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Callie Simon is technical advisor for adolescent and youth sexual and reproductive health (AYSRH) at Pathfinder International. Based in Washington DC, Ms. Simon provides technical assistance to Pathfinder’s AYSRH programs globally, in addition to supporting Pathfinder’s AYSRH advocacy efforts domestically and abroad.
Claire Cole is technical documentation advisor at Pathfinder International. Based in Boston, MA, she supports Pathfinder’s global offices in implementation analysis to advance technical practice.
Today’s generation of young people is the largest in history. Through the sheer size of their numbers and where they live— predominantly in resource-limited countries—young people represent the future and present of development. Yet, essential sexual and reproductive (SRH) health services that have the power to help a young person shape the direction of his or her life (and health) are often out of reach. Young people are unable to access the high-quality services they need because of community and provider stigma, lack of confidentiality and privacy, and health-system limitations like cost, operating hours, location of services, and shortages of trained providers.
Thankfully, in recent decades this issue has increased in prominence among our global health professional community. The concept of youth-friendly services (YFS) is more readily discussed as a core part of global health services—as evidenced at the 2011International Conference on Family Planning in Dakar, as well as the 2012 International AIDS Conference just last month in Washington, D.C.
Unfortunately though, when we think of the size of the global population of young people, we have to recognize how insufficient current coverage of YFS is to meet the challenge posed to us. Boutique YFS programs and small-scale pilots are never going to enable us to ensure these populations have the health services they need. Scalable YFS strategies are essential to fulfilling the rights of the nearly 3 billion people under the age of 25 who need these services now, and who will continue to need them in the years to come. But getting to this goal will require multi-dimensional thinking on our part. What does multi-dimensional thinking mean in this context? It means recognizing that geographic expansion to more and more clinics is not going to be a sufficient answer to the challenges posed by larger upstream factors that create barriers to sustainable, institutionally-supported YFS. We need solutions like pre-service training, which has the power to produce providers readily able to respond to young clients’ needs from the start of their medical careers, and policies that support young people’s right to quality SRH —regardless of marital status or sexual orientation. We need to capitalize on opportunities to take existing YFS to scale, and push wherever possible to introduce YFS into current large-scale programming.
In Pathfinder’s experience in Ethiopia over the past eight years, we’ve learned a substantial amount about what it looks like to do this. We found ways to mainstream adolescent and youth sexual and reproductive health by introducing YFS into large-scale reproductive health and family planning programs. When funding gaps looked to be signaling the end to our first large-scale YFS effort, we found ways to work YFS into our next large-scale collaboration with the FMOH—in this case via the Integrated Family Health Program (IFHP)[1]. Working in regions that comprise more than 80 percent of the country’s population, the potential for geographic scale was a given. But institutional scale—that is, ensuring that YFS was part of the national reproductive health strategy, that there were national training curricula, guidelines, and standards for YFS, and that YFS was a part of regional MOH work planning and monitoring structures—was equally important. Working at these two angles in tandem, we were able to support the FMOH in navigating the myriad challenges that are inevitably part of scaling a critical but often neglected and stigmatized service like YFS.
But more is needed. We need collective action, partnerships, and learning to ensure YFS is brought to scale more regularly across our global health landscape. Across agencies, we need to share our lessons, our challenges, and our failures from implementation as we strive toward this goal. With the increased attention being given to YFS, there’s good cause for optimism that this learning-oriented dialogue around YFS will only continue to grow. Our recent technical brief, Bringing Youth Friendly Services to Scale in Ethiopia, captures many of the key lessons and take-aways from our experience scaling YFS through IFHP. We look forward to continuing this important dialogue with the greater YFS community in the future.
[1]IFHP is a five-year (2008-2013) USAID-funded project that collaborates with the government of Ethiopia to promote an integrated model to strengthen family planning, reproductive health, and maternal and child health services for rural and hard-to-reach populations. The project works in six regions: Oromiya; Tigray; Southern Nations, Nationalities, and Peoples (SNNPR); Amhara; and parts of BenishangulGumuz and Somali. The project is led by Pathfinder International and John Snow, Inc. in partnership with the Consortium of Reproductive Health Associations (COHRA) and 11 other local implementing partners.
“The Stories Behind the Statistics” is a series we developed for the Gates Foundation blog, “Impatient Optimists.” The following post is the second in our three-part series on contraception. The original post, located on “Impatient Optimists,” is available here. Max Kamin-Cross is a self-proclaimed political junky and youth activist
There is one action that we, as a world population, could take today to change our future more than any other single action.
