areas, it becomes an aberration and a form of social disorganization for the teenage mother, her family and the society at large. Whereas teenage pregnancies can be relatively accepted and cushioned in an appropriate cultural context, they can become recipes for disaster in a wrong social environment, such as Freetown.
 
A Fourth reason for teen pregnancies is the destabilization of the family or household unit. Societal mores and responsibilities for socialization of children as well as codes of sexual behavior are being undermined, especially in the urban areas. Although rural to urban migration has been a trend for centuries, many of the stable rural-based institutions of the family and household as well as social sanctions and codes of conduct that regulate sexual behavior are eroded in the urban environment. Discipline becomes difficult to enforce, especially if parents, out of necessity, have to eke out a living in the precarious and low wage activities dominated by petty trading and other menial services.

Many children are left to look after themselves due to the exigencies of a challenging urban economy where low wages and challenging working hours are the norm. This leaves many homes without adult supervision. Children can be seen roaming the streets as petty traders, panhandlers, thieves or teen prostitutes. Urban areas pose major threats to economic wellbeing since there are very few jobs in the formal labor market. As a result, a large percentage of the population remains chronically unemployed or underemployed or try to survive in the precarious informal urban labor market.

Attitude is a fifth contributing factor to teenage pregnancy, leading some of the girls to have wrong priorities and desire material things like cell phones, shoes, clothes, money and so forth from men in exchange for sex. Others are not interested in getting an education and would rather roam the streets as petty traders. For some girls, being pregnant is seen as a badge of honor and renders them some status as ‘little mothers’ in a society where motherhood is valued and could serve as compensation for the low social and economic status. Nonetheless, the reality of their lives is fraught with hazards and personal risks. Girls selling foodstuff and other goods late at night are often in danger of being abducted or raped. Most of the men involved are older but some are also teenagers. The attitude of the majority of men and boys is also in question. They tend to be reckless and may harbor feelings of disdain for these girls, fueled by deep- seated misogynistic proclivities. They prey on these girls and see their bodies as sites of exploitation, in violation of laws like the Sexual Offence Act.

A seventh reason for teenage pregnancy is the high rate of illiteracy in Sierra Leone, which stands at almost 50%. It can lead to poverty and disempowerment in terms of unemployment; lack of access to resources requiring literacy skills, lack of access to information and a diminished ability for informed decision-making. Illiteracy also deprives people of knowledge about the laws, such as laws relating to the protection and rights of women and girls. It can also result in lack of sex education, knowledge about contraceptives, lack of action in terms of participation in pre-natal and post- natal care and lack of awareness about the medical and social consequences of teenage pregnancy.

Rape and sexual violence constitute the eighth cause of teenage pregnancy. These acts are widespread due to the criminal and irresponsible behavior of some men and the breakdown of traditional norms and values. These acts were exacerbated by the ten-year civil war that resulted in massive population displacement. According to an article in the Awareness times of August 17th, 2018, the very fear of rape has led many families to marry their daughters off at an early age in the hope that this will help protect them from predators. According to a UNICEF case study in 2017, the Family Support Unit (FSU) of the Sierra Leone Police estimates that over 1,000 children experience sexual violence in the country each year. The research further states that between January and September of 2016, the Family Support Unit recorded 764 sexual offences against children.

A World Vision 2017 Research report confirms that sexual violence continues to surge and affects boys at 13.2% and girls at 21.5%. It ranges from sexual harassment, to kissing, rubbing, feeling, fondling or caressing, including verbal, emotional, inappropriate touching or physical harassment to actual sexual penetration. The same study also revealed that the perpetrators of sexual abuse and exploitation are normally people who live in the same community and are known to the children, with more than 35% being either close relative or an extended relative.

It is against this backdrop that World Vision Sierra Leone through its campaign: ‘It takes a world to end violence against children. End child sexual violence in Sierra Leone! It Takes Us All,’ has called on the government of Sierra Leone to take tougher steps ‘to put an end to this hideous act of sexual violence against children.

Culture of Sexuality and Sexual Activity
Culture interprets and assigns meaning to social processes and customs that wary from one society to another. It not only represents definitions and diagnosis; it also arranges treatment and handles morbidity and mortality in culturally-appropriate ways. In this case, sexuality and sexual activities are embedded in the cultural frames of the various ethnic groups in Sierra Leone, all of which have codes of conduct that regulate sexuality and sexual activity. However, rapid social change, urbanization, the weakening of cultural norms and mores have all eroded the cultural prescriptions and prohibitions regarding sexuality and sexual activity.
 
