EVALUATION OF BIXBY PEER REPRODUCTIVE HEALTH PROGRAM ON ADOLESCENTS IN AN INDIGENOUS COMMUNITY IN SAN QUINTIN, MEXICO. A Thesis.

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1 EVALUATION OF BIXBY PEER REPRODUCTIVE HEALTH PROGRAM ON ADOLESCENTS IN AN INDIGENOUS COMMUNITY IN SAN QUINTIN, MEXICO A Thesis Presented to the Faculty of San Diego State University In Partial Fulfillment of the Requirements for the Degree Master of Public Health by Margarita Santibanez Fall 2012

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3 iii Copyright 2012 by Margarita Santibanez All Rights Reserved

4 iv ABSTRACT OF THE THESIS Evaluation of Bixby Peer Reproductive Health Program on Adolescents in an Indigenous Community in San Quintin, Mexico by Margarita Santibanez Master of Public Health San Diego State University, 2012 Reproductive health is an important issue for adolescents in the indigenous communities. Adolescent mothers are more likely to live in poverty, have lower academic achievements and have reduced job opportunities; pregnancy during adolescence represents higher health risks for the young mothers and their babies. Adolescent fertility is an emergent issue in Latin America, reproductive health programs have reduced fertility among young married women, but they have not had the same effect on adolescent fertility. Great advances have been made in Mexico for reducing the birth rate from 6 children per woman in 1960, to 2.2 in 2011.Unfortunately this reduction has not been equal for all demographic groups, the birth rate among indigenous women remains at 3 children per woman. Indigenous women have their children at a younger age, have lack of spacing between children, have larger families and poor health care. Very few programs have addressed this issue as we can observe in the scarce literature. Reproductive health programs must be tailored to the specific population, and towards young people. The materials must also be relevant to them. Peer-to-Peer programs are a popular way to provide information to young people, which is based on the fact that adolescents spend a lot of time interacting with each other and get a lot of reproductive information from their peers. The Bixby program was implemented in an indigenous community in San Quintin, Mexico. It had a quasi-experimental design, and compared the differences in knowledge, intentions and opinions of reproductive health, between an intervention and a control group. The program lasted 2 months and the participants received a peer session and a teacher-led class, a baseline and a post-intervention survey. The demographic analyses revealed profound differences, while the intervention showed to be younger, in lower level grades and with more indigenous presence, the control group was older, in higher level grades, and more sexually experienced. The postintervention analyses found few statistically differences in knowledge, and no differences in intentions and opinions regarding reproductive health and specifically condom use. Nonetheless, two important differences were found: the intervention group was 2.5 times more likely to identify 2 correct answers regarding contraceptive methods which prevent sexually transmitted diseases, when compared to the control group. Also, the intervention group correctly identifies the necessary time between each pregnancy, to give adequate space between children with a significant difference when compared to the control group.

5 The lack of more positive results could be explained due to the profound demographic differences between the two groups. Additionally, the integrity of the intervention may have been compromised as there was no oversight of delivery, and the intensity was less than what has been described as required for behavior change. Importantly, this study did demonstrate the feasibility of introducing reproductive health curriculum in secondary school students in an indigenous community in Mexico. The program was highly accepted by students, teachers and parents. More intensive interventions and with careful control designs and implementations must be done in the future to determine the usefulness of this Bixby program. v

6 vi TABLE OF CONTENTS PAGE ABSTRACT... iv LIST OF TABLES... ix LIST OF FIGURES... xi ACKNOWLEDGEMENTS... xii CHAPTER 1 INTRODUCTION...1 Statement of the Problem...2 Purpose of the Study...3 Hypotheses LITERATURE REVIEW...4 Sexual and Reproductive Health...5 Early Sexual Relations...6 Teenage Pregnancies...7 Health Consequences of Teenage Pregnancies...9 STIs and HIV Infection...9 Contraceptive Use...10 Sexual and Reproductive Health Programs...11 Reproductive Health Programs and Organizations in Mexico...12 Peer-To-Peer Programs...13 Peer Education And Empowerment Program (PEEP)...14 Sociodemographic Characteristics of the Mexican Population...15 Indigenous Population in México...16 Health Disparities in México...16 Gender Inequality in México...17 VIIDAI Overview METHODOLOGY...20

