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RHO archives : Topics : Adolescent Reproductive Health

Key Issues

This section provides summaries of key adolescent reproductive health topics. Click article references to read abstracts in the bibliography. More detailed discussions of specific key issues are included in the Annotated Bibliography and Program Examples page.

Be sure to use the Glossary if you are unfamiliar with any of the terms on this page. Click here to see a complete list of the tables included in this section.

Advocating for public support of adolescent reproductive health

Advocating to increase awareness of and support for effective programs and policies is essential to the success of any adolescent reproductive health effort (Senderowitz 2000; Upadhyay and Robey 1999). The subject of adolescent reproductive and sexual health is controversial in many communities, making advocacy and awareness-raising even more important. Parents, religious leaders, health officials, and young people themselves may have strong opinions about the issue. People may oppose programs that teach or discuss adolescent reproductive health issues because they believe that the issues are taboo, promote promiscuity, or are too embarrassing to discuss publicly. Effective advocacy will build a case to persuade these people that providing comprehensive reproductive and sexual health information and services to young people can safeguard their lives (Shannon 1998). Programs that have partnered with male cultural leaders or traditional indigenous institutions have effectively promoted activities that address adolescent sexual reproductive health and prevention of HIV infection. This approach has furthermore enlisted leadership to influence reproductive health and HIV/AIDS policies and programs.

The types of advocacy activities and their intensity or duration will vary according to the environment into which they are being introduced (Sharma 1998). In places where there is broad acceptance of the need for information and services and national guidelines have been established, advocacy efforts may focus on sustaining attention on the issues; in places where there is little awareness of or support for adolescent reproductive health programs or policies, advocacy efforts may focus on providing basic information about the issues to key audiences in order to gain their support. Successful advocacy may include activities such as collecting data, developing goals and objectives, establishing a coalition, identifying key audiences, developing persuasive messages, working with the media, and measuring success (Shannon 1998; Upadhyay and Robey 1999). Advocacy efforts can focus on bringing about change at the local, regional, or national level by targeting stakeholders who influence the acceptability of providing reproductive health information and services to young people. Individuals and organizations that are well-positioned to shape public perceptions, policies, and programs can be key in strengthening support for funding and implementation of relevant programs, thereby increasing the likelihood of program success.

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Components of successful programs

Reproductive health programs for adolescents tend to be most successful when they: (1) accurately identify and understand the group to be served; (2) involve adolescents in the design of the program; (3) work with community leaders and parents; (4) remove policy barriers and change providers' prejudices; (5) help adolescents rehearse the interpersonal skills needed to avoid risks; (6) link information and advice to services; (7) offer role models that make safer behavior attractive; (8) and invest in long-enough time frames and resources (Finger 1997; PATH/Outlook 1998; McCauley and Salter 1995; Senderowitz 2003; Senderowitz 1997; Purdy and Ramsey 1998). (Also see Ten Characteristics of Effective Sex and HIV Programs, Table 1.) Adolescents' reproductive health needs and ability to access services differ depending on whether they are sexually active, in school, working, living in urban or rural areas, or exposed to sexual violence (PATH/Outlook 1998; FOCUS 1998). (For more detailed information on social and cultural influences, see Table 2.) Programs that involve youth, community leaders, and parents can identify a program's needs and goals more effectively and can ensure broad community support (McCauley and Salter 1995; Finger 1997; Purdy and Ramsey 1998; UNFPA 1997). Including evaluation components can help ensure that programs have clearly defined goals, measurable objectives, and plans to sustain and expand programs into the future (Finger 1997; Adamchak et al. 2000; Stewart and Eckert 1995). (For information on evaluating adolescent reproductive health programs, see Table 3.)