The result is a climate of tolerance or deviation from accepted norms and codes of conduct. Religious prescriptions that regulate sexual behavior are often circumvented or disregarded. Pre-marital and extra-marital sexual relations are tolerated, sanctioned and even expected, especially for men. Marriage is not a prerequisite for sexual activity, even among the most pious members of society. Given this kind of libidinous environment, the normative expectation is unbridled sexual activity.
 
Adolescence sexuality is a challenge since most of the sexual activities of teenage girls tend to be voluntary even though there are incidents of rapes and prostitution. Sex education is not widespread and tends to be limited to biology classes in schools. The link between sexuality and responsible sexual conduct and questions of morality, vulnerability and protection are not usually taught or understood. Due to the lack of strong institutional structures in the urban context that provide adequate socialization and guidance to children and adolescence, there is an irreparable breakdown in family integrity, stability and responsibility. This makes it difficult for parents to exert effective discipline and control over the sexual behavior of their children.

In Sierra Leone 85% of girls and women 15-24 had their first sexual experience with a partner 10 or more years older; 28% of girls 15-19 are pregnant or have already had a child. According to Government of Sierra Leone research over 1,400 girls under 18 years of age, became pregnant during the Ebola period. (Awoko News’ November 26, 2016)

Due to the idealization of motherhood, giving birth is a cultural imperative for women. This is reinforced by religion, including traditional African religions and universal religions of Islam and Christianity. In this context, children are seen as gifts from God. Childbirth is celebrated and elevates the status of the mother. In some African societies, the marriage process is only complete with the birth of the first child. The destiny of a woman in the social construction and worldview is to be pregnant and have children. Pregnancy and motherhood rank high in the system of merit for women in most ethnic groups.  So, ingrained is this belief that if a woman is barren or chooses not to have a child she is seen as a misfit. 

When motherhood occurs in its proper context, i.e. through marriage, there is much to be celebrated about bringing forth a new life. However, pregnancy outside of marriage involving teenagers is not socially sanctioned in many ethnic groups. This objectifies and sexualizes girls and women in ways that can undermine their agency and personhood. Once a girl starts exhibiting signs of sexual maturity in terms of the increase of her breast size; the rounding up of her buttocks and other parts of her body and her menarche, she is viewed as a sexual object by men regardless of her age, which may be well below 18, the legal age of maturity in Sierra Leone. It is not unusual to have men compliment or tease girls about the development of their bodies in ways that could be deemed as sexual harassment in some countries.

War and Ebola
The protracted Rebel War from 1991-2002 caused 50,000 people their lives and destroyed the infrastructure and social fabric of Sierra Leone society. It led to large displacements of people from the rural areas to Freetown. As is characteristic of most situations of war, it also led to a breakdown of norms and mores that regulate sexual behavior, leading to an increase in rapes, violence against women and prostitution.

The Ebola Crisis which lasted from 2014 to 2016 in Guinea, Sierra Leone and Liberia and left 4000 people dead in Sierra Leone, was another major social catastrophe, with implications for teenage pregnancy. According to a study by the United Nations Development Program (UNDP), teenage pregnancy increased to 65% during the Ebola epidemic. The epidemic disrupted many institutions including schools, hospitals and places of employment that reinforced as well as increased conditions of poverty. This led some girls to engage in prostitution in exchange for basic food items, water and a means of financial survival.

A joint study by Plan International, Save the Children, World Vision and UNICEF which also found that teenage pregnancy increased during the Ebola crisis. It has been argued that epidemics and women’s vulnerabilities to rapes and violence should be examined more fully as is done in the case of wars and their association with rapes. As Monica Onyango, a clinical assistant professor of Global Health at Boston University puts it: ‘Epidemics are just like a conflict situation. You have a loss of governance; you have chaos and instability; and all of that leaves women vulnerable to gender-based violence.’ (Yasmin, 2016, p.3)

The Joint Study also noted that many of the emergency measures concerning curfews, school closings and other public health measures tend to make women and girls vulnerable to sexual aggression. It is also widely known and confirmed in a study by Save the Children that poor and vulnerable girls were forced into sex work for food and housing needs. Since Ebola killed a number of breadwinning men and adult women, young girls and children were often left destitute.


