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Childbirth-related complications are the number one cause of death among adolescent girls ages 15–19. Every year an estimated 14 million girls in this age group give birth. The actual rate of pregnancy among adolescent girls is likely to be even higher.  Many pregnancies among adolescents are uncounted because pregnancies among this age group are often not carried to term. In developing countries, approximately one-third of adolescent girls give birth before their 20th birthday.

There are several factors that increase adolescent girls’ risk of early or unintended pregnancy, including poverty, gender inequality, lack of education, and early marriage. The same factors that increase the likelihood of early or unintended pregnancy among adolescents are further exacerbated by the occurrence of early or unintended pregnancy. For example, girls who become pregnant are more likely to leave school early, have a lower income, and have more children at shorter intervals throughout their lifetime. In contrast, young women who avoid unintended pregnancy are more likely to stay in school; participate in the work force; and have healthier, more educated children.

Unintended and early pregnancy is preventable. Interventions to help girls stay in school and delay marriage can have numerous positive effects on the lives of young women, including decreasing their risk of unintended pregnancy. Proven interventions such as comprehensive sex-education for both in-school and out-of-school youth, as well as improved access to contraception (including condoms), can vastly reduce high rates of pregnancy among this age group.

Strategic investment must be made to curb the multiple vulnerabilities that place girls at risk of unintended pregnancies, pregnancy-related complications, and death. Strategies to reduce the number of pregnancies among adolescents include:

  • Expanding access to youth-friendly reproductive health services
  • Supporting comprehensive sexuality and family life education
  • Promoting programs that keep girls in school
  • Expanding interventions that prevent early marriage
  • Enforcing laws against child marriage
  • Increasing attention to the reproductive health needs of married adolescents
  • Improving girls’ economic opportunities
  • Targeting gender inequalities

To learn more about adolescent pregnancy visit our newest topic page.

Elizabeth Doggett is an associate technical officer at FHI 360, where she works in the Research Utilization department on a portfolio of activities on preventing mother-to-child transmission of HIV, as well as activities on gender and health.

Youth-focused sexual and reproductive health (SRH) programming would greatly benefit from increased attention on gender inequality, because girls and boys are harmed by inequitable gender norms and relations. Girls, in particular, are vulnerable to some of the most egregious manifestations of gender inequality, including early marriage and various forms of gender-based violence (GBV). Gender inequality also limits girls’ access to education, recreation, and income-generation in many contexts. While gender inequality disproportionately harms girls, boys’ health and potential are also limited by expectations to be violent, aggressive, and to take sexual risks. Boys may experience GBV, too—especially when they do not live up to society’s expectations related to masculinity and heterosexuality.

However, youth may be uniquely open to thinking and behaving in more gender-equitable ways, which poses an opportunity for health programming. As part of an initiative to integrate gender into all our work—including youth SRH projects—FHI 360 recently led regional workshops in Africa and Asia to build staff’s capacity to design and implement programs to increase gender equality.

The workshops took place in Kenya in 2011 and in Thailand in 2012. “Gender focal points” from each of FHI 360’s country offices participated in the training. We shared common terms and definitions related to gender and sexuality; practiced conducting a gender analysis and designing, monitoring, and evaluating gender-integrated programs; and shared evidence-based best practices for promoting gender equality in development programs.

Image from FHI 360 gender workshop

One of the tools we introduced in the workshop that staff found most useful was the Gender Integration Continuum, which we adapted from the USAID Interagency Gender Working Group. The continuum encourages program staff to employ gender-aware approaches, meaning that programs consider the desired project outcomes related to gender norms and the status of girls/women and boys/men. The continuum also emphasizes that gender-aware projects should either work around and accommodate harmful gender norms or even seek to transform harmful norms and promote gender equality.

