Adolescent Fertility and Reproductive Health Programmes in Developing Countries Ann Biddlecom, PhD Presentation for Panel Discussion, Population Division, Department of Economic and Social Affairs December 15 2008
Overview Current status, trends & context of adolescent fertility Key levers influencing adolescent fertility Programmatic approaches
Why care about adolescent fertility? Pregnancies should be Wanted Safe At the right time
Why care about adolescent fertility? 1) Lower maternal mortality and morbidity 2) Improve schooling achievement 3) Prevent HIV transmission 4) Raise gender equality 5) Reduce poverty
Adolescence is a time when changes in sexual activity happen fast Sex by age 15 9 13 17 21 South America Sex by age 18 41 44 57 59 Caribbean/ Central America Eastern/ Southern Africa Sex by age 20 61 62 77 77 Western/ Central Africa 0 20 40 60 80 100 % of 20-24 year old females who had sex by certain ages
And the pace of change is similar for adolescent males Sex by age 15 Sex by age 18 12 14 31 31 40 45 70 73 Western/ Central Africa) Eastern/ Southern Africa) Caribbean/ Central America Sex by age 20 61 65 84 87 South America 0 20 40 60 80 100 % of 20-24 year old males who had sex by certain ages
Childbearing begins by age 18 for many girls % of females 20-24 who had a birth by age 18 11 16 22 24 27 31 Western Asia/Northern Africa South America Caribbean/Central America South-central/Southeastern Asia Eastern/Southern Africa Western/Central Africa 0 20 40 60 80 100 NRC & IOM (2005)
Adolescent childbearing is less common than among older generations % of females who had a birth by age 18 Age 40-44 Age 20-24 21 12 24 32 38 39 11 16 22 24 27 31 Western Asia/Northern Africa South America Caribbean/Central America South-central/Southeastern Asia Eastern/Southern Africa Western/Central Africa 0 20 40 60 80 100 NRC & IOM (2005)
And this is especially the case for very early childbearing (by age 16) % of females who had a birth by age 16 Age 40-44 Age 20-24 7 3 9 14 16 21 3 4 7 9 9 13 Western Asia/Northern Africa South America Caribbean/Central America South-central/Southeastern Asia Eastern/Southern Africa Western/Central Africa 0 20 40 60 80 100 NRC & IOM (2005)
The majority of births still occur within marriage South-central/Southeastern Asia 97 3 Eastern/Southern Africa 70 30 Western/Central Africa 82 18 Caribbean/Central America 89 11 Western Asia/Northern Africa 99 1 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Within marriage Outside of marriage % distribution of births to mothers age 20-24 years by marital status
But many births to teen mothers are wanted later or not at all Nigeria 82 9 7 Burkina Faso 82 17 Senegal 70 27 Birth was wanted then Ethiopia 69 20 11 Birth was wanted later Uganda 68 23 9 Malawi 67 18 15 Birth was not wanted at all Ghana 42 37 21 South Africa 20 66 13 0% 20% 40% 60% 80% 100% % distribution of wantedness of births to mothers under age 20
Unwanted and mistimed pregnancies are a major problem 7.9 million pregnancies Planned births 53% Miscarriages 16% Abortions 13% Pregnancy outcomes for adolescents aged 15-19 in Sub-Saharan Africa Unplanned births 18%
Key levers influencing adolescent fertility
Timing of marriage Beginning of more frequent sex More unprotected sex Pressure to begin childbearing
Early marriage declining but still a common experience South-central/Southeastern Asia Western/Middle Africa 42 45 58 58 Eastern/Southern Africa 37 53 Western Asia/North Africa 23 46 Caribbean/Central America 35 38 0 20 40 60 80 100 20-24 year olds 40-44 year olds % of women who were ever married by age 18 NRC & IOM (2005)
Schooling School attendance & higher education lower adolescent fertility Rising % of girls attending school after the age of puberty rising % exposed to pregnancy while in school
Contraceptive use Challenges for adolescents Provider & general social stigma Location, hours, cost Policy constraints Condom use (HIV & pregnancy prevention)
Contraceptive use has risen among sexually-active young women (18 African countries) Single 33 Any method (1993) 37 5 19 Any method (2001) 13 Condoms (1993) Married 1 2 18 Condoms (2001) 0 20 40 60 80 100 % of 15-24 year old sexually-active women Cleland, Ali & Shah (2006)
Programmatic approaches
Youth-friendly health services Evaluations show need intervention at facility, provider & community level Modifications at existing health facilities (hours, space, staff training) Stand-alone youth centres
School-based programs Family life, sex, or AIDS education Most tested Strong effects on knowledge & attitudes Weaker effects on behavior Not associated with increased risk behaviors
At best, only about half of adolescents receive any school-based sex education 100% 80% 15 25 52 23 47 60% 40% 20% 32 61 39 0% Burkina Faso Ghana Malawi Uganda Received sex education Attended school & did not receive sex education Attended school & sex education not offered Never attended school
Other programs specific to RH Peer education Mass media Community mobilization Social marketing
Is the program reaching adolescents in need?
One in four people reached by peer educators have never been to school (Burkina Faso) 100 90 80 70 60 50 40 30 20 10 0 27 24 19 18 54 58 None Primary Secondary or higher Level of schooling of those reached by peer educators Females Males Lardoux & Jones (2006)
But most adolescents in Burkina Faso have never been to school 100 90 80 70 60 50 40 30 20 10 0 63 51 26 35 11 14 None Primary Secondary or higher Level of schooling of 12-19 year olds Females Males Guiella & Woog (2006)
Programs that indirectly affect adolescent RH Youth development (addresses wider range of needs; target at-risk subgroups) Micro-credit School retention
Adolescent fertility part of achieving larger development goals Lower maternal mortality and morbidity Improve schooling achievement Prevent HIV transmission Raise gender equality Reduce poverty
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