Training Course in Sexual and Reproductive Health Research Adolescent Pregnancy: A global perspective Dr Alma Virginia Camacho MD MPH camachov@who.int & Dr Venkatraman Chandra-Mouli MBBS MSc chandramouliv@who.int Training Course in Sexual and Reproductive Health Research Geneva 2010

Adolescent pregnancy What is the magnitude of adolescent pregnancy ? 2. What are the consequences of adolescent pregnancy ? 3. What are the circumstances in which adolescent pregnancy occurs ? 4. What needs to be done to respond to adolescent pregnancy ? 5. What is the relevance of adolescent pregnancy to the Millennium Development Goals ? Adolescent pregnancy The presentation will cover the five points listed on this slide. 2

About 16 million girls aged 15-19 years give birth annually About 16 million girls aged 15-19 years give birth annually. 90% of them are in developing countries. The characteristics of young mothers are common across the regions of the world: Little education, Rural dwelling, Low income. Source: Growing up global: The Changing Transitions to Adulthood in Developing Countries (National Research Council, 2005). The magnitude of adolescent pregnancy is enormous. About 16 million women aged 15-19 years give birth yearly. Although adolescent pregnancy is a worldwide phenomenon, it primarily occurs in developing countries. In developed countries, the highest levels are in the USA, and in the UK. In both developed and developing countries, it primarily affects those adolescents from marginalized groups.

More than 1/5 of women in the poorest regions have a child by age 18. Overall one if five women in the world have a child by the age of 18. The figure ranges from just over 10% in West Asia and North Africa to just over 30% in West and Middle Africa. Source: Tabulations of demographic & health surveys from 51 countries,1990-2001. (National Research Council, Growing up global: The Changing Transitions to Adulthood in Developing Countries, 2005). 4

Adolescent pregnancy What is the magnitude of adolescent pregnancy ? 2. What are the consequences of adolescent pregnancy ? 3. What are the circumstances in which adolescent pregnancy occurs ? 4. What needs to be done to respond to adolescent pregnancy ? 5. What is the relevance of adolescent pregnancy to the Millennium Development Goals ? Adolescent pregnancy The presentation will cover the five points listed on this slide. 5

Greater likelihood of maternal mortality Child birth at an early age is associated with great health risks for the mother. The risk of dying from pregnancy-related causes is twice as high for adolescents aged 15-19 as for older women. The factors contributing to this are: Giving birth for the first time Lower social status Lower economic status Poor access to health services Between the ages of 15-19, age may not be the decisive factor but below the age of 15, there are risks associated with the fact that the pregnant girl is not fully developed. Some estimates suggests that for girls aged 101-14, the risk of dying may be 5 times higher than for women in their twenties. The risk of dying from pregnancy-related causes is twice as high for adolescents aged 15-19, as for older women. Source: Safe Motherhood Initiative Factsheet, 1998. Adolescent Sexuality & Childbearing.

Clinical causes of maternal mortality among adolescents – 1/3 Unsafe abortion1 Study from a teaching hospital in Nigeria (over a 10 year period) – abortion was the cause of 36.9% of maternal deaths in 10-19 year olds Obstructed labour2 Strong indications of higher risk in mothers below16 years since pelvis is still not fully developed Many studies use caesarean section incidence as a proxy for obstructed labour – many studies in Africa and one in India found a greater likelihood of this in adolescents than in adults Now we’re going to look briefly at the clinical causes of maternal mortality in adolescents. Of the 18 million abortions that take place in developing countries each year, about 12 to 22 percent are to adolescents. This shows an elevated incidence in adolescents, given that this percentage would be equal to 14 if it were proportional by age, and particularly considering that adolescents experience fewer pregnancies than older women. Results from a study in Nigeria confirm the burden of abortion within adolescent maternal mortality. Over one-third of maternal deaths among 10-19 year olds were due to abortion. 08_XXX_MM7 Sources: 1.Ujah, 2005; 2. WHO, 2004

Clinical causes of maternal mortality among adolescents – 2/3 Hypertensive disorders Two studies – one in Turkey1 and one in Mozambique2 – found an increased incidence of hypertensive orders in adolescent mothers, when compared to non-adolescent mothers. However, other studies3 have shown no difference But they did not standardize for parity Some studies but not others suggest that hypertensive diseases are more likely to occur in adolescents. 08_XXX_MM8 Sources: 1. Bozkaya et al, 1996; 2. Granja et al, 2001; 3. Ministerio de Salud, El Salvador, 2007