As noted above, youth SRH programs may be particularly well-suited for gender-transformative approaches, given that young people are at a time in their lives when they may be more willing to question gender norms and experiment with more equitable ideas, behaviors, and relationships. For example, we see the power of gender transformative approaches with young people in Program H, a program originally developed in Brazil and now considered a “gold standard” in the gender field. Program H engages with young men to critically question harmful gender norms, especially those related to sexuality and HIV prevention. The program’s evaluation found that participants adopted more gender-equitable attitudes. For instance, men were less likely after the intervention to agree that caring for children was only women’s responsibility. The participants’ sexual health also improved; for example, the percentage of participants reporting symptoms of sexually transmitted infections decreased 19-24 percentage points after one year in the program.

FHI 360’s youth programming is increasingly taking gender into account. For instance, the UJANA project, an HIV prevention program for youth in Tanzania, is undertaking an extensive set of GBV prevention activities, in recognition of the link between GBV and HIV. UJANA’s GBV prevention activities include peer education among youth, community mobilization, and mass media messaging about the harms of GBV. UJANA is also piloting an activity that links women’s income generation with GBV prevention, and an activity that works in schools to raise awareness of GBV among students, teachers, and staff.

FHI 360 is committed to expanding the pursuit of gender transformative programming, particularly among youth. By building our staff’s capacity to design, implement, and evaluate programs that challenge harmful gender norms and inequalities, FHI 360 will generate better and more sustainable outcomes for youth, increase the status of girls and women, and make relationships between girls and boys healthier.

Regina Benevides, Pathfinder International, Evidence to Action Project

IYWG:  What were you like as an adolescent?

I remember that as a teenager I was both thoughtful and cheerful. I enjoyed moments of solitude but also spending time with friends enjoying music and dancing. I was very active in my school and was a member of many different clubs and activities, including Brazilian dance, painting, theater, music, and foreign languages. I also loved to participate in the community outreach activities that the school did with the poorer communities nearby.

IYWG: How did you first learn about sex? What were you told? Who gave you this information? 

I first learned about sex from reading magazines, books, and talking with other girls. But, overall I received very little information about sex from adults or even from books and peers. Most of the information I received was about how exciting it was to have a boyfriend and the “things that happened” when you grow up. When I was a young adolescent, about 13 or 14, girls talked about the “romance and excitement that you could feel when you kissed a boy.” 

What else do you wish you had been told?

I wish I could have discussed sexuality and romance in a more open way, not only dry explanations and discussions about the “female reproductive system.”

IYWG: What challenges do you think young people face in accessing information about sexual and reproductive health?

Young people face challenges in both accessing information and in having real and unbiased discussions about sexuality. They need clear and simple information about their sexual and reproductive health without the weight of the conservative and moralistic society in which we live and they need the opportunity to discuss sexuality – which means discussing feelings, sensations, fears, and expectations.

IYWG: Why is comprehensive school-based sex education so important?

First we must ensure that comprehensive school-based sexuality education is truly comprehensive and participatory and not just the same old information about how to be abstinent, how the reproductive system works, and so forth. If the school-based sexuality education is really designed so that young people have the space and time to discuss the ways they experience sexuality, then it is absolutely critical to help them navigate adolescence in a healthy and positive way.

IYWG: How did you get started in the field of youth sexual and reproductive health?

Professionally I started in the field of youth sexual and reproductive health as a psychology professor and as a school psychologist in Brazil. After some years of practicing in this area, I went into clinical psychology work at the university and did some work in the private setting as well.  After this, I worked for a long time with the public health sector in Brazil, focused on young people. In 2007, I joined Pathfinder International in Mozambique as a youth technical advisor for the multisectoral, national adolescent and youth sexual and reproductive health and rights program – Geração Biz. I recently left Mozambique and now work with Pathfinder as the senior technical advisor for youth on the Evidence to Action project.

IYWG: Why is the health and well-being of young people especially important to you?

It is particularly important to me because young people will have the chance to dream and build another better world.  And, they can only do it if you create the appropriate space and time for it. I really love to be with young people – to work with them, talk with them, and learn from them.

