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 9 13

Sex by age 15

South America

17 21 41 44

Sex by age 18

Caribbean/ Central America

57 59 61 62

Sex by age 20

0

20

40

60

Eastern/ Southern Africa

77 77

80

% of 20-24 year old females who had sex by certain ages

Western/ Central Africa

100

And the pace of change is similar for adolescent males Western/ Central Africa)

12 14

Sex by age 15

31

31

Eastern/ Southern Africa)

40 45

Sex by age 18

Caribbean/ Central America

70

73 61

South America

65

Sex by age 20

84

87

0

20

40

60

80

% of 20-24 year old males who had sex by certain ages

100

Childbearing begins by age 18 for many girls % of females 20-24 who had a birth by age 18 Western Asia/Northern Africa

11

South America

16 Caribbean/Central America

22

South-central/Southeastern Asia

24 27

Eastern/Southern Africa

31

0

20

40

Western/Central Africa

60

80

100 NRC & IOM (2005)

Adolescent childbearing is less common than among older generations % of females who had a birth by age 18

12

Western Asia/Northern Africa

21

Age 40-44

24

South America

32 38 39

Caribbean/Central America South-central/Southeastern Asia

11 16 22 24 27 31

Age 20-24

0

20

40

Eastern/Southern Africa Western/Central Africa

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

7 3 9

Age 40-44

3 4 7 9 9

Age 20-24

0

Western Asia/Northern Africa South America

14 16 21

Caribbean/Central America South-central/Southeastern Asia Eastern/Southern Africa Western/Central Africa

13 20

40

60

80

100 NRC & IOM (2005)

The majority of births still occur within marriage South-central/Southeastern Asia

Eastern/Southern Africa

30

70

Western/Central Africa

18

82

Caribbean/Central America

11

89

Western Asia/Northern Africa 0%

3

97

1

99

10%

20%

Within marriage

30%

40%

50%

60%

70%

80%

Outside of marriage

% distribution of births to mothers age 20-24 years by marital status

90% 100%

But many births to teen mothers are wanted later or not at all Nigeria

82

Burkina Faso

82

9

17

70

Senegal

7

Birth was wanted then

27

Ethiopia

69

20

11

Uganda

68

23

9

67

Malawi

18

42

Ghana

South Africa 0%

37

20 40%

60%

Birth was not wanted at all

21

66 20%

15

Birth was wanted later

13 80%

100%

% distribution of wantedness of births to mothers under age 20

Unwanted and mistimed pregnancies are a major problem 7.9 million pregnancies

Miscarriages 16%

Planned births 53% 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 42

South-central/Southeastern Asia

58

45

Western/Middle Africa 37

Eastern/Southern Africa 23

Western Asia/North Africa

58

53 46

35 38

Caribbean/Central America

0

20 20-24 year olds

40

60

80

100

40-44 year olds

% of women who were ever married by age 18 NRC & IOM (2005)

Schooling •

School attendance & higher education Æ lower adolescent fertility

•

Rising % of girls attending school after the age of puberty Æ 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) 33

Any method (1993)

37

Single

5

19

Any method (2001)

13

Condoms (1993) 18

Married

1

Condoms (2001)

2

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%

15

80%

25

23 47

52

60% 40%

61 39

32

20% 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

54 27

24

None

19

58

Females Males

18

Primary

Secondary or higher

Level of schooling of those reached by peer educators 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 Females Males

51 26

35 11

None

Primary

14

Secondary or higher

Level of schooling of 12-19 year olds 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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