Clinical causes of maternal mortality among adolescents – 3/3 Injuries – suicide and homicide In a study in Bangladesh, violence-related injuries were highest among pregnant adolescents1 Again some studies suggest that violence, including self-inflicted violence, is a contributor to mortality in pregnant adolescents. A study in Bangladesh showed that pregnant adolescents were significantly more likely than any other age group – pregnant or not pregnant – to commit suicide or be victims of homicide. 08_XXX_MM9 Sources: 1. Ronsmans et al, 1999

Maternal morbidities in adolescents – 1/2 Anemia Large, high quality study in Latin American & Caribbean found that mothers below16 years old had a 40% increased risk of anemia, compared to mothers age 20-241 There were no significant differences for older adolescents Moving to morbidities, anaemia is more likely to occur in adolescents than in adults. 08_XXX_MM10 Sources: 1. Conde-Agudelo, Belizán & Lammers, 2005

Maternal morbidities in adolescents – 1/2 Malaria In a recent study in Mozambique, malaria was the cause of death in twice as many adolescent mothers (26.9%) as non-adolescent mothers (11.7%)1 Obstructed labour – fistulae Studies in Africa have shown that 58-80% of women with obstetric fistulae are under age 20, with the youngest aged only 12 or 13 years2 59% and 27% of fistulae cases occurred in women below 15 & 18 years respectively3 Also, malaria contributes to higher levels of both mortality and morbidity in adolescents. 08_XXX_MM11 Sources: 1. Granja et al, 2001; 2. Ministry of Health, Kenya, and UNFPA, 2004; 3. Ampofo, 1990

Babies born to adolescent mothers face higher risks Adolescents are at an increased risk for pre-term labour & delivery, compared to older women. Babies born to adolescent mothers are more likely to be of low birth weight. Babies born to adolescent mothers are at an increased risk of perinatal & infant mortality. Source: Adolescent pregnancy – Issues in adolescent health and development. Geneva. WHO 2004. Babies born to adolescent mothers face higher risks.

Relationship between maternal age and perinatal outcomes Rigorous study in Latin American & the Caribbean showed that: Adolescent mothers had higher risks of regular & very preterm delivery, & of giving birth to infants that were low & very low birth weight, as well as small for gestational age (compared to women aged 20-34) Infants born to women below 16 years faced a 50% increase in risk of early neonatal death All risks increased as maternal age decreased Babies born to adolescent mothers faces also risks: As we can see, an important good quality study have shown that there is an important relationship between maternal age and perinatal outcomes. 08_XXX_MM13 Source: Conde-Agudelo, Belizán & Lammers, 2005

Potential risks to the adolescent mother's life prospects Pregnancy can bring status for a married adolescent in cultures where motherhood is the core aspect of a woman's identity. On the other hand, an unmarried pregnant adolescent may be driven away by her family, or abandoned by her partner & be left with no means of support. Let me now move from health risks to social risks. (Read text on the slide).

Socio-economic deprivation: both a cause & consequence of adolescent pregnancy Socio-economic deprivation appears to be both a cause and a consequence of adolescent pregnancy. As I said earlier in my presentation, girls from poor communities get pregnant in their early or middle adolescence. This in turn leads to loss of educational and employment opportunities keeping them in poverty. " We young women are not prepared to become mothers. I would like to continue my studies. But since I have had my daughter, my options have changed because I have many more obligations now. I hope that this will not be a barrier for me to succeed in life." Eylin 19, Honduras January 2006. Source: World Development Report 2006 (World Bank, 2006.) 15

Adolescent pregnancy What is the magnitude of adolescent pregnancy ? 2. What are the consequences of adolescent pregnancy ? 3. What are the circumstances in which adolescent pregnancy occurs ? 4. What needs to be done to respond to adolescent pregnancy ? 5. What is the relevance of adolescent pregnancy to the Millennium Development Goals ? Adolescent pregnancy The presentation will cover the five points listed on this slide. 16

First sexual activity occurs between 15-19 for the majority of adolescents; it is not occurring earlier than in the past. For many girls it occurs in the context of coercion & violence. Over 1/3rd of adolescents girls marry (or are "married off") before 18. It is very important to note that : Source: WHO. Women & Health. Today's evidence, tomorrow's agenda.2009.