7 Study Location...20 Needs Assessment...21 Bixby Pilot Student Promotor Program...21 Study Population...22 Informative Meeting and Consent Procedures...23 Baseline...23 Intervention...24 Promotores...24 Teachers Training...25 Bixby Reproductive Health Program Content...26 Materials Used and Developed...26 Data Collection...27 Data Analysis...28 Data Management RESULTS...31 Languages Spoken by The Students and Their Parents...32 Household and Family Characteristics...33 Baseline Knowledge...34 Baseline Pregnancy Knowledge...34 Baseline STIs Transmission Knowledge...35 Baseline Knowledge of STIs Prevention...36 Baseline STIs General Knowledge Concepts...36 Baseline Opinions and Attitudes Regarding Condom Use...36 Baseline Opinions and Attitudes Regarding Family Planning, Child Spacing, and Other Concepts...39 Baseline Behaviors and Skills Regarding Sex and Condom Use...43 Future Intentions of Condom Use in Pre-Intervention...43 Baseline Total Knowledge Score...44 Students Who Received a Reproductive Health Lesson by a Peer Student...44 Post-Intervention Knowledge Score...45 Post-Intervention Opinions About Number of Children in a Family vii

8 viii Post-Intervention Opinion for the Best Age to Begin Having Sex...46 Post-Intervention Knowledge of Methods to Prevent STIs...48 Post-Intervention Opinions Regarding Condom Use...48 Post-Intervention Intentions Regarding Condom Use...49 Post-Intervention Opinions Regarding Spacing Between Children and Family Planning DISCUSSION...52 Demographic Characteristics...52 Baseline Knowledge...54 Knowledge of STIs and Contraceptive Methods...55 Improvement in Their Attitudes and Opinions Regarding Condom Use...55 Skills Regarding Reproductive Health...56 Greater Perceived Benefits for Delaying Sexual Activity, Child Spacing and Having Smaller Families...56 Feasibility of the Intervention...57 Study Limitations and Possible Explanations for Study Findings...58 Program and Survey Implementation...59 Future Investigations...60 Conclusions...61 REFERENCES...63 WORKS CONSULTED...67 A ENGLISH AND SPANISH CONSENT FORM...69 B ENGLISH AND SPANISH QUESTIONNAIRES...77 C BIXBY REPRODUCTIVE HEALTH PROGRAM...87

9 ix LIST OF TABLES PAGE Table 1. Demographic Characteristics of Participants (N=167)...31 Table 2. Languages Spoken by Participant Students and Their Parents. San Quintin, Mexico (N=167)...33 Table 3. Selected Household and Family Characteristics of Student Participants. San Quintin, Mexico (N=167)...34 Table 4. Baseline Knowledge Regarding Pregnancy of Student Participants. San Quintín, México, (n=167)...35 Table 5. Baseline Knowledge of STIs Transmission in Student Participants. San Quintín, México, (n=167)...37 Table 6. Baseline Knowledge of STIs Prevention in Student Participants. San Quintín, México, (n=167)...38 Table 7. Baseline General Knowledge of STIs in Student Participants. San Quintín, México, (n=167)...39 Table 8. Responses for Baseline Opinions and Attitudes Regarding Condom Use in Student Participants. San Quintín, México, (n=167)...39 Table 9. Responses for Baseline Opinions and Attitudes Regarding Family in Students Participants of San Quintín, México, (n=167)...42 Table 10. Responses for Baseline Behaviors and Skills Regarding Sex and Condom Use of Student Participants of San Quintín, México, (n=167)...44 Table 11. Intentions Regarding Baseline Condom Use in Control and Intervention Groups of Student Participants in San Quintín, México, (n=167)...46 Table 12. Baseline Results for Knowledge Score, for Student Participants in San Quintin, Mexico (N=167)...46 Table 13. Number and Percent of Student Participants Who Received a Reproductive Health Talk, San Quintín, México, (n=167)...47 Table 14. Baseline and Post-intervention Results for Knowledge Score and Index of Change, for Students Participants in San Quintin, Mexico (N=167)*...47 Table 15. Post-Intervention Results for Opinions about Number of Children, for Student participants in San Quintin, Mexico (N=167)*...47