We could lift millions of people of all races and both genders out of poverty throughout the world. By doing this action, we could significantly decrease the number of premature deaths, as well as the number of lives claimed by deadly infections like HIV. Accessibility to food and medications for people living in developing countries would increase, and the quality of life for millions more people would be drastically improved. This single action, if done in conjunction with the major governments of the world, would complete all of this and more. The action: improving access to contraceptives.
More than 700,000 women and newborns die every year during or shortly after birth of an unintended pregnancy. While contraceptive access can be a controversial topic here in the United States, where I live, other developed countries, such as the United Kingdom, have realized that this is an international health issue. In some developing regions, more than 60 percent of young women report that they lack proper access to contraception that they would like to use. If that number were in the single digits, our world would be a much different place. Women would be able to put off childbirth until they were both emotionally and financially ready. They would also be able to plan the spacing of their children and the size of their family, increasing their chances of rising out of poverty. Adequate access to condoms would also greatly reduce a young woman’s chances of being infected with HIV.
Contraception isn’t cheap, not by a long shot. Data from the Center for American Progress suggest a woman in the United States can expect to pay well over $10,000 in her lifetime for contraception.
If she doesn’t have insurance for all or even just part of her life, that cost quickly comes closer to $70,000. This overwhelming burden can hurt the people who need birth control most: impoverished women and young people. In almost every country in the world there is a growing, and unmet, need for low-cost contraception.
This issue should not be controversial. The future of my generation truly may rely on the fate of contraceptive access.
This video and the post below were developed by Pathfinder International and originally appeared on their blog on July 23, 2012.
Can you imagine walking 18 miles to get contraceptives? Or being told your clinic is out of stock? It seems absurd right? But in many countries, this happens every day. Doctors are overworked, under supported, and stressed out. Women struggle to care for their large families and access the services they need, sometimes waiting hours, even overnight to visit a clinic.
We try to make it funny in this video but the reality is no joke. Choice matters about if, when, and how often to have children; choice matters about getting tested for and STI or HIV; choice about sexual and reproductive health matters for all women, everywhere.
If you agree, share this video today! The more people who understand the issues, the more voices we have calling for change.
Even here in the United States, we see barriers to reproductive choice. However, oftentimes those barriers are even more challenging in developing countries. Shannon Wu, one of our donors said, “Most women in America have access to knowledge and health care when it comes to their sexual and reproductive life. But in other parts of the world, women’s health is almost always the last thing to be discussed or taken care of, if at all.”
Right now more than 222 million women want, but lack access to contraceptives. One woman dies every 90 seconds during pregnancy or childbirth because she lacks access to maternal care. And HIV is the number one cause of death for women of reproductive age in the developing world.
If you want to change these numbers, and improve the lives of women, take a simple action now: share the video. Help start an important conversation with your friends, family, girlfriends, boyfriends, husbands, wives, colleagues that reproductive health care is no joke. Choice matters.
We’d love to know what you think of the video. Did it remind you of the reproductive health care issue that drives you to make a difference? Use the comments below and thank you for sharing!
A note from the IYWG
Young people face multiple negative sexual and reproductive outcomes including unintended pregnancy, HIV and other sexually transmitted infections, and maternal mortality and morbidity. Each year, lack of access to family planning services leads to approximately 7.4 million unintended pregnancies among adolescents, and each year nearly 70,000 women between the ages of 15 and 19 die in childbirth. Preventing unintended pregnancies among adolescents would reduce the number of maternal deaths as well as improve educational and employment opportunities for young women. To learn more about young people and contraceptive,s view our blog archive for contraceptives posts or our topic page on Contraceptive Options for Young People.
“The Stories Behind the Statistics” is a series we developed for the Gates Foundation blog, “Impatient Optimists.” The following post is the first in our three-part series on contraception. The original post, located on “Impatient Optimists,” is available here.
Over the past couple of months, in our Stories Behind the Statistics series, we shared with readers the overwhelming rate of adolescent pregnancy and its devastating effect on the lives of girls. One of the commitments made on July 11, 2012 at the Family Planning Summit was to increase access to contraceptives for young women and girls. These global commitments could not be timelier in a world where approximately 16 million girls between the ages of 15 and 19 give birth each year; one million die or suffer serious injury or disease as a result of pregnancy; and millions more face discrimination in their communities, are forced to drop-out of school, and face social isolation as a result of unplanned or unintended pregnancy.
It is estimated that as many as half of all pregnancies worldwide are unintended and a disproportionate amount of unintended pregnancies occur among young, unmarried girls who often lack access to contraception. Approximately 85-95 percent of sexually active young women who do not use contraceptives become pregnant within one year of initiating intercourse.
