Please note: This archive was last updated in 2005.

RHO archives : Topics : Adolescent Reproductive Health

Overview/Lessons Learned

Introduction

Adolescents are a large and growing segment of the population. More than half of the world's population is below the age of 25, and four out of five young people live in developing countries (WHO/UNFPA/UNICEF 1999). During adolescence, young people develop their adult identity, move toward physical and psychological maturity, and become economically independent. Although adolescence generally is a healthy period of life, many adolescents often are less informed, less experienced, and less comfortable accessing family planning and reproductive health services than adults (PATH/Outlook 1998).   Adolescents may experience resistance or even hostility from adults when they attempt to obtain the reproductive health information and services they need. They therefore may be at increased risk of sexually transmitted infections (STIs), HIV, unintended pregnancy, and other health consequences that can affect their futures—and the future of their communities—for many years to come. In addition, gender inequities, particularly unequal power in relationships, may limit their ability to use contraceptives or seek reproductive health services.

The World Health Organization (WHO) defines adolescents as individuals between 10 and 19 years of age. The broader term "youth" encompasses the 15- to 24-year-old age group. This site addresses the needs of 10- to 24-year-olds unless stated otherwise. Adolescents' circumstances and needs vary tremendously depending on individual characteristics such as age, sexual activity, schooling, and employment status, as well as their position within the range of the adolescent years.

Top of page

Global youth today

Young people worldwide face social, economic, and health challenges that were unimaginable even a decade ago. While young peoples health and educational prospects are improving, and marriage and childbearing are occurring at later, more mature stages of life compared with previous generations, some serious concerns remain. Despite increasing attention given worldwide to education, 121 million children worldwide are out of school, with 9 million more girls than boys. Educating girls is essential to reducing child mortality, HIV/AIDS, and other diseases. Furthermore, educated women will most likely have healthy children who will complete schooling. (UNICEF 2003). For women ages 15 to 19, complications of pregnancy, childbirth, and unsafe abortion are the major causes of death. Young people ages 15 to 24 have the highest rates of sexually transmitted infections (STIs), including HIV. Statistics on rape suggest that between one-third and two-thirds of rape victims worldwide are 15 years old or younger (PRB 2000).

In the least developed countries, only 22 percent of boys and 13 percent of girls are able to continue their education beyond the primary level. In Burundi, the Central African Republic, Mali, and Niger, fewer than 10 percent of girls receive at least seven years of schooling. Youth with low levels of education experience severely limited future prospects for economic self-sufficiency (AGI 1998). Rapid population increases and urbanization place pressure on national health, education, and social infrastructures, further reducing access to basic needs. Urbanization and population growth also have dramatically altered traditional cultural and family structures that in many cases provided clear norms regarding sexual behavior.

Top of page

Adolescent sexual activity

Young women are reaching menarche earlier and, in some countries, marrying later (AGI 1998). As a result, a significant number of adolescents of childbearing age around the world are sexually active, and an increasing proportion of sexual activity is occurring outside of marriage (PRB/CPO 1994). Surveys show that about 43 percent of women in sub-Saharan Africa and 20 percent of 20-year-old women in Latin America have had premarital sex. In some developed countries, the rates are higher: 68 percent of adolescents in the United States and 72 percent in France have had premarital sex by age 20 (AGI 1998). A recent study of 14 countries throughout the world found that for never-married young people, particularly men, sexual intercourse appears to be very sporadic and probably involves a number of partners over time. The lower incidence of nonmarital sexual activity among young women raises the possibility that in countries where very high proportions of young men initiate sexual activity before age 15 and young women postpone having sex, young men may be initiating intercourse mostly with sex workers (Singh et al. 2000).

Along with increased exposure to STIs and unintended pregnancy, adolescents who engage in sexual activity outside of marriage may face social stigmas, family conflicts, problems with school, and the potential need for unsafe abortion. Married adolescents who become pregnant may not encounter the same social risks as their unmarried counterparts, but they may face the same complications from STIs and to the health risks of early pregnancy.

Top of page

A time of opportunities and risks

Adolescence is a period of transition, growth, exploration, and opportunities. At the same time, adolescents typically are poorly informed about how to protect their sexual health. As a result, they may be susceptible to unwanted pregnancies, the health risks associated with early pregnancy, unsafe abortions, STIs, and HIV. In addition, an estimated two million girls undergo harmful health practices such as female genital mutilation each year (see RHO's Harmful Health Practices section for more information about female genital mutilation).

Each year, 15 million adolescents aged 15 to 19 years give birth, accounting for up to one-fifth of all births worldwide. In the developing world, an average of 40 percent of women give birth before the age of 20, ranging from a low of 8 percent in East Asia to a high of 56 percent in West Africa (Noble et al. 1996). In many developed regions, only about 10 percent of adolescents begin childbearing as early. In the United States, however, about 19 percent of adolescent women give birth by age 20 (Noble et al. 1996; United Nations 1995). Each year 1 million to 4.4 million adolescents in developing countries undergo abortion, and most of these procedures are performed under unsafe conditions (PRB/CPO 1994; Noble et al. 1996). Complications of pregnancy, childbirth, and unsafe abortion are major causes of death for women age 15 to 19. (For more information, see the Early and Unintended Pregnancy Key Issue as well as RHO's Safe Motherhood section). Young women's frequently limited knowledge of or confidence in accessing the health care system results in limited prenatal care, which also contributes significantly to complications (Mothercare Matters 1995).