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Involving youth in a meaningful way

Adolescents can be involved at all stages of program development, implementation, and evaluation (Shah 1999). A recent evaluation of nearly 500 organizations that implement reproductive health programs aimed at young adults throughout the world found that young people helped implement programs in almost 70 percent of cases (Herdman 1999). Involving adolescents can increase their sense of project ownership and relevance; improve recruitment and communication; generate new ideas for reaching other adolescents; and increase self-esteem and leadership skills (McCauley and Salter 1995; Senderowitz 1998). Inviting adolescents to share power and authority can present challenges (and may require extra training, staff time, costs, or schedule/procedural adjustments), but most of these factors can be overcome by training and commitment to making plans work (PATH 2003; IPPF 1996).

Peer education can be an effective approach for involving adolescents (AIDSCAP/FHI; WHO/UNFPA/UNICEF 1999). Trained to assist their peers with reproductive health information and services, adolescent educators receive special training in decision making, making client referrals, and providing commodities or services (Senderowitz 1997). Programs that use peer educators build on the evidence that adolescents relate well to people of similar age, interest, and backgrounds. Peer programs are economical, although it is important not to underestimate the amount of support and training needed by the peer educators in order to help them do their best work and avoid burnout. With adequate support and training, peer educators often reach their target audience as well as relatives, friends, and neighbors. Peer promoters themselves can gain long-term benefits from this experience, including an understanding of responsible reproductive health behavior, leadership skills, useful employment, and personal development (see developing life skills research topic) (Senderowitz 1997; WHO/UNFPA/UNICEF 1999; PATH/Outlook 1998).

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Youth-friendly clinic services

"Youth-friendly" reproductive health services are ones that are developed and provided in a way that recognizes that the challenges, difficulties, and obstacles facing adolescents are very different than those confronted by adults (PATH/Outlook 1998; Webb 1998). Adolescents generally are less informed, less experienced, and less confident about sexual matters and their own abilities than are adults. Specialized approaches are needed to attract, serve, and retain adolescents as reproductive health clients (Senderowitz 2003; Senderowitz 1999; Finger 1997). These include having appropriately trained providers who can address adolescents' specific biological, psychological, and health needs; respect for adolescents' privacy and confidentiality; accessible facilities and convenient location; reasonably priced services; flexible hours (such as during evenings and weekends); and an environment that feels appropriate and comfortable for all adolescent populations, including groups such as young men or married adolescents (Senderowitz 1999; Senderowitz 1997; Armstrong 1999; Webb 1998). In order to make services friendly and comfortable, program managers should consider adolescents' input on clinic components such as informational pamphlets and the style of the waiting room (McCauley and Salter 1995; Senderowitz 1997). Services should be offered in places where adolescents congregate to learn, socialize, and work (see reaching underserved adolescents research topic), and privacy and confidentiality should be ensured (Ginsburg 1995).

Biases, judgmental attitudes, and, at times, even hostility on the part of service providers can create persistent and critical barriers to reproductive health services (Webb 1998). Judgmental teachers or health care workers can become barriers to services even where law and policy give adolescents access to reproductive health information and services. Because health care workers often reflect the attitudes and values of their society, it is important to offer training that helps providers work with adolescents respectfully and confidentially, recognize and assess their own feelings about serving adolescents, and avoid appearing judgmental (PATH/Outlook 1999).

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Providing information and services to adolescents