IYWG: What do you think is the biggest issue young people face today?

The biggest issue?  I would say they face multiple issues – the violent environment, the lack of work opportunities, the exposure to unrelenting consumerism, and weak engagement in collective social-rights movements. All of this can lead young people to a cynical or selfish way of living and being.

IYWG: What do you think is the most important thing that could be done to improve the health and well-being of adolescents today?

Much has being said about the importance of the participation of young people in the solutions to the problems they face. However it [youth involvement] has become a buzzword and it is rarely recognized that this is not trivial and it is not easy to do. I think that it’s extremely important to foster youth-led networks engaged in collective problems and youth forums that allow for serious discussion and enable young people to bring ideas and actions to advocate for and ensure their own sexual rights. These types of efforts form a foundation for improving the health and well-being of adolescents. Without these youth-driven initiatives, efforts are not sustainable or responsive to the real needs of young people.  In addition, of course, we should continue to increase access to quality service delivery, support youth-led outreach programs, and tailor programs to address girls and gender inequality, among other initiatives. We must focus our efforts on the most underserved, those who live in countries/regions/areas where there is nothing but poverty, hunger, and no future. All young people deserve and have the right to dream and to fight for a better world for all.

 

Lisa Marie Albert, MS, MPH is a Research Associate at FHI 360 and a documentary photographer focusing on global health issues and human rights advocacy.

“I left my home because my father was beating me quite often. The father chased away my mother, so I had been staying with my step-mother…. Every time I went home I was beaten …. there were times that the step-mother would beat me with a mangling stick, used for making the local bread, a strong stick. And at times she would throw the pounding pistal [used to grain things] at me. She would even task me with the responsibility of washing her clothes. So I felt it better to come to the streets. So I started staying on the streets…” – Moses Lira,Uganda

Children in Uganda end up on the streets because of war and violence, abuse, neglect, loss of parental control, rebellion, poverty, and orphanhood. Uganda is slowly recovering from a 23-year rebel war and has also been hard hit by HIV and AIDS. UNICEF estimates that there were 2,500,000 orphans in Uganda in 2010. Many of these vulnerable orphans become children living on the streets, often exploited and abused with nowhere to turn for a safe home.  Any available estimates of street children are most likely grossly underestimated.  

Current programs that address the needs of children outside of family care include those provided by nongovernmental organizations or governments. These programs tend to address immediate needs such as providing food, education, health care, showers, and sometimes shelter, with the aim to resettle the children with their extended families. One challenge facing government programs is that they are typically police-enforced, which can foster distrust or fear in children. This distrust can lead children to go “underground,” hiding from the police and becoming even more isolated. In an evaluation done in Uganda, nearly half of the children settled through the police-enforced program ended up back on the streets. While there are some success stories,Uganda has a growing number of children living on the streets. 

I volunteered with Child Restoration Outreach because I wanted to provide an opportunity for these children to tell their personal accounts about how they came to be living on the streets. With the final goal of advocacy in mind, I designed and implemented a photography- and illustration-based workshop using a modified version of Photovoice, a community-based participatory research method. The children were very excited to take their first photographs and to share their personal stories. Several children told me that no one had ever bothered to ask them what happened in their life that forced them to live on the streets. 

These photos, illustrations, and stories were combined into posters. In October 2010, 12 posters were hung in 9 venues in Lira, Uganda. Alongside the posters. we provided very practical guidelines about how community members can help to prevent children from going to the streets and how citizens can change their mentality about street children. My hope is that the adults and stakeholders in Uganda will change their perspective from thinking of street children as troublemakers to thinking of them as vulnerable children, and then offer to assist or protect them in some way. This change needs to happen on a cultural level, in addition to a policy level.  There is a great need for continued research on the circumstances faced by hard-to-reach children, as well as evaluations of current programs with vulnerable children who are living outside of family care. In the meantime, my hope is that this exhibit will raise awareness of the struggles of children around the world and motivate people to action.