The Role and Responsibility of Men
It is clear that men are mainly responsible for the epidemic of teenage pregnancy in Sierra Leone because they drive demand for teenage prostitution and encourage the exploitation of the bodies of teenage girls through predatory and promiscuous sexual activities. The current situation reveals a high degree of gender-based discrimination due to the irresponsible sexual behavior by men and disdain for women by some men. A counselor from another country in Africa that is working in the program for pregnant teens and mothers in Sierra Leone is convinced that the problem is with men and not with the girls. She feels that in the case of Sierra Leone ‘there is something seriously wrong with the heads of the men.’ She noted that in her country, which is also in Africa, teenage pregnancy is not a widespread problem, even though there are several unmarried mothers, who are usually in their twenties or older.
 
If any progress is to be made to control the epidemic of teenage pregnancy in Sierra Leone, the involvement and active participation of men is imperative! The onus has always been on women and girls in terms of using contraceptives and abstaining from risky sexual behavior. The fathers of their babies usually escape the biological consequences, responsibilities, stigma and dropping out of school. The gender imbalance in relation to sexuality is a cultural problem that is triggered by polygamy and child marriage among some ethnic groups and gender-based discrimination and violence against women in all ethnic groups.
 
In addition, some ethnic groups have systems of mediation in customary law for situations of sexual violence or sexual relationships outside of marriage. Known among some groups as ‘woman damage,’ compensations can be negotiated between the family of the victim and the accused or the man could be pressured to marry the victim. This is against the sexual offence law of Sierra Leone. However, due to the lack of effective punitive measures, the laws are easily circumvented or ignored. The existence of legal pluralism, whereby customary, religious and statutory laws exist simultaneously, renders women vulnerable and can violate their rights in matters of sexual violence and rapes.


Re-education and Sex Education
At present, there is inadequate sex education in the country. The government has an important role in re-educating the population through an appropriate general curriculum but also in promoting comprehensive sex education and sensitization. Such sex education programs should involve boys and men in participatory roles. Unfortunately, some teenagers may not respond to sex education even when they know that the consequence could be pregnancy. The social and economic pressures tend to overshadow applying the lessons from sex education that include prevention of pregnancy and sexually-transmitted diseases.

In 2015, when schools in Sierra Leone reopened after the Ebola crisis, the minister for education banned visibly pregnant girls from school and from sitting exams. This discriminatory ban persists and has been strongly condemned by Amnesty International, among others. As Alioune Tine, Amnesty International’s Regional Director for West and Central Africa puts it:

“The prohibition on visibly pregnant girls attending mainstream schools and taking exams is hopelessly misguided, and is doing nothing to address the root causes of Sierra Leone’s high teenage pregnancy rate, which surged during the devastating Ebola crisis, and remains high despite this ban……Rather than humiliating and excluding teenage girls, Sierra Leone’s authorities should focus on increasing sexual and reproductive health information in schools, and protecting girls from sexual violence and abusive relationships. Unless these issues are addressed the cycle of unwanted early pregnancy will continue for generations to come.”

A “bridging system” was started where girls can seek alternative education elsewhere, but the disruption remains huge. Often girls will be prevented from sitting exams and need to repeat a whole year of school, causing them to drop out entirely. This discriminates against the girls, but not the men who got them pregnant. After giving birth they face continued problems reintegrating into their schools of choice. Alioune Tine continues:

“Unless barriers to education are removed, Sierra Leone’s government is badly letting down its girls and putting their futures at risk. In line with its international obligations the government should take concrete steps to progressively ensure access to education for all girls – including subsidies for girls who require them – as part of its education strategy.”

Legislation and Challenges
Although there are legal measures to protect teenage girls from sexual abuse, rapes and sexual violence, enforcement of these measures remains weak. Significantly, the culture of many ethnic groups in Sierra Leone tolerate sexual abuse of women and girls. A culture of impunity and machoism can be said to exist that encourages the perpetuation of sexual violence and rape, which are contributory factors to teenage pregnancy.