Adolescents need age-appropriate information about physical and emotional development, the potential risks of unprotected sex, substance abuse, how to access health services, and educational, vocational, and recreational opportunities (WHO/UNFPA/UNICEF 1999). Effective programs use multiple approaches to disseminate reproductive health messages including mass media, interpersonal communication, and community mobilization (JHU/CCP 1995; Piotrow 1997). Programs have been most successful when information and education are provided interactively and are linked to services (McCauley and Salter 1995). Most adolescents are eager to learn about reproductive health and are open to advice on how to handle personal problems (JHU/CCP 1995). Mass-media entertainment (radio, television, music, video, film, comic books) can be a cost-effective way to communicate messages that can influence knowledge, attitudes, and behaviors (McCauley and Salter 1995; Piotrow 1997). Entertainment media can reach a wide audience and can help promote communication between parents and adolescents. Media can be especially useful in reaching at-risk adolescents who may be illiterate, out of school, or unemployed (Webb 1998). Personal counseling and referrals to clinic services can be integral to helping young people adopt responsible behaviors. Services can be offered over a telephone hotline, radio call-in show, through counselors stationed at public places, or in the privacy of a health or hospital clinic (JHU/CCP 1995; Piotrow 1997). Community mobilization efforts also can be used to address broad social groups (Israel and Nagano 1997), and can include topics such as advocacy for girls' education and raising awareness about the harmful effects of practices such as female genital mutilation. School-based programs, peer-education programs, and outreach programs also offer excellent opportunity to provide education and skills development.

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Contraception for adolescents

Adolescents have the right to clear and accurate information about contraceptive methods, including correct use, side effects, and how to reach a health care provider with their concerns (ICPD 1994). In general, adolescents are healthy and not yet affected by adult health issues such as high blood pressure or chronic diseases. As a result, they can choose from a wide range of contraceptive options, although condoms often are a clear first choice for unmarried adolescents. (See Table 4 for information about specific contraceptive methods.) The recent availability of several new combination oral contraceptive pills has expanded the choices for teenagers. New contraceptive methods bring unique side effect profiles and delivery systems that may be more youth-friendly and improve overall contraceptive compliance, especially among teenagers who are more prone to misuse contraceptives because of a wide array of side effects and compliance issues (Sucato and Gold 2001). Appropriate counseling is also essential to helping adolescents manage potential side effects and any issues regarding the proper use of contraceptives. Counseling should address both pregnancy prevention and STI protection (FOCUS/Q&A).

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HIV and STIs in adolescents

According to WHO, 333 million new cases of STIs occur worldwide each year, and at least 111 million of these cases occur in people under age 25 (WHO/UNFPA/UNICEF 1999). Nearly half of all HIV infections occur in men and women younger than 25 years, and, in many developing countries, data indicate that up to 60 percent of all new HIV infections are among 15- to 24-year-olds (UNAIDS/WHO 1998). Infection among females outnumbers infection among males by a ratio of 2 to 1 (UNAIDS/WHO 1998; ICRW 1996). One study in Tanzania found that young women were more than four times more likely than young men to be infected with HIV, even though the females were less sexually experienced and had considerably fewer sexual partners than their male counterparts (Mwakagile 2001). Young people are at high risk of STIs and HIV for a variety of reasons, such as lack of knowledge about STIs, including HIV; not perceiving themselves to be at risk; lack of access to or inconsistent use of condoms; increased number of sexual partners leading to increased risk of exposure; biological factors (a young woman's cervical epithelium is more susceptible to infections); economic factors (adolescents may live or work on the street and participate in "survival sex" or "transactional sex"); and social factors (such as being forced into a sexual relationship, lacking the skills or power to negotiate condom use, and encountering gender norms, double standards, or cultural/religious norms regarding sexuality and fertility) (Best 2000; McCauley and Salter 1995; WHO/UNFPA/UNICEF 1999; Senderowitz 1995; ICRW 1996; Noble 1996). Adolescents may be reluctant or unable to seek treatment for STIs or HIV because they fear the disapproval of family or the community, are afraid to get tested, or do not know how to recognize the symptoms. In addition, since HIV infection may be asymptomatic, they may not know they are infected.

For more information on adolescents and HIV, see the HIV/AIDS section's Special Focus: Young People and HIV/AIDS. For more general information on STIs and HIV, see RHO's Reproductive Tract Infections and HIV/AIDS sections.