You can learn more about Lisa’s Photovoice project by visiting: http://www.lisamariealbert.com/photography/global-health/orphans-and-vulnerable-children/street-kids-advocacy-campaign/

A note from the IYWG: Adolescents who are orphaned and made vulnerable by HIV and AIDS are a large and growing population with numerous unmet needs. While many programs and publicity efforts focus on young children, more than half of all orphans are in their teen years. Adolescents who are orphaned or vulnerable because of AIDS face particular challenges. Compared to non-orphans, they have less access to education and health care, show more indicators of psychosocial distress, and face greater degrees of child neglect, abandonment, and abuse.  Learn more about the sexual and reproductive health needs of orphans and vulnerable children by visiting our topic page.

 

 

“She is the world’s most powerful force for change. An adolescent girl stands at the doorway of adulthood. If she stays in school, remains healthy, and gains skills, she will marry later, have fewer and healthier children, and earn an income that she’ll invest back into her family.”—The Coalition for Adolescent Girls

One out of every eight people is a girl or young woman between the ages of 10 and 24. Approximately 600 million adolescent girls live in the developing world.  Adolescent girls are among the most vulnerable people in the world; they face multiple inequalities and experience negative sexual and reproductive health outcomes.  Every year 3 million girls are at risk of female genital cutting in Africa. Every day more than 25,000 girls under the age of 18 are married. Adolescent females are disproportionally affected by the HIV epidemic; females make up more than 60% of all young people living with HIV.  Young women face high rates of early and unintended pregnancy, and childbirth-related complications are the number one cause of death among adolescent girls ages 15–19.  Adolescent girls are also less likely to be educated and more likely to be poor than boys of the same age.

During adolescence, health and social behaviors are established for life; the decisions a girl makes during this period and the situations she faces will have long-term consequences for her sexual and reproductive health, and the overall health of her future children and family.  Adolescent girls in developing countries who receive seven or more years of education marry on average four years later than their less-educated peers and have 2.2 fewer children. One additional year of primary education increases a girl’s eventual income by between 10 and 20 percent; one additional year of secondary school raises this percentage to between 15 and 25.  When women and girls earn an income, they reinvest 90% into their families compared to men who on average only reinvest 30-40%.

“Adolescent girls hold the key to a world without poverty.” —UNFPA

An investment in adolescent girls is an investment in our future.  With the right skills and opportunities, girls are able to invest in themselves now and in their families later. When girls are able to stay in school, delay marriage, postpone pregnancy and reach their full potential, they and their families are better educated and healthier.  By intervening to counter risks that exist and by promoting positive relationships and behaviors for girls, we are investing in the women and leaders of our future.

There are many organizations and campaigns committed to increasing investments in adolescent girls including:

To learn more about the sexual and reproductive health needs of adolescent girls, visit our topic page.

Gender is a critical issue to consider when addressing youth sexual and  reproductive health (YSRH). Traditional gender norms contribute to unintended pregnancy, STIs, HIV and AIDS, sexual violence and coercion, and early marriage and other harmful practices among young women.  Last week, the U.S. Agency for International Development  (USAID) released its Gender Equality and Female Empowerment Policy, the agency’s first gender policy since 1982. The policy “seeks to improve the lives of citizens around the world by advancing equality between women and girls and men and boys, and empowering women and girls to participate fully in and benefit from the development of their societies.”  The policy recognizes the many gender gaps that exist across sectors and their detrimental effects on the health and well-being of both women and girls.