Circumstances in which adolescent pregnancy occurs. Intended pregnancy Sex within marriage Adolescent Pregnancy. Unintended pregnancy Let us begin with intended pregnancies (wanted pregnancies). In some parts of world, girls are still expected to marry and begin child bearing in their early or middle teenage years, well before they are physically or mentally ready to do so. 18

Circumstances in which adolescent pregnancy occurs. Intended pregnancy Sex within marriage Adolescent Pregnancy. Sex outside a recognised union Unintended pregnancy In other parts of the world, many young women have their first baby in the middle or late teenage years, outside a recognised union. There may be incentives for them to do this (e.g. asserting their womanhood) and no disincentives to prevent them from doing so (e.g. no real alternatives for education or employment). 19

Pregnancy within & before marriage: Data from developing countries The majority of births to adolescents occur within marriage. However, having a child outside a recognized union, is not uncommon in many countries of the world – such as those in Latin American, the Caribbean, sub-Saharan Africa and in some developed countries. Source: National Research Council & Institute of Medicine, 2005

Circumstances in which adolescent pregnancy occurs. Intended pregnancy Sex within marriage Adolescent Pregnancy Sex outside marriage Consensual sex - Within marriage - Outside a recognised union Unintended pregnancy Moving to unintended pregnancies, in many places, adolescents become sexually active at an early age when they do not know how to avoid unwanted pregnancies. They often lack access to condoms and other contraceptives that they need to avoid pregnancies. The pressure to conform to media stereotypes and the norms of their peers as well as impaired judgment resulting from the use of alcohol and other psychoactive substances may act as barriers to contraceptive use. Even if they have condoms, girls and young women are often powerless to insist on their use. This is particularly so when they feel compelled by economic pressures to exchange sex for money or favours. 21

Circumstances in which adolescent pregnancy occurs. Intended pregnancy Sex within marriage Adolescent Pregnancy Sex outside a recognised union Consensual sex - Within marriage - Outside a recognised union Unintended pregnancy The sheer numbers of girls and young women around the world who are subjected to violence, including sexual violence, is staggering. In some cases, the perpetrators are strangers. In many other cases, they are peers or influential adults within - or in close contact with - their families. This makes it harder to refuse unwanted sex or to resist coerced sex. Many girls and young women bear this burden in silence. Even if they do gather the courage to tell someone what has happened, families are often reluctant to act because of fear of bringing shame and stigma upon themselves. The fact that law makers tend to look away from this problem, contributes to the continued existence of this scourge. Non-consensual sex 22

Levels of coerced sex & its association with age of first sex For many young women’s first sex is coerced. In a WHO study, rates of coerced first sex for all women ranged between 0.4 and 29.9% (World Health Organization, 2005). The study also showed that the likelihood of coerced sex was highest in girls who initiated sex at an early age. In three-quarters of the sites, more than 30% of women who had first sex before 15 reported being coerced. World Health Organization, 2005

Adolescent pregnancy What is the magnitude of adolescent pregnancy ? 2. What are the consequences of adolescent pregnancy ? 3. What are the circumstances in which adolescent pregnancy occurs ? 4. What needs to be done to respond to adolescent pregnancy ? 5. What is the relevance of adolescent pregnancy to the Millennium Development Goals ? Adolescent pregnancy The presentation will cover the five points listed on this slide. 24

Choosing the right interventions. Intended pregnancy Sex within marriage Adolescent Pregnancy Advocate with families & communities & Provide opportunities for study & work Sex outside a recognised union Unintended pregnancy To prevent too early pregnancy within marriage or outside a recognized union, we need to advocate with families and communities in order delay marriage and child bearing in marriage. We also need to enable girls to stay in school and to provide them with livelihood opportunities.

Choosing the right interventions. Intended pregnancy Sex within marriage Adolescent Pregnancy Sex outside a recognised union Enhance capacity to make well informed & judicious choices Consensual sex - Within marriage - Outside a recognised union Unintended pregnancy To prevent unintended pregnancy resulting in consensual sex, we need to improve the skills and capacities of adolescents to make the right choices.