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Meeting the needs of the youngest adolescents

More than 500 million young people aged 10 to 14 live in developing countries, where studies suggest that the age of first intercourse can be low, ranging from 9 to 13 years for boys and 11 to 14 years for girls (Sedlock 2000; U.S. Bureau of the Census 1998). Research shows that educating these youngest adolescents about reproductive health and helping them develop life skills can be especially effective strategies for safeguarding their sexual health and well-being (WHO/UNFPA/UNICEF 1999; Barnett 1997). Combining age-appropriate sexual health information with activities to help develop communication and negotiation skills can help young people who are not already sexually active to delay the onset of sexual activity (WHO/UNFPA/UNICEF 1999). Because youth frequently leave school at an early age in some countries, providing sexuality education in schools to the youngest adolescents may be the best opportunity these youth have to learn about and build skills related to their sexual health (Sedlock 2000). Youth in this age group who already are sexually active may develop the knowledge, skills, and motivation necessary to practice safer sexual behaviors. It is important for program planners to understand that many youth in this age group who already are engaging in sexual activity are not sexually active by choice, and they will require a separate set of interventions and support.

Meeting the reproductive health needs of young people aged 10 to 14 can be challenging. Parents, educators, and health providers may feel uncomfortable or unwilling to discuss sexual health issues with this age group. Some may incorrectly believe that sexuality education leads to increased or earlier onset of sexual activity (Baldo et al. 1993; Grunseit 1997). Youth this age who choose to be sexually active may have limited access to services because of a lack of autonomy, mobility, or resources. Further, they may feel stigmatized if they attempt to receive health services. Finally, many in this age group are coerced into sexual activity, which may indicate a need for alternative education and skills-building strategies that differ from those developed for adolescents who willingly engage in sexual activity (Sedlock 2000).

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Early and unintended pregnancy

Many adolescents are sexually active (although not always by choice). Each year, approximately 15 million adolescents give birth (UNFPA 1997; Safe Motherhood Inter-Agency Group). In poor countries, pregnancy is the leading cause of death among young girls aged 15 to 19. An estimated 70,000 young girls die each year from causes related to pregnancy and childbirth. In addition, their babies also face the risk of death before they reach their first birthday, 50 percent higher than babies born to women in their twenties (Save the Children 2004).

If these young girls and their babies survive, they face enormous health risks. Adolescents at this age are more likely to experience obstructed delivery, prolonged labor, and difficult deliveries that can result in long-term complications or hemorrhage (AGI 1998; AGI, Issues in Brief; PATH/Outlook 1998; McCauley and Salter 1995). Fistula is a health risk commonly associated with early pregnancy because of the young mother’s underdeveloped pelvis and birth canal. Some two million adolescent girls are living with fistula; up to 100,000 new cases occur every year (ICRW 2003). For their infants, they also face significant risks including premature births, birth injuries, and lower birth weight (Alauddin and McLaren 1999; Save the Children 2004). Young women’s frequently limited access to, knowledge of, or confidence in accessing an existing health care system also contributes significantly to further complications (Mothercare Matters 1995).

In developing countries, approximately 60 percent of pregnancies and births to married and unmarried adolescents are unintended (ICRW 1996). Unplanned births can lead to emotional distress and economic hardship. If the young woman is unmarried, she may also face disapproval from the community. Pregnant students in developing countries often seek abortion to avoid being expelled from school (Zabin and Kiragu 1998). In countries where abortion is illegal or restricted by age, young women may seek an illegal provider who may be unskilled or may practice under unsanitary conditions. Unsafe abortion represents a high proportion of the maternal deaths among adolescents (PATH/Outlook 1998; Koontz and Conly 1994).

In addition to the reduction of health risks in early and unintended pregnancy, postponing adolescent childbearing has benefits for women and societies. Young women who delay the birth of their first child until after adolescence have greater opportunities to acquire the education and skills necessary for raising a family and competing successfully in the job market. Increased education is strongly associated with young women's postponement of marriage and childbearing until after her adolescent years (AGI 1998).

For more information on maternal mortality and morbidity, see RHO's Safe Motherhood section.

