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This post, written by Elizabeth Futrell, originally appeared on the K4Health blog and can be accessed here.

© 2003 Ansem Ansari, Courtesy of Photoshare

I was overjoyed to give birth to my first baby—a girl—earlier this year. Before becoming a mother at age 32, I graduated from high school, college, and graduate school. I served as a Peace Corps volunteer in Morocco and married a fellow volunteer.  I traveled the world, living and working on three continents. I changed careers. I volunteered as a prison tutor, an advocate for people living with AIDS, a financial literacy mentor for low-income women, an editor of a quarterly literary publication, and an auxiliary board member of Heshima Kenya.

Without contraception, my life likely would have been quite different. In fact, while I now have a baby, several of my childhood friends have teenaged children. My junior year in high school, nine of my friends or acquaintances were pregnant. Several more miscarried or had abortions. I was raised Catholic in a middle-class American suburb, and my weekly teen group taught us that abstinence was our only contraceptive option. By the time we finished high school, 2 of the 12 members of our group had given birth. 

 Though U.S. teen pregnancy rates have dropped in recent years, access to quality reproductive health and family planning information and services for young women is still a pressing issue in America and around the world. The World Health Organization (WHO) estimates that 16 million girls, ages 15-19 give birth every year; 95 percent of these births occur in developing countries. Interestingly, WHO reports that seven countries account for half of all adolescent births: Bangladesh, Brazil, the Democratic Republic of Congo, Ethiopia, India, Nigeria, and the United States.

Unlike my high school friends, who generally received prenatal services and gave birth in hospitals under the care of obstetricians, many adolescent mothers in developing countries receive little or no prenatal care and give birth without the presence of a skilled birth attendant. As a result, many of these young women face debilitating but preventable conditions such as obstetric fistula, uterine rupture, or even death. Like my high school friends, they are less likely to finish school and to have economic opportunities than their peers who have not given birth during adolescence.

World Contraception Day, which falls each year on September 26, is a global campaign with a vision for a world where every pregnancy is wanted. Its mission is to raise awareness of contraception so that young people can make informed sexual and reproductive health decisions.

Contraception saves lives. It also changes lives. When girls and women are able to choose with their partners when and how often they have children, their educational path lengthens, their economic opportunities strengthen, and their capacity to become active, dedicated citizens of their communities, and the world, soars. The benefits of a woman’s access to family planning reach far beyond her and her family; there is no limit to the good a woman can do in the world when her potential is unleashed. For proof, visit Women Deliver’s list of the 100 most inspiring people delivering for girls and women.  

To learn more about contraceptive options, please visit the K4Health Toolkits.

“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.

Every year, lack of access to family planning services contributes to approximately 7.4 million unintended pregnancies among adolescents. The unmet need for contraception among adolescents is as as high as 68% in some regions, such as sub-Saharan Africa, South-central Asia, and Southeast Asia.  Although young people might not be accessing family planning services, youth are increasingly using HIV testing services. 

Young people who use voluntary counseling and testing (VCT) services  likely engage in sexual behaviors that that put them at risk for both HIV and unintended pregnancy. Globally, there has been a push to integrate contraceptive services at HIV testing sites; however, little is known about the effectiveness of providing contraceptive services at VCT centers.

In 2009, researchers from FHI 360 set out to determine the factors associated with contraceptive uptake among young people visiting VCT centers.  The study was conducted in Kenya at both youth VCT clinics and general VCT clinics. At each facility, researchers conducted baseline and follow-up client interviews, provider interviews, and clinic observations to determine which client-, provider-, or facility-based characteristics were associated with same-day uptake of contraception, intention to use contraception, and use of contraceptives three months after a VCT visit.

Before visiting the VCT center, 72% of youth participants reported sexual activity in the past three months, and 37% of all participants were currently using contraceptives. Only 18% were using a modern contraceptive method other than the male condom and only 18% always used a condom. One-third of the clients reported they did not want to get pregnant, were not using a method and did not intend to use a method. Seventy-eight percent of providers reported ever counseling VCT clients on contraceptive use in the past week, and only 17% reported always asking female clients about whether they wanted to get pregnant. 

After visiting the VCT center, many clients reported they were never screened for family planning need, were not given contraceptives by the VCT provider and/or did not intend to follow up on a provider referral for contraceptive services.  Youth who had a current partner, higher levels of education, more children, and a desire to delay pregnancy were significantly more likely to begin using a contraceptive method at the time of their visit. Young people who intended to use family planning before visiting the clinic, and who were provided with contraceptives at the time of visit, were more likely to use contraceptives at the three month follow-up.