In some regions of the world, such as sub-Saharan Africa, South-central Asia, and Southeast Asia the unmet need for contraception among adolescents is as high as 68 percent. Young people face multiple barriers to accessing contraceptives including lack of information, social stigma, provider bias, lack of confidentiality, and policy restrictions.
Lack of information about contraceptives, and myths related to side effects, are commonly reported by young people as reasons for not using contraceptives. Young people need information, skills, and products to make informed decisions about how they can protect themselves from pregnancy in a way that is consistent with their own values. Young people also face multiple medical and institutional barriers to receiving contraceptive services, including provider bias, parental consent restrictions, notification laws, and unnecessary medical tests such as pelvic exams.
In many societies, young women have limited control over their contraceptive choice. Often they do not have the power to negotiate contraceptive use with their partners; their family planning decisions might be made for them by parents, partners, spouses, or in-laws. Married adolescents face particular barriers to contraceptive access including increased societal pressure to have children, fear of their spouse, or lack of transportation to health services.
Fulfilling the unmet need for family planning among adolescents could prevent an estimated 7.4 million unintended pregnancies. Preventing unintended pregnancies among adolescents would reduce the number of maternal deaths as well as improve educational and employment opportunities for young women. Expanding young people’s access to contraceptives means giving girls and young women the choice to determine their own future.
In the next two posts of this series we will hear from two young people–one from Zimbabwe and one from the United States– about why contraceptive access is important to them.
Ward Cates MD, MPH, is president emeritus and distinguished scientist at FHI 360, one of the largest nonprofit organizations in international public health and development, with field activities in more than 60 countries. He has worked to improve youth sexual and reproductive health throughout his nearly four-decade career.
During the month of July 2012, two landmark gatherings advanced our global agenda in sexual and reproductive health. The Family Planning Summit was held in London on July 11. Co-hosted by the UK Government and the Bill and Melinda Gates Foundation, the Summit’s goal was to offer millions of vulnerable women around the world renewed hope that they will soon have the means to determine the timing and spacing of their pregnancies through access to modern family planning methods. The AIDS 2012 Conference was held in Washington DC from July 22-27. Organized by the International AIDS Society, AIDS 2012 was a multitrack, week-long convention of 24,000 attendees, including heads of state, celebrities, philanthropists, researchers, activists, and people living with HIV and AIDS. Their optimistic vision is to attain an AIDS-free generation.
Youth provide the common denominator for achieving the sexual and reproductive health (SRH) goals of both these conferences. FHI 360 uses five fundamental principles to design research and implement SRH programs for youth:
- Youth are Assets to society and are capable of practicing positive, life-affirming SRH behaviors when equipped with accurate information plus problem solving and decision-making skills.
- Youth Participation is Critical: youth must be full partners in SRH programs if they are to have real impact.
- Human Rights are Youth Rights: youth should live free from violence and discrimination and with access to services that permit them to live healthy, productive lives.
- Gender Equity Promotes Good Reproductive Health through responsible sexuality and mutual respect between the sexes.
- Building on Existing Capacity Improves Sustainability and helps to achieve high quality SRH/HIV programs for youth.
Instilling youth with values based on sexual health, rather than sexual disease, will pay future dividends for all of us. This requires partnering with young people and fostering youth leadership. Consulting with and involving youth from the outset of educational initiatives will help develop trust and alliances across generations. Efforts to build young people’s SRH capacities in advocacy, communication and peer education–among other issues–are also effective approaches to ensuring education on sexual and reproductive health.
Youth networks can serve as trainers in these areas. Many young people work at community/municipal levels using various media, such as radio, video, writing and theatre. Partnerships that train peer educators can expand the reach of education on sexual and reproductive health to young people out of school. The establishment of clubs for discussing and providing peer education in primary and secondary schools can also help set sexual health values.
Building support at the local level among parents, teachers and community leaders is critical for sustainability when working with youth. On-going advocacy, technical and financial support, and capacity-building of government bodies in charge of educational curricula, teachers, youth networks and youth-led led organizations provide a reinforcing platform for youth programs.
Sexual and reproductive health education is one of the key priorities identified by the United Nations’ initiative to develop a global action plan on youth. Data are clear that age-appropriate SRH curricula do not lead to earlier sexual activity. The most effective programs in education on SRH are those that provide correct information, clarify values and reinforce positive attitudes. In addition, strengthening decision-making and communication skills add practical value to youth transitioning into responsible adulthood.