The policy aims to achieve three overarching outcomes:

  • Reduce gender disparities in access to, control over and benefit from resources; wealth opportunities; and economic, social, political, and cultural services
  • Reduce gender-based violence and mitigate its harmful effects on individuals and communities
  • Increase the capability of women and girls to realize their rights, determine their life outcomes, and influence decision-making

USAID intends to achieve these outcomes through the following seven operational principles:

  • Integrate gender equality and female empowerment into USAID’s work
  • Pursue an inclusive approach to foster equality
  • Build partnerships across a wide range of stakeholders
  • Harness science, technology, and innovation to reduce gender gaps and empower women and girls
  • Address the unique challenges in crisis- and conflict-affected environments
  • Serve as a thought leader and a learning community
  • Hold ourselves accountable

The operational principles of the Gender Policy were developed in conjunction with USAID’s Youth in Development Policy, which is currently under development and expected to be released this year.  The Gender Policy recognizes the importance of addressing gender inequality experienced by adolescent girls, stating that “closing gender gaps in adolescence is particularly important since gender inequalities in education, time use, and health can accumulate across the life cycle if not broken early.” Adolescence provides an opportunity for addressing gender issues and related reproductive health concerns.

Working at changing gender norms with young people is a proven and cost-effective way of redressing gender inequalities and improving reproductive health and HIV and AIDS outcomes .The IYWG welcomes this policy and its potential to affect the health and wellbeing of adolescent females and males worldwide.

To learn more about this policy, you can read it in full here, or watch the launch video here. To learn more about YSRH programs targeting gender inequality visit our gender topic page.

During her adolescence, Bi Umanzi Vuai (now in her 50s) recalls that she did not understand the changes happening to her body. As was the case among most of her peers, Bi Umanzi’s parents did not tell her much. She was raised knowing that parents do not talk to children about sexual matters. Parents believed that if you told children about these things it was the same as encouraging them to have sex.

“My mother used to tell me I would get pregnant if I were to ‘meet’ with men,” says the soft-spoken mother of two adult daughters. “This created a lot of fear in me when I was young to the extent that for some time I did not even respond when men greeted me! (Laughs) My mother should have told me that one can get pregnant by having sex, NOT simply by meeting with men!”

In Bi Umanzi’s community inZanzibar, most adolescents—her grandchildren’s peers—still receive little information from their parents about sex. This lack of information  can lead young people to take risks that may bring about lifelong harm. Bi Umanzi wanted to help bring about change; she is a Madrassa teacher, and in April 2011, she was trained as a facilitator for “Daraja” (meaning bridge in Swahili), a curriculum-based life skills initiative to promote sexual and reproductive health in youth by bridging the communication gap between parents and children.

Bi Umanzi is one of 10 adult and 10 youth volunteers trained by an NGO called UMATI Unguja. UMATI Unguja is implementing Daraja in five wards inZanzibar. Adult–youth pairs of participants attend 20 sessions spread over three days. The first day is for adults, the second day for youth, and the third day brings adults and youth together. Four hundred and fifty adult–youth pairs have participated since April (56% of participants were female). Daraja is an initiative of the American Red Cross, Tanzania Red Cross Society and FHI 360 under the UJANA project supported by the U.S. Agency for International Development (USAID).

Since she started to facilitate Daraja sessions, Bi Umanzi has become a strong advocate of parent–child communication in her community. She hopes to see a society where children are not left to face the challenges of growing up alone as happened to her and her daughters. The seed sowed by her effort and that of colleagues has started taking root in an environment that has many strong taboos. “We are getting a lot of interest from religious leaders and local leaders who want us to extend Daraja to their areas,” says Said Salim Maalim, the UMATI Unguja coordinator.

Bi Umanzi sees the effect of Daraja in her community. “Talking openly about things like pregnancy, homosexuality and drugs has improved a lot. A large number of youth as well as parents in this community are getting to accept that open parent–child dialogue lays a firm foundation for youth to lead a healthy life,” she concludes.

Read the full success story here.

To learn more about the role of parents in youth sexual and reproductive health visit our “parents” topic page.

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This blog is brought to you by the Interagency Youth Working Group (IYWG) with financial assistance from the U.S. Agency for International Development and the U.S. President's Emergency Plan for AIDS Relief. The content is managed by FHI, which functions as the secretariat for the IYWG.
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