Youth who visited VCT centers that had higher scores of HIV /family planning integration were more likely to begin a contraceptive method at the time of their visit.  Clients of providers who were younger or who had received training in family planning were more likely to use contraceptives at the three month follow-up. Youth clinics (compared to general clinics) received better scores on integration and youth friendliness but clients were less likely to use contraceptives after visiting; however, youth clinics might be serving a higher-risk group of youth. 

The research results demonstrate that young people visiting VCT centers have a high risk for unintended pregnancy. However, very few clients who attended the clinics were counseled on contraceptive methods other than condoms, received contraception at the time of visit, or were referred to other family planning services.  Further research is needed to better understand the specific factors that influence contraceptive uptake among young people so that programs integrating VCT and family planning can best meet the needs of their clients.  Because young people might be more likely to visit VCT centers than family planning clinics, programs must ensure there are no missed opportunities in meeting the contraceptive needs of young people attending VCT centers.

To learn more about this issue, read the full study “Service delivery characteristics associated with contraceptive us among youth clients in integrated voluntary counseling and HIV testing clinics in Kenya.”

This post originally appeared on the Women Deliver website on April 30th, 2012 and can be accessed here.

Late Friday, 27 April 2012, at the 45th Session of the United Nations© 2003 Arturo Sanabria, Courtesy of Photoshare Commission on Population and Development (CPD), member states issued a bold resolution in support of young people’s sexual and reproductive health and human rights.

This victory comes on the heels of a UNICEF report released this week highlighting the challenges that the largest-ever generation of young people face—including HIV/AIDS, violence, and unintended pregnancy—and reaffirms long-standing international agreements including the 1994 United Nations International Conference on Population and Development Programme of Action.

“This CPD is one of the most important events to take place – to talk about young people, for young people and with young people,” said Kgomotso Papo, speaking on behalf of the South African Delegation during the closing plenary. “We must remove all barriers that compromise the health, well-being and development of youth; and ensure the right of every individual to autonomous decision-making in regards to their bodies, their health and their sexual relationships. On these points, there can be no compromise.”

Key points of the final resolution include:

  • The right of young people to decide on all matters related to their sexuality
  • Access to sexual and reproductive health services, including safe abortion where legal, that respect confidentiality and do not discriminate
  • The right of youth to comprehensive sexuality education
  • Protection and promotion of young people’s right to control their sexuality free from violence, discrimination and coercion

Much has changed since the landmark International Conference on Population and Development (ICPD) in 1994. Shifting global health funding, a maturing HIV epidemic, and the rise of the largest-ever generation of youth have all affected the current sexual and reproductive health and rights landscape. Similarly, several key global processes—a 20-year review of global sustainable development goals (Rio+20), a 20-year review of progress towards achieving the Cairo Programme of Action (ICPD+20), and a review of the Millennium Development Goals—are happening within the next few years, all with implications on the future of the global sexual and reproductive health and rights agenda.

“At this time of global uncertainty, there is no more important investment to be made,” said Janna Oberdorf, Director of Communications at Women Deliver. “Only healthy young people whose human rights are protected can be fully productive workers and effective participants in their country’s political processes. When young people are healthy and empowered, they can contribute to building strong communities and vibrant nations.”

In closing the session, Commission Chairperson Ambassador Hasan Kleib (Indonesia) called on member states to realize these agreements at the national level, stating that “we now have to walk the walk.”

Read the Chair’s text from the 45th CPD

This is the second post of our Gates Foundation series, “The Stories Behind the Statistics.” The following was originally posted on the Gates Foundation Blog, “Impatient Optimists” and is available here.

Catherine Gathoni works at K-Note as a field officer in the prevention program where she leads a support group for mothers ages 12-19, in Kenya.

I lead a support group for mothers ages 12-19, in Kenya. Most of the mothers I work with are out-of-school youth; many live on the streets, work in the informal economy, or are orphaned. As a part of our support program, we provide weekly peer-to-peer sessions focusing on uptake of antenatal care, child welfare, family planning services, post-rape care, and antiretroviral therapy.  The support groups for the adolescent mothers are formed to provide social support and reduce stigma.

The majority of the girls who get pregnant at this age never plan the pregnancies. Most of the unplanned pregnancies are a result of transactional sex; sexual and gender-based violence, including rape and incest; or alcohol and substance abuse. Many of these girls have grown up in challenging family environments, and within their communities early pregnancies are often accepted as normal.

I remember one girl telling me that when she visited a clinic, the nurses told her that family planning services were for women not girls, and if they provided her with these services it would be equal to them permitting her to go have sex.