Promoting gender equality and the empowerment of women as a basic human right are priorities of the Millennium Declaration. They are seen as prerequisites for effectively combating poverty, hunger and disease and stimulating sustainable development. The unacceptably high rates of maternal mortality in sub-Saharan Africa, especially in Sierra Leone, would derail efforts in the implementation of this declaration.

Teenage pregnancies have important policy and multi-sectoral programmatic implications because of their long-term and structural effects. A multi-dimensional approach will be needed to stem the tide of teenage pregnancy and integrate the mothers and their babies into society in a manner that will enhance their human development capabilities and prepare them to contribute meaningfully to their society and valued citizens.

Currently, there are a number of policies, programs and legislative mandates that serve as supporting pillars for change. Sierra Leone ratified the United Nations Convention on the Elimination of all forms of Discrimination Against Women (CEDAW) in 1988 but has been slow in passing legislation to domesticate and enforce the rights contained in the convention. Despite its participation in the four United Nations Conference on Women, the country has a low rank at the bottom of the Gender-related Development Index. It must be noted that many of these development indices of the United Nations, in my view, tend to be biased in favor of countries of the Global North and use questionable methodologies. Nonetheless, the country has made some progress in promoting gender equality and the advancement of women in terms of the Gender Acts of 2007, but more needs to be done
.
Legislative Mandates
There are three type of laws in Sierra Leone. These are Statutory law, Customary Law and Scriptural Law, particularly Muslim Law. The three Gender Acts of 2007, namely the Domestic Violence Act, the Devolution of Estates Act, the Registration of Customary Marriage and Divorce Act as well as the Sexual Offence Act of 2012, could provide protection to women. 

The Domestic Violence Act of 2007
With reference to maternal mortality and teenage pregnancy, The Domestic Violence Act is the most relevant since a number of pregnancies, especially teenage pregnancies, are ‘technically’ the result of statutory rape. According to this law, domestic violence has a broad definition that includes economic abuse (unreasonably withholding or destroying the other person’s financial resources); harassment; emotional, verbal or psychological abuse; intimidation; physical abuse and sexual abuse. Under this law, domestic violence becomes a criminal office as does marital rape. The law also strengthens the ability of the police and Family Support Units to respond to domestic violence. Under this law, people can bring civil proceedings that can result in the issuing of restraining orders for protection.
 
Sexual Offences Act 2012
This landmark law offers protection for all children under 18 years by stating categorically that these children cannot give consent to sexual activity. If implemented and enforced fully, this will make a major change to the attitudes and behaviors surrounding teenage sexual activity and pregnancy in the country. It also stated that marriage of a defendant and victim shall not be a defense to an offence under the Act. The offences under this law include rape, indecent assault, causing a person with a mental disability to engage in sexual activity, incest, harassment, indecent exposure, causing or inciting prostitution, production, publication and distribution of indecent material. The law also has offences against children that include sexual penetration of children, sexual touching of children, sexual activity in the presence of children, causing a child to watch sexual activity and meeting a child for sexual purpose.

Sexual abuse by persons in trust towards a child is an offence punishable to imprisonment not exceeding 15 years. The punishment does not include payment of fines. Other offences in relation to children include producing and distributing child pornography, possessing or accessing child pornography, use of children for pornographic purpose, obtaining the service of child prostitute, offering arranging or benefiting from child prostitution, parent facilitating child prostitution, organizing or promoting child sex tourism.

Despite the existence of these laws, implementation and enforcement measures are weak or non- existent. Workers at so-called ‘Rainbo Centres’ facilities that provide medical care and legal support to rape survivors have frequently reported their difficulties in dealing with the rise in gender-related sexual offences in the media. ‘The Family Support Units’ that were established in 2001 within the Sierra Leone Police to deal with incidents relating to the family, especially domestic violence and sexual violence have not been as effective as they should and end up returning the victims to their original situation of abuse.
 
The Urgent Need to Implement, Enforce and Monitor Legislative Mandates and Policy Instruments.
Implementing these laws that can protect teenage girls has been an enormous challenge, primarily because of lack of human and material resources and a strong political will. Large-scale sensitization campaigns will be necessary, including extensive collaboration with the media. Massive mobilization of communities will be required and has to involve traditional leaders, religious leaders, local authorities, households, local organizations and so forth. Men and boys in particular have to be given active roles as change agents to sensitize and compel other men and boy to desist from these reckless sexual behaviors. Attitudes towards women will also have to be changed, especially in young men and boys that already exhibit misogynistic tendencies. It has been reported that even at the highest level of government, some politicians still hold the view that women should be blamed for rapes by dressing in provocative ways and have asked for a dress code law to be passed to prevent sexual violence.