STIs also pose significant risk for adolescents. The highest rates of infection for STIs, including HIV, are found among young people age 20 to 24; the next highest rate occurs among adolescents age 15 to 19 (Noble et al. 1996). Each year, one out of every 20 adolescents contracts an STI, some of which can cause lifelong health problems (such as infertility) if left untreated (see RHO's Reproductive Tract Infections section for more information). WHO estimates that half of all people infected with HIV are younger than age 25 and, in developing countries, up to 60 percent of all new infections occur among 15 to 24 year olds (Shane 1997). Every day, 7,000 young people worldwide acquire the virus, which amounts to about 2.6 million new infections over one year among youth. Some 1.7 million of these are in Africa and 700,000 in Asia and the Pacific (UNAIDS 1998). New infections among females outnumber those among males by a ratio of 2 to 1 (UNAIDS/WHO 1997). For more information, see the HIV and STIs in adolescents Key Issue.

Access to reproductive health information and services is critical, but this alone will not necessarily result in young people adopting safer sexual behaviors. Like adults, young people require motivation to make healthy decisions about their sexual behavior; adopting healthy sexual attitudes and behaviors cannot happen in a vacuum. Indeed, it is becoming increasingly clear that adolescent sexual and reproductive health is closely linked with educational and economic opportunities (Esim 2001). Early marriage, adolescent pregnancy, abortion, and STIs often curtail adolescents'—especially girls—ability to obtain an education and learn skills that can help them develop livelihood options. Conversely, developing economic options and skills at a young age can significantly influence a persons future social and economic mobility; it also decreases their exposure to health risks, improves fertility outcomes, and enhances overall well-being. Programs that link adolescent reproductive and sexual health with broader youth development can take a holistic approach to young people's concerns. These programs can help young people develop the skills, self-esteem, and motivation necessary to postpone or "take a break" from sexual intercourse, while also helping to develop life skills that can serve them well into adulthood. Youth who choose to be sexually active will be better able to protect themselves from early pregnancy and STIs by using contraceptives (WHO/UNFPA/UNICEF 1999; Senderowitz 1997).

It is important to note, however, that many health experts acknowledge that sexual experience during adolescence in and of itself does not necessarily involve risk. If young couples use effective methods of protection against pregnancy and STIs, and if their decision to enter into a relationship is voluntary, physical and psychological risks are minimized. The concern is pressing, however—especially for women—when sexual relationships are involuntary or not sanctioned by law or custom and when contraceptive use is absent or inadequate (Singh et al. 2000). Programs recognizing that adolescents can engage in healthy, fulfilling sexual relationships, rather than focusing only on the negative outcomes, may go far in reaching young people with important information.

Top of page

Promoting healthy development

In 1994, the International Conference on Population and Development (ICPD) Programme of Action called for organizations to initiate or strengthen programs to better meet the reproductive health needs of adolescents (ICPD 1994; Alcala 1995). The importance of adolescent health is now acknowledged, and numerous programs have been developed to address their reproductive health needs. However, much still needs to be done to ensure adequate information and services to the world's young people.

Focusing on adolescent reproductive health is both a challenge and an opportunity for health care providers. Adolescents often lack basic reproductive health information, skills in negotiating sexual relationships, and access to affordable confidential reproductive health services. Many do not feel comfortable discussing sexuality with parents or other key adults with whom they can talk about their reproductive health concerns (PATH/Outlook 1998). Likewise, parents, health care workers, and educators frequently are unwilling or unable to provide complete, accurate, age-appropriate reproductive health information to young people. This often is due to their own discomfort about the subject or the false belief that providing the information will encourage increased sexual activity (Baldo et al. 1993). In addition to STI and pregnancy risks, many young people who are sexually active have been forced into sexual relationships either through violence or for economic reasons, and are in need of counseling, information, and contraceptive services. Many of the Key Issues in the Adolescent Reproductive Health section address these issues in greater detail.

Despite these challenges, programs that offer accurate information, access to contraceptives and other reproductive health services, as well as the motivation young people need to protect themselves, can make a difference. Adolescents are a central resource for their countries' health and development in the present as well as in the future. But even more important, young people have the basic human right to receive the information and services necessary to protect themselves from STIs, early pregnancy, and their associated poor outcomes. Targeting young people for health information and services can be a gateway to promoting healthy behaviors. Working together, parents, community leaders, and health professionals can create programs that address young people's needs and help them to enjoy a healthy adolescence and to become healthy and responsible adults (UNICEF 1998).

Top of page

Lessons learned

Although few programs have been rigorously evaluated, guidelines on building successful programs and reaching young people are emerging. Well-designed youth programs consider the many factors that shape young people's lives and influence sexual behavior and reproductive health decision-making.

  • Key strategies for reaching and serving youth include:
    - developing youth-friendly services;
    - involving youth in program design, implementation, and evaluation;
    - training providers to attend to the special needs and concerns of adolescents;
    - encouraging community advocacy efforts to support youth development and promote positive adolescent health behaviors;
    - implementing programs that provide complete and accurate sexual health information; and
    - incorporating skills-building exercises into youth programs to help young people improve their self-esteem, develop their communication skills about sexuality, and strengthen their ability to negotiate safer sexual practices.
  • Adolescent programs work best when they provide life skills education in addition to sexual health information and services (WHO/UNFPA/UNICEF 1999). Programs should help young people develop skills and talents that offer them opportunities for economic viability and develop their sense of having a potentially successful adulthood. Such opportunities, combined with reproductive health information and services, can help motivate youth to postpone sexual activity by helping them understand the long-range impact of their decisions and the importance of planning their futures.
  • Both young men and women may need reproductive health education, including information on sexuality, contraception, reproduction, abstinence, abortion, STIs, and gender roles.
  • Adolescent sexuality is a sensitive subject in all cultures. Programs that offer reproductive health services to adolescents can expect to encounter some resistance from their community.

Go to Key Issues   Top of Page