It can be very hard for a young woman to receive family planning information or contraceptives. There are many myths and misconceptions in our community about contraceptives, and many girls do not know about the services available for pregnancy prevention.  Those who do know about the services are often afraid of being judged by health care workers. 

Many health service providers are hesitant to offer these services to girls less than 21 years old who do not yet have children.  I remember one girl telling me that when she visited a clinic, the nurses told her that family planning services were for women not girls, and if they provided her with these services it would be equal to them permitting her to go have sex.  It is this sort of judgment that often prevents young women from seeking reproductive health services.

Without access to family planning services, many young women end up unintentionally pregnant. 

When “Shiro” first came to our group she looked like a 9-year-old. She asked me to take her to the hospital; she said she had stopped going to school after developing vaginal discharge that would wet her dress and make pupils ridicule her. An examination and some tests established that she had not only contracted an STI (sexually transmitted disease), but she was also pregnant. She did not seem to comprehend what this meant. She only wanted to get treated so that she could go back to school.

“Shiro” never went back to school and currently works in an illegal liquor den.

Life is very challenging for adolescent mothers. Often they are unable to secure a meaningful source of income and end up working in illegal liquor dens, as sand harvesters, or as sex workers. Or they marry very early.

One young woman in my support group, “Rozie,” is 18 years old. She has never admitted to being involved in sex work but will occasionally mention having slept with someone in exchange of cash or food. This is sometimes the only means she has to feed her two sons, whom she lives with on the street.   Sometimes when I am working with girls like Rozie, I feel totally helpless.

Making family planning and pregnancy prevention services more accessible would greatly improve the lives of girls. They would get to have an education, escape becoming involved in sex work, and avoid HIV infection. We need interventions to reduce their vulnerability, empower them to take charge of their own health, and allow them to become economically independent.  The needs of adolescent girls are serious and pressing but currently they are not being addressed.

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.

Researchers at the Boston University School of Public Health have found that multi-person sex (MPS), defined as sexual activity involving several people simultaneously, may be an emerging public health problem among teens.   Results of their exploratory study conducted in the greater Boston area among females ages 14-20 years old showed that 1 in 13 participants had ever engaged in MPS.

Participants ages 14-15 were the most likely to report ever engaging in MPS, and over half (54%) of all study participants who reported ever engaging in MPS had their first experience before they turned 16 years old. More than half of the young women (65%) reported that their involvement in MPS had been pressured, forced, or coerced.  Not surprisingly, alcohol and substance use were related to events of MPS.  According to Dr. Emily Rothman, lead researcher on the study, “one-third of the young women who had a multi-person sex experience had used alcohol or drugs immediately prior, and of those, 50% said the alcohol and drug use itself was not consensual.”

One of the most interesting findings was the relationship between pornography and MPS.  “Exposure to pornography in the past month was associated with a five-fold increase in the odds of having had a multi-person sex experience,” Rothman said. Among participants who reported involvement in MPS, 50% reported that they had been pressured to perform a sexual activity that their partner had seen in porn. “That really raises questions about whether pornography may be influencing the sexual behavior of very young teens and young adults.”

Why is MPS a public health concern for teens?

Participants reported low levels of condom use during acts of MPS, increasing their vulnerability to HIV, other STIs, and unintended pregnancy. “What’s particularly worrisome in terms of public health is that 45% of the most recent multi-person sex experiences, at least one male had not used a condom,” Rothman said.  Forced or coerced sex is also linked to increased risk of STI/HIV transmission. Researchers point out that young women who experience unwanted sex, or sex with multiple partners in a row, may not be physiologically prepared for intercourse, increasing the risk of vaginal tearing and thus the risk of contracting HIV or other STIs. Finally, researchers believe that the risks of STI/HIV transmission associated with multiple concurrent partnerships also likely translate to MPS.

What’s next?

The study conducted by the Boston team was an exploratory study; thus, further research is needed to determine the prevalence of MPS among adolescents in other parts of theUnited Statesand the world. There is a need for larger studies examining the relationship between MPS and HIV/STI risk. Also, more research is needed to determine how engaging in risky sexual behaviors, such as MPS, during the teenage years affects sexual and reproductive health outcomes later in life.

“The take-home message here is that both consensual and non-consensual group sex is happening among youth,” Rothman said. “Parents, pediatricians, health organizations, and rape crisis centers really need to be prepared to talk about, provide education about it, and address it.”

To learn more about this issue, read the full study, “Multi-person Sex among a Sample of Adolescent Female Urban Health Clinic Patients.”

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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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