Finally, community attitudes promoting gender-based violence have to be eradicated. Above all, men need to become advocates against gender-based violence and behaviors that lead to teenage pregnancy. I was impressed by a group of young men and women called ‘Inspiration for her’ whose main objective is to prevent the exploitation of women and girls and end the epidemic of teenage pregnancy, with plans to help these girls return to school. Some of these men referred to themselves as ‘feminists’ and earned my highest respect. Men are central to any program aimed at bringing about change in the situation of teenage pregnancy.

Conclusion
The teenage epidemic in Sierra Leone has to be addressed as a matter of extreme urgency and has important implications for the prospect of human development. Solutions have to be multi-dimensional involving all the major ministries, NGO, religious leaders, traditional secret societies and the general public at large. Comprehensive and high quality sex education must be established in all the schools as well as in communities and at the household level. Consideration should also be given to providing safe and reliable contraceptives to teenagers right after they experience menarche.

The Critical Medical Anthropology Analytical Framework is best suited to providing explanatory insight about the situation of teenage pregnancy and maternal mortality in Sierra Leone. The framework focuses on social inequality and unequal power relations in terms of access to and control over the basic material and non-material resources that sustain and promote life, health and well-being at a high level of satisfaction. Critical Medical Anthropology is concerned with the ways power differences shape social processes. (Bear, et. als. 2009) It is clear that the underlying problem of teenage pregnancy and maternal mortality in Sierra Leone is related to poverty and powerlessness. In addressing this problem, major changes would have to be made in Sierra Leone that address the social, economic and cultural determinants of teenage pregnancy and maternal mortality at both the macro-level of the political economy and the micro level of the household and the individual.

Providing access to resources would require major measures in rigorously promoting economic development; expanding education and providing employment and other income generating opportunities in an equitable and sustainable manner. It will also require implementing the laws that protect and guarantee the rights of women, girls and children. Effective and severe punishment, including long-term imprisonment, has to be imposed on men that violate the bodies of women and girls in line with the dictates of retributive justice. This would likely bring better results than many of the current programs of support and rehabilitation that exist at a basic and rudimentary level in Sierra Leone. Going forward, the dominant narrative and imperative should be to drastically change the political economy of poverty, powerlessness, economic injustice and violation of the rights of women and girls, if teenage pregnancy is to be avoided and controlled.



Amnesty International, 2016, ‘Sierra Leone Pregnancy Ban in Schools Threatening Teenage Girls Future.’ London, Amnesty International.

Awareness Times, August 17, 2018.

AWOKO, 2013, ‘Girl Prostitution Increases in Kono and Kenema, Freetown, Awareness Times, September 21, 2013.

Bear, H., Singer, M., Susser, I. 2009, Medical Anthropology and the World System, Second Edition, London, Praeger.

Benjamin, G. 2015 ‘Freetown’s Dens of Commercial Sex Workers.’ Concord Times, Freetown, July 6, 2015.

Mitchell, A. 2017,  ‘Sierra Leone Teenage Girls Are Dying From Unsafe Abortion and Risky Pregnancy,’ The Guardian, July 20, 2017.

OXFAM ‘Policy and Practice,’ London, OXFAM.

The Multiple Indicator Cluster Survey on Sierra Leone for 2017, Freetown, Statistics Sierra Leone and several UN organizations, Freetown, 2017.

UNDP, 2017, ‘About Sierra Leone’ www.sl.undp.org

UNFPA, 2017, Recovery from the Ebola Virus Disease: Rapid Assessment of Pregnant Adolescent Girls in Sierra Leone, New York, UNFPA/

UNFPA, 2017, Sierra Leone Latest Maternal Death and Surveillance Report, May 31, 2017.

UNFPA, 2018, Adolescent Pregnancy New York, UNFPA

Yasmin, S, 2016, ‘The Ebola Rape Epidemic No One Is Talking About’ Washington, D.C. The Foreign Policy Group.