Provide information & education Linking HIV & pregnancy prevention. Schools Provide information & education Promote individual responsibility & protective norms Provide health services & products Mass media Strategies for preventing pregnancies and HIV are intrinsically linked: - Creating an enabling environment that promotes protective norms and supports the right of every adolescent to information on sexuality and sexual and reproductive health services - Improving knowledge and understanding - Promoting individual responsibility for safe behaviours - Ensuring the availability and accessibility to quality adolescent sexual and reproductive health services and related commodities and products Civil Society (Community Organizations) Health services

Work with young men within & outside the context of marriage or other recognised union. Working with boys and men is a critical component of successful interventions in reducing unwanted pregnancies, coerced sex and abuse. Furthermore, it is an essential approach to improving gender equality to allow adolescent girls to exert their rights to having a safe and happy sexual life. Useful reference. The RSDP/Pathfinder Bangladesh Newlywed strategy: Results of an assessment. Washington DC, Pathfinder-Focus on Young Adults. 1999. Useful reference: Promoting healthy relationships & HIV/AIDS. Prevention for young men: Positive findings from an intervention study in Brazil. Horizons Research Update, 2004. 28

Choosing the right interventions. Intended pregnancy Sex within marriage Adolescent Pregnancy Sex outside a Recognised union Consensual sex: - Within marriage - Outside a recognised union Unintended pregnancy When adolescents have an unwanted pregnancy, they need the support of a safety net. Provide a safety net & a second chance. Non-consensual sex

Provide a safety net. Making Emergency Contraceptive Pills (ECPs) widely available & accessible. Useful reference: Program for Appropriate Technology. Increasing youth access to services. Directions in Global Health. 2004; 1 (1) 4-5. The safety net is provided by: - Ensuring availability and accessibility to ECPs - Providing safe abortion services where it is legal, and effective post abortion care otherwise Providing safe abortion services (where legal) or Providing effective post-abortion care. Useful reference: Herrick J post abortion care programs for adolescents. FOCUS Youth Adolescent Reproductive Health Briefs. No. 5, Washington DC, USA. Pathfinder International. Focus on Youth Adults. 2002. 30

Preventing subsequent pregnancies is key Preventing second pregnancies by supporting adolescent mothers. Useful reference: McNeil P. Women's Centre of Jamaica Foundation. Preventing second adolescent pregnancies by supporting young mothers. Youth Adult Reproductive Health. Project Highlights. Focus on Young Adults Directions in Global Health. 1998. Ensuring the availability of a second chance for continuing the personal and social development of adolescent girls is critical in any adolescent pregnancy prevention programme. Jamaica has provided an excellent example of delaying second pregnancies. 31

Choosing the right interventions. Intended pregnancy Sex within marriage Adolescent Pregnancy Sex outside a Recognised union Consensual sex: - Within marriage - Outside a recognised union Unintended pregnancy Sexual coercion is hidden issue that needs to be properly addressed. Break the silence against sexual coercion & fight it vigorously. Non-consensual sex

Break the silence against sexual coercion & fight it vigorously. Bring perpetrators to justice. Mobilize public opinion to be intolerant of it. Protect girls/women from sexual harassment & coercion in educational institutions, work places & in other community settings. Empower them to protect themselves, and to ask for & get help when needed.. There are clear interventions for dealing with coerced sex as noted in the slide. 33

Policy maker Creates an environment that supports the health of pregnant women & new borns Community Advocates & facilitates preparedness & readiness actions Family Support pregnant woman’s plans during pregnancy, childbirth & the postpartum period. Woman Prepares for birth, values & seeks skilled care during pregnancy, childbirth & the postpartum period Facility is equipped, staffed & managed to provide skilled care for the pregnant woman & the new born When pregnancies do occur, young pregnant women need the health care and social support they need to achieve their reproductive goals. Provider provides skilled care for normal & complicated pregnancies, births & the postpartum period Ensuring that young pregnant women get the health care & social support they need

Adolescent pregnancy What is the magnitude of adolescent pregnancy ? 2. What are the consequences of adolescent pregnancy ? 3. What are the circumstances in which adolescent pregnancy occurs ? 4. What needs to be done to respond to adolescent pregnancy ? 5. What is the relevance of adolescent pregnancy to the Millennium Development Goals ? Adolescent pregnancy The presentation will cover the five points listed on this slide. 35

The relevance of adolescent pregnancy to the Millennium Development Goals (MDGs) Adolescent pregnancy contributes to maternal mortality Adolescent pregnancy contributes to perinatal and infant mortality Adolescent pregnancy contributes to the vicious cycle of poverty.