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School-based sexuality education

With more children than ever attending school (AGI 1998), school-based sexuality education can be an efficient way to reach young people and their families with reproductive health education (Birdthistle and Vince-Whitman 1997). School-based sexuality education programs that have appropriate curricula, adequate time, and trained, supportive instructors can help prevent early pregnancy, HIV/AIDS, and STIs (McCauley and Salter 1995; Birdthistle and Vince-Whitman 1997; WHO/GPA and UNESCO 1995). According to the U.S.-based Sexuality Information and Education Council (SIECUS), age-appropriate sexuality education should begin in early elementary school when children are 5 to 8 years old and should continue through adolescence (ages 15 to 18). Courses should be taught by trained teachers; community involvement is essential in the development and implementation of the program (SIECUS 1996).

Evaluations carried out among young adults in both developed and developing countries have shown that school-based sexuality education can help delay first intercourse for adolescents who are not yet sexually active. For young people who are sexually active, sexuality education can encourage correct and consistent use of contraception and STI protection (Barnett 1997). Evidence from surveys carried out by WHO and other organizations found that sexuality education in schools does not lead to earlier or increased sexual activity in young people (Grunseit 1997; WHO/Reproductive Health Library 1999; Kirby 1999). Findings from these studies suggest that programs that promote both postponement of sex and protected sex are more effective at preventing pregnancy than those promoting abstinence alone, and that sexuality education is most effective when given before a young person becomes sexually active. Improvements in young people's knowledge about sexuality, contraception, and STIs do not always result in changes in sexual risk-taking behaviors, however (Grunseit 1997; PATH/Outlook 1998). Programs therefore should include components that may lead to healthy behaviors, such as skills building, condom negotiation, risk reduction, and values discussions.

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Developing life skills

Training in life skills enables adolescents to develop positive and adaptive behaviors that help them make decisions and manage the challenges of their lives. Along with information and access to services, life skills help adolescents translate knowledge, attitudes, and values into healthy behaviors (WHO 1994; WHO 1997). Life skills education can develop adolescents' ability to reduce specific health risks (such as unintended pregnancy and STI/HIV transmission) and adopt healthy behaviors that improve their lives in general (such as planning ahead, seeking help, and forming positive relationships) (Hughes and McCauley 1998; Keller 1997; Gage 1998). (For information on specific life skills, see Table 5). Life skills programs that work to strengthen self-esteem can contribute to adolescents' confidence in their ability to perform certain tasks such as persuading male partners to conform to safe-sex practices (Gage 1998).

All adolescents, including those who are not sexually active, can benefit from skills building (Hughes and McCauley 1998). Life skills and self-esteem training can be particularly important for female adolescents, who may be subject to social constraints that promote unhealthy behaviors (Keller 1997; Shanler 1998). Programs aimed at improving adolescents' life skills are most effective when they use experiential learning methods (for example, discussion groups, role plays, debates, and interactive games) (Advocates for Youth/CPO 1989). Reproductive health education offered in nonclinical settings, such as in sports programs (Brady 1998), can build self-esteem and decision-making skills, and increase knowledge. Long-term programs (such as school-based programs) are particularly effective (Hughes and McCauley 1998).

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Reaching underserved adolescents

Bringing services to hard-to-reach adolescents requires special planning and advocacy efforts. Because of adolescents' cultural, social, and geographic diversity, reproductive health programs based in schools and health facilities cannot reach all segments of the adolescent population. Not all adolescents attend school, for example, and an increasing number of adolescents have become marginalized from their communities (Senderowitz 1997). Invisible or hard-to-reach groups include adolescents who work or live on the streets, young people who have been sexually abused or exploited, adolescents who have struggled with substance abuse, adolescents from indigenous groups, young married couples, gay adolescents, young men, disabled adolescents, migrant or trafficked youth, and refugee adolescents. (For more specific information on the circumstances and needs of these groups, see Table 6.)