10 Table 16. Post-intervention Results for Opinion of the Best Age to Begin having Sex, for Student Participants in San Quintin, Mexico (n=167)*...48 Table 17. Odds Ratio for Having 2 Correct Answers* vs. 0-1 About Methods to Prevent STIs, for Student Participants in Intervention vs. Control, San Quintin, Mexico (n=162)**...48 Table 18. Post-Intervention Logistic Regression for Agreement with Selected Opinions Regarding Condom Use, for Student Participants in Intervention vs. Control. San Quintin, Mexico (n=167)*...49 Table 19. Post-Intervention Logistic Regression for Agreement with Intentions Regarding Condom Use; Intervention vs. Control groups of Student Participants in San Quintin, Mexico (n=167)*...50 Table 20. Odds ratio for Opinions Regarding What is the Ideal Time between Children**; Intervention vs. Control group for Student Participants in San Quintin, Mexico *...50 Table 21. Odds ratio for Opinion Regarding What is a Reason for Using Family Planning**; Intervention vs. Control group for Student Participants in San Quintin, Mexico *...51 x

11 xi LIST OF FIGURES PAGE Figure 1. Bixby Peer Reproductive Health Education program design Figure 2. Timeline - Full Bixby Program Figure 3. Selection of the sample population. *Tx=Intervention, C=Control Figure 4. Student grade level Figure 5. Response for baseline opinions and attitudes regarding family in students participants of San Quintín, México Figure 6. Response for baseline behaviors and skills regarding sex and condom use of student participants of San Quintín, México....45

12 xii ACKNOWLEDGEMENTS I owe my deepest gratitude to my mentor and Chair Dr. Stephanie Brodine for her invaluable guidance and support, not only for this project but also for the last three years of graduate school. Thank you to the members of my committee Dr. Ming Ji, and Dr. Audrey Shillington for their time and suggestions. A special thanks to Dr. Noe Crespo for all the time and patience that he gave me. I want to extend my regards to all who supported me in any form during the completion of my thesis. Finally, thank you to Karim, Aisha y Alexia for all the time they let me borrow from them to be able to successfully finish this dream.

13 1 CHAPTER 1 INTRODUCTION Reproductive health programs are important as an attempt to reduce the amount of unplanned pregnancies and sexually transmitted infections (STIs); and are particularly relevant for adolescents. Unplanned pregnancies have high costs for teenagers, particularly among female adolescents. Furthermore, adolescent mothers are more likely to drop out of school before graduating and are more likely to live in poverty (Guttmacher Institute, 1998). This phenomenon is a more severe problem in developing countries than in developed countries, where the rate of adolescent pregnancies is significantly lower. This is apparent when looking at the birth rate among adolescents for the United States in 2006, 41 annual births per 1,000 adolescents; compared with the birth rate among adolescents in Mexico in the same year, 82 annual birth rates per 1,000 adolescents (United Nations Department of Social Affairs Population Division [UNDSAPD], 2010). Although reproductive health programs have proven to reduce the fertility rates in married young women, adolescent pregnancy is an emerging issue in Latin America (Rodriguez, 2011). Adolescent pregnancies are not the only consequence of early sexual activity. Sexually active adolescents have a higher risk of developing STIs than adults. They also have an increased risk of premature labor, miscarriage, maternal mortality and still births (Langer, 2002). The Bixby Reproductive Program was implemented in Mexico, in a rural setting, where the vast majority of residents are indigenous. The Mexican Institute for Indigenous Populations has reported that the indigenous birth rate has not followed the reducing trends of the general population in the country (Comisión Nacional para el Desarrollo de los Pueblos Indígenas [CID], 2009). The Bixby Reproductive Health program was developed for the Viaje Interinstitucional de Integracion Docente, Asistencial y de Investigacion (VIIDAI) team, as a result of a grant received by the Bixby Foundation. The VIIDAI program is a coordinated effort between the Universidad Autonoma de Baja California (UABC), San Diego State University (SDSU) and the University of California San Diego (UCSD), where medical,