Development of SRH curricula must be based on cultural context. Norms on gender and sexuality, equality, empowerment, non-discrimination and respect for diversity are scarcely addressed in most SRH programs. Yet curricula that take gender and power relations into account have been shown to positively affect health-related behaviors (e.g., age at first intercourse, number of sexual partners, use of condoms and contraception,), health outcomes (e.g., lower rates of sexually transmitted infections) and non-health outcomes (e.g., student performance, parenting and critical thinking skills). Additionally, many programs do not provide scientifically accurate information about relevant psychosocial and health topics. Nor do they invest in visually engaging materials that provide young people with such information in ways that are age-appropriate.
One challenge to education on SRH is its limited reach to out-of-school youth and other groups of marginalized young people. Many young people most in need of information and education are not enrolled in any educational programs. Girls and young women especially often drop out of school at an early age because of various social and economic factors. Therefore, SRH education needs to begin at a young age and continue through adolescence to reinforce messages over time with age-appropriate content and methodology.
To conclude, I believe we proactively need to set our global priority for investing in the sexual and reproductive health of the world’s youth. As the saying goes, today is the first day of the rest of our lives, and the best value for money comes from strengthening youth.
Millions of people around the world have been captivated by this year’s Olympic Games. The world is likely enthralled by many aspects of the games, such as the excitement of the competition and the athletes’ almost super-human abilities. But one of the most heart-warming characteristics of the games is witnessing individuals achieve their childhood dreams. Last week the U.S. morning news show, the “Today Show,” interviewed the gold-medal-winning U.S. Olympic gymnastics team. This group of five teen women shared stories about how, as children, they watched the Olympic gymnastics teams and dreamed of one day competing in the international arena.
Like the U.S. gymnasts and many other Olympic athletes, little girls all over the world dream of a bright future. They dream of becoming astronauts, doctors, cowgirls, even Olympians. Yet for some, the dreams are more modest: a future where a girl is able to complete school, marry a man she chooses, and avoid early pregnancy. However, for many girls, poverty, gender inequality, high rates of early marriage, lack of education, and negative sexual and reproductive health outcomes put these dreams out of reach.
New research suggests that involvement in sports might help to mitigate barriers that hinder the future of many adolescent girls. Sports can help build social networks for girls in developing countries, allowing them to challenge gender norms that contribute to their vulnerability. In addition to promoting gender equity, sports can enhance physical and mental well-being, promote social integration for girls, provide girls with adult mentors and encourage the development of new skills, knowledge, and self-confidence.
Additional research is beginning to show that participation in sports might have a positive effect on sexual behaviors, knowledge, and attitudes as well. Many HIV prevention programs are beginning to incorporate sports as a platform for disseminating HIV prevention messages. Girls-only sports programs might be able to address issues such as self-confidence, social identity, and the way that family and communities perceive girls.
While not every girl who is involved in a sports program will become an Olympic athlete; the evidence suggests that sports programs might enable adolescent girls to achieve many other childhood dreams.
To learn more about how participation in sports can help girls build social networks, challenge gender norms, and enhance their physical and mental well-being, also see the latest IYWG YouthLens: Sports for Adolescent Girls.
“The Stories Behind the Statistics” is a series we developed for the Gates Foundation blog, “Impatient Optimists.” The following post is the third in our three-part series on adolescent pregnancy. The original post, located on “Impatient Optimists,” is available here.
Gaj Bahadur Gurung works as the program coordinator for the National Federation of Women Living with HIV and AIDS in Nepal.
For a young girl in Nepal or South Asia, pregnancy can be disastrous. If it occurs outside the context of marriage, it will bring her disgrace and might lead to expulsion from her family and school. The young woman may be perceived as deviant in the community and will be considered a curse for her family.
Young women have little choice or control over contraceptives. For unmarried young girls in South Asia, male condoms are their only contraceptive option. Yet, patriarchal gender roles and norms make it difficult or impossible for girls to negotiate condom use with a male partner and often inhibit girls from even buying condoms or other types of contraception.
A lack of appropriate information also contributes to adolescent pregnancy. Parents rarely discuss sexual and reproductive health with their children, and the school curriculum has outdated and inadequate information. In spite of the attempts by nongovernmental organizations to disseminate information, some people are difficult to reach, especially low-income girls in mobile populations.
Early marriage is another major contributor to pregnancy among adolescents. Early marriage is quite normal in this culture, and once married, a young woman is expected to give birth to prove her family’s honor. Once a young married woman becomes pregnant, she receives tons of affection, but often she drops out of school, becomes more economically dependent on her family, and has less social interaction.
Policies and programs must both help prevent early and unintended pregnancy (for married and unmarried women) and mitigate the negative consequences for girls who do become pregnant. Programs should provide young women access to, control over, and informed choice about sexual and maternal health services. Youth-friendly maternity services with easy access for young girls would minimize health risks to mother and baby during pregnancy, delivery, and the post-delivery period.