Because hard-to-reach adolescents generally do not seek reproductive health services or information on their own, programs must identify underserved groups and develop programs to reach them. Multipurpose youth centers (for example, centers that offer recreational or vocational services) and outreach sites that reach adolescents where they socialize (such as in discos, pool halls, video arcades, the marketplace, and local fairs) offer opportunities to provide information, condoms, and referrals (Marques 1993). The workplace model, where information and services are provided by the employer, is an effective way to educate and motivate adolescents who are no longer in school (Senderowitz 1997). Telephone hotlines, drop-in centers, shelters, "Under 20 Clubs, " discussion groups, and other innovative outreach approaches can be used to serve hard-to-reach adolescents. For adolescents with limited access to family planning information and services, or for those who fear their family's or community's disapproval of contraception, community-based distribution can be an effective way of distributing contraceptives (Mita and Simmons 1995; Stewart and Guilkey 1995; Population Briefs 1999).

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Gender-specific issues

Gender inequities have profound implications for both the physical and psychosocial well-being of adolescents. (For in-depth discussions of gender considerations and reproductive health, see the Gender and Sexual Health and Men and Reproductive Health sections of RHO.) Adolescents face social, cultural, and economic forces that affect their sexual experiences and ability to adopt preventative behaviors (ICRW 1996). Gender-based differences and double standards may limit females' educational and economic opportunities as well. Young people, especially girls, also are vulnerable to sexual violence, coerced sex, and unequal power relationships; may have the need to prove fertility; and may be at risk of female genital mutilation (Network 2000; AGI 1998). In some cultures, risky male behaviors are tolerated and sometimes even encouraged (Finger 2000). Because gender attitudes have proven intractable in many adolescent reproductive health efforts, programs must directly confront the issue of unequal gender relations. Programs that ask young women to take actions that contradict accepted female roles, such as refusing sex or insisting on condom use, must first help young women build the skills and self-confidence needed to empower them to make these decisions (Kim 2001).

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Sexual violence and youth

Recent studies suggest that adolescents, both girls and boys, are particularly vulnerable to sexual coercion and violence. Adolescents experience sexual coercion that involves the use of force and at other times it is subtler and involves economic or psychological manipulation. Perpetrators are usually people they know, including their spouses or partners, peers, family members, teachers, and other youth and adult acquaintances (YouthNet 2004).

The health consequences of coercive sex are physical, psychological, and social. Non-consensual sex can result in unintended pregnancy, abortion, and STI/HIV infection. Psychologically, consequences can range from symptoms of anxiety and depression to suicide attempts. It can also lead to risk-taking behavior, including early onset of consensual sex, multiple partners, and non-use of condoms (Jejeebhhoy and Bott 2003).

There are a number of reasons why adolescents do not seek help or protect themselves from sexual coercion. Research has found that in societies where strict gender roles and double standards exist, it is often difficult for girls to seek help or escape from coercive sexual advances. In addition, lack of communication between partners or the inability to negotiate on sexual matters, especially by youth, is often difficult and can result in force and coercion. Lastly, youth often lack access to trusted adults, peers, or local school or health centers where they can talk about sexual health matters, especially coercive sex.

Health programs rarely address the reality of non-consensual sex experienced by adolescents. However, a recent conference in New Delhi, India, included program recommendations to be added into existing health programs. First, education, counseling, and service activities that address non-consensual sex among young people. Second, sexuality education activities must counter traditional gender stereotypes and equip young people with the awareness and skills necessary to protect themselves from coercive encounters and to seek appropriate care in case of such incidents. Thirdly, parents, teachers, and other trusted adults must be sensitized to the importance of communication about sexual matters with youth and of providing a supportive environment. Lastly, providers must be trained to identify adolescent victims, to understand the links between sexual violence and health and rights, and to provide sensitive counseling, appropriate services, and safe options (Jejeebhhoy and Bott 2003); YouthNet 2004).