14 2 dental and psychological assistance is provided to a rural community in San Quintin, Mexico twice a year. During this medical visit, students from the SDSU Graduate School of Public Health conducted a coinciding research project. The VIIDAI team for the Bixby Reproductive Program was composed of teachers and students from SDSU s Department of Public Health and teachers and students from UABC s Medical Psychology Departments. A needs assessment was conducted in 2004 in the community among married women ages 18 to 49 years old. The results revealed that 46% of the girls in the community gave birth to their first child between the ages of 13 and 17 years old. These women also had a large number of children and the reported rate of contraception use was low, contrasting with the reproductive health progress that has been made in the general Mexican population. The results of this baseline study supported the need for reproductive health education and intervention. The Community of Lomas San Ramon requested that the VIIDAI Team design a reproductive health program to address unplanned pregnancies in adolescents and increase knowledge in contraception and transmission of STIs. The first program targeted children in elementary school in 5th and 6th grade, corresponding to 11 to 12 years of age. The pilot study was well received by the community. After the first program, the adults in the colonia expressed interest in expanding it to reach more adolescents and older students from middle school, who were perceived to be at higher risk to engage in sexual activities. STATEMENT OF THE PROBLEM The indigenous population of Mexico generally faces more barriers when trying to access healthcare; overall, they are less educated; and on the average they are in a lower socioeconomic level than the general population. These characteristics make them a vulnerable population, especially when it comes to having less access to reproductive health programs. The lack of access is typified by the status of reproductive health in indigenous women, as the birth rate is one more child than the general birth rate of women in Mexico. Reproductive health programs in Mexico are commonly developed and implemented in urban settings, as seen by the lack of cited programs among rural indigenous populations in related literature. There is a definite need to convey reproductive health knowledge, to change the intentions, and to develop skills among this specific population.

15 3 With the implementation of the Bixby Reproductive Health Program in the colonia in San Quintin, composed mainly of indigenous people, the intention is to increase reproductive knowledge and awareness. PURPOSE OF THE STUDY The purpose of this study is to describe and analyze the results of an evaluation of the Bixby Reproductive Health Program in the Colonia Lomas de San Ramon community. After the program was implemented, it was necessary to determine the impact and effectiveness of this program in the community with an evaluation. The Bixby Reproductive Health Program addresses topics such as family planning and the prevention of sexually transmitted diseases. During the evaluation, a survey was conducted to assess the differences in knowledge and attitudes between the intervention group and the control group. This program was unique, not only because it was implemented in a developing country, but also because the participants included were mainly of indigenous descent. Additionally, this program was developed for children in secondary school, which is earlier than most sexual health programs are taught; however, was thought to be the appropriate level by the parents and teachers of this population. If this program is found to be feasible and useful for increasing the reproductive health knowledge and attitudes among adolescents in this specific community, it can be used in same settings in other states of Mexico, or other countries in Latin America with indigenous populations. HYPOTHESES The following hypotheses are intended to be addressed with this study: 1. Students who receive an intervention will have a significant improvement in knowledge of STIs and contraceptive methods, when compared to students in a control group. 2. Students in the intervention group will demonstrate improvement in their intentions regarding condom use when choosing to engage in sexual activity, as compared to the control group. 3. Students in the intervention group will develop greater skills regarding reproductive health, such as where to find condoms in their community, when compared to the control group. 4. Students exposed to the program will show greater perceived benefits for delaying sexual activity, having smaller families and giving adequate space between having children, when compared to students in the control group.

16 4 CHAPTER 2 LITERATURE REVIEW Although there have been many great advances made in reproductive health in Mexico in the last decades, the improvements have not been made equally for all demographic groups. This is especially true for the indigenous population, and even more so for what is widely considered the most vulnerable age group; adolescents. Before 1970, the reproductive policies of Mexico were focused on population growth. With economic crisis and elevated population numbers reflected in the census; however, the need to implement reproductive programs with the goal of decreasing birth rates and improving prevention of STIs was clear. It is apparent that these implemented programs worked, since the data show a reduction of birth rates from 6 children per women in 1960 to 3.3 children per woman in The current birth rate for females in Mexico is now 2.2 children (Consejo, Nacional de Población, [CONAPO], 2009). Even though the national birth rate decreased, the population of Mexico doubled from 48.2 million in 1970 to 97.5 million in 2000 (Guttmacher Institute, 2008). Unfortunately, the birth rate reduction did not hold the same for marginalized groups, as we can see in the indigenous population where the birth rate is still an average of 3 children per women (CID, 2009). That is a difference of almost one more child per indigenous female than per female from the general population. These differences can be explained in part by indigenous culture and traditions as well as the limited supply of family planning programs and services in rural areas, where most indigenous live. Currently in Mexico, as in other parts of the world, adolescents are beginning their sexual lives at early ages (Kirby, 2011), and at the same time postponing marriage. This commonly translates to high rates of sex before marriage (Juarez, Palma, Singh, & Bankole 2010). Therefore, there is a definite need of adequate reproductive education programs with the goal of decreasing pregnancy rates and preventing STIs in this young population. Programs such as these must be tailored to specific population characteristics, culture, and age. Research has shown that reproductive education programs for adolescents are of