The relevance of adolescent pregnancy to the Millennium Development Goals (MDGs) Adolescent pregnancy contributes to maternal mortality Adolescent pregnancy contributes to perinatal and infant mortality Adolescent pregnancy contributes to the vicious cycle of poverty. Addressing adolescent pregnancy is Important for achieving the MDGs to reduce poverty, childhood mortality & maternal mortality

Prevention of too early pregnancies – within or outside marriage. Reducing maternal mortality in adolescents: Actions needed at three levels. Prevention of too early pregnancies – within or outside marriage. Prevention of unsafe abortions, and deaths due to abortions. Prevention of deaths during pregnancy and child birth. The prevention of adolescent pregnancy should be a key element of a three-pronged strategy to reduce maternal mortality. Without this, the Millennium Development Goal on childhood mortality reduction and maternal mortality reduction will not be achieved in many countries.

These actions should be closed linked with actions to prevent HIV. Reducing infant & maternal mortality in adolescents: Actions needed at three levels. Prevention of too early pregnancies – within or outside marriage. Prevention of unsafe abortions, and deaths due to abortions. Prevention of deaths during pregnancy and child birth. These actions should be closed linked with actions to prevent HIV. The prevention of adolescent pregnancy should be a key element of a three-pronged strategy to reduce maternal mortality. Without this, the Millennium Development Goal on maternal mortality reduction will not be achieved in many countries.

Contraceptive use in adolescents Substantial proportions of young women are not using contraception even though they are sexually active and do not want to have a child. A study of women in 53 developing countries found that the unmet need for contraception was highest in the youngest women, averaging 23.3% of women in the 15-24 age group. Source: Demographic & Health Surveys,2008

Use of maternal health care by adolescents – 1/2 Use of antenatal care (ANC) A systematic review of maternal health care use Women under 20 years are less likely to receive ANC during the first trimester (high quality studies from Jamaica, Brazil, South Africa, India/Kerala, Ecuador)1 In the Philippines, only 29% of mothers below18 received ANC, compared to 81% of mothers aged 20-302 Use of facility-based delivery Significant age differences in favour of older women (high quality studies from India, Morocco, Guatemala)1 Studies show that pregnant adolescents are less likely to obtain antenatal care, and to give birth in health facilities. 08_XXX_MM41 Source: 1. Say L, 2007 (unpublished data); 2. Dela Cruz, 1996

Use of maternal health care by adolescents – 2/2 Use of skilled delivery assistance No age-difference appears to exist (high quality studies from Bangladesh, India, Nepal)1 Higher education (both woman’s and her partner’s), problems during delivery, living standards, and women’s autonomy are more significant in influencing the receipt of assistance from a skilled health worker during delivery In an older review, mothers below the age of 19 were significantly less likely than mothers aged 19-23 to receive skilled childbirth care in 7 of 15 countries2 Some studies, but not others, suggest that adolescents are less likely to receive skilled care at birth. 08_XXX_MM42 Source: 1. Say L, 2007 (unpublished data); 2. Family Health International, 2003

Within a multifaceted approach, we need to ensure that every adolescent is able to obtain the health information & services she needs. We need to ensure that contraceptive services, antenatal services and skilled care at delivery are widely available. We need to ensure that these services are accessible to adolescents. We need to ensure that health care providers who provide these services are trained and support to respond to adolescents competently & with sensitivity. Health services need to be available, accessible and acceptab le for all adolescents - girls and boys. Scaling up quality health services is an important step towards universal access – one key target in Millennium Goal 5.

" For too long, when an adolescent becomes pregnant, we have pointed the finger at her. It is time that we pointed the finger at ourselves. If a girl gets pregnant that is because we have not provided her with the information, education, training and support she needs to prevent herself becoming pregnant." Pramilla Senanayake, Former assistance Director International Planned Parenthood Federation. Finally, we need to constantly bear in mind that pregnant adolescents do not bear the blame for their situation. Society and particularly adults have an enormous responsibility in providing adolescent girls the environment and means to protect themselves from unwanted and too early pregnancies. 44

Assignment Is adolescent pregnancy a public health priority in your country? Please support your answer with 3 facts.

Assignment Story: Please hear the story WHO | Teenage pregnancies cause many health, social problems - Listen to this episode Based on the story, please respond to the following: What are the three main factors that contributed to this? What can be done by families and communities to prevent this happening to other girls? What can the Ministry of Health do to reorient the health care system to meet the needs of girls such as the one who story you have heard?