17 5 particular public health importance since they make a deep impact on the empowerment of women and eventually help reduce poverty among families (International Planned Parenthood Federation, 2010). This section aimed at exposing characteristics of reproductive health; the prevalence of teenage pregnancies and STIs in Mexico; reproductive health programs in Mexico; characteristics of indigenous population; as well as emphasizing the overall reproductive needs of indigenous adolescents in Mexico. SEXUAL AND REPRODUCTIVE HEALTH In Mexico, the health sector defines reproductive health as the capacity of individuals and their partners to enjoy a satisfactory and healthy sexual and reproductive life without risks, and with the absolute liberty to decide upon the number and spacing of their children in a responsible and informed manner (Gonzalez, 2009). Furthermore, the World Health Organization (WHO, 2012b) affirms that Reproductive health addresses the reproductive processes, functions and system at all stages of life, inclusive is the right to be informed of and to have access to safe, effective, affordable and acceptable methods of fertility regulation. According to the aforementioned definitions and in order to achieve these goals, is necessary to have competent reproductive health programs working at all levels within the country. An essential component of reproductive health is education. This component is of critical importance when it is focused on young people. Reproductive health education empowers adolescents to have a deeper understanding of the consequences of sexual behavior and to reconstruct their decision-making strategies. Sexual relationships are a fact among many teenagers, with two probable yet unintended consequences for this behavior: unwanted pregnancies and STIs. Adolescent mothers are less likely to graduate from high school and more likely to live in poverty, as well as to receive public assistance (Rodriguez, 2011). Pregnancy in adolescents affects not only their personal and family lives, but also increases their risk of becoming impoverished. In addition, it perpetuates the cycle of poverty (Rodriguez, 2011). Within the Millennium Development Goals, goal number five aims to reduce maternal mortality. In regard to this goal, the United Nations emphasized important points such as the fact that poverty and a lack of education perpetuates adolescent pregnancy. It

18 6 was also emphasized that the use of contraception is lowest among the most impoverished women and those without education. Progress in expanding the use of contraception has slowed, and the lack of funding for family planning programs has failed to improve women s reproductive health (Rodriguez, 2011). In many countries adolescents face economic, social, cultural and religious barriers to access reproductive health programs. These challenges have deep consequences for global health (WHO, 2012a). In order to ensure the best reproductive health outcomes, adolescence is a decisive period to ensure a deep and thorough understanding of family planning and the prevention of STIs, including Human Immunodeficiency Virus (HIV) infection. EARLY SEXUAL RELATIONS In Mexico, 76% of adolescents males, and 35% of adolescents females have had their first sexual relationship before turning 20 years old (Wetli, 1995). In 2000 CONAPO reported that the average age for a Mexican national s first sexual activity was 15.4 years with a difference in geographic areas of 13.8 years in rural areas and 16.7 years in urban areas (Givaudan, Vijver, & Poortinga, 2005). Although, different research has shown slight variations in reference to the age of the average first sexual encounter (Gayet, Juarez, Pedrosa, & Magis, 2003), it is also reported that the average first sexual activity is normally unplanned. Mexican adolescents are often uninformed about safe-sex practices and do not use any form of contraception. Only a small percentage reported using contraception (Gayet et al., 2003, Givaudan et al., 2005). It is not uncommon for some Mexican male adolescents to have their first sexual encounter with a prostitute (Givaudan et al., 2005). It is a fact that adolescents are having sexual relationships at earlier ages. This may be due to better nutrition, resulting in earlier physical development, menarche and spermarche (Kirby, 2011); more education, delayed age for first marriage, and the influence of media on adolescents. This affirmation is supported by Brieger s study, which reported the median age for first intercourse for boys and girls in Ghana is 17 years (Brieger, Delano, Lane, Oladepo, & Oyediran, 2011). Gayet et al., emphasize that adolescents who engaged earlier in sexual relations are more likely to have low education; less academic and working expectations of themselves; and overall have less self-esteem and less assertiveness (Gayet et al., 2003). This study also

19 7 found that male adolescents are 3.5 times more likely to use a condom during their first sexual intercourse experience than women. After controlling for a number of other variables, Gayet, et. al., (2003) found, the older the adolescents that had his/her sexual debut, the more likely he/she will use a condom. For example, an eighteen year old is 3.5 times more likely to use a condom in his first sexual activity than adolescent of 12 to 13 years old. Being more educated, living in urban areas, and not speaking an indigenous language were also factors that increased the likelihood of condom use in first-time sexual relations (Gayet et al., 2003). Boonstra mentioned in her article that one disseminated myth among young population, is that they think that adolescents women cannot get pregnant the first time they have sexual relationships (Boonstra, 2007). Due to this belief, it is very important to reach adolescents with educational reproductive health information before they become sexually active. There is a definite need to reach young males due to the multiple pressures of societies in subdeveloping countries, like Mexico, where sexual behavior for single women is restricted or condemned. It is not; however, the same for young men, which frequently results in sexual activity at earlier stages for males. (Guttmacher Institute, 1998) Trends in Mexico and other countries show that young people are delaying marriage (Juarez et al., 2010; Kirby, 2011). The gap between the first sexual activity and marriage is widening. In a report by Encuesta Nacional de la Dinamica Demografica (Consejo Nacional de Población, 2009) research showed that the average age for first time sexual intercourse was 19.3, and the average age for marriage was This gap of 3 years between both events shows that adolescents are in a vulnerable period in their life where unplanned pregnancies and STIs are not uncommon. This phenomenon can be explained in part by the limited availability of condoms and other contraceptives; the lack of self-perception of risk; the influence that gender inequality has over sexual activity without using protection; and the social norms that support early pregnancies, particularly in rural and poor settings (Juarez et al., 2010). Whether they are married or are single, a vast majority of teens are having sex. Therefore, the need for health reproductive health services, including education needs. TEENAGE PREGNANCIES In Latin America, adolescent fertility is an emergent and important issue with the second highest adolescent fertility rate in the world, after Africa (Rodriguez, 2011).

20 Rodriguez reported that this could be explained by several factors including: while reproductive programs have reduced fertility among young adult married women they have not had the same effect on adolescent fertility; the poorest adolescents are the ones who suffer the highest fertility rates; adolescent fertility is one essential component of the poverty production cycle; adolescent mothers have higher health risks for herself and the baby, have lower educational achievements and reduced job opportunities; adolescent mothers suffer from social stigma, discrimination, disapproval and condemnation; adolescents are more vulnerable to sexual violence, peer pressure and risky behavior (Rodriguez, 2011). In 1995 in México, among women less than 20 years of age there were approximately 450,000 births, equal to 16.1% of the total birth rate. Since 1995, the fertility rate has been declining among adolescents. In 1997, the birth rate of women between 15 and 19 years of age was 82 per 1,000. In 2006 this rate decreased to 63 per 1,000, which decreased the overall number in 2006 to 321,000 (Juarez et al., 2010). It is important to note that the percent of adolescent pregnancies have persisted. In 1995 and 2006 adolescent pregnancies made up 16% of the total number of pregnancies in Mexico. Becoming pregnant at an early age is more prevalent in rural areas, and rates have not decreased over time. In 1997, a 12% of urban females had a child before her 18 birthday which increased to 14% in 2006 of births in urban areas. In rural areas, these rates were higher at 21% in 1997 and 22% in 2006 (Juarez et al., 2010; Langer, 2002). In México, there are number of characteristics that have been described in adolescent mothers: 1. Maternity has a great value. 2. Adolescent mothers are more likely to have feelings of not being loved, or accepted. 3. Many adolescent mothers initiated their sexual life while looking to fill an emotional emptiness % of adolescent women didn t go to school or dropped out during middle school or earlier (Galicia, Jimenez, Pavon, & Sanchez, 2006; Secretaria de Salud, 2002). In 2006, in Mexico and the USA there were respectively 82 and 41 annual births per 1,000 women ages 15 to 19 (UNDSAPD, 2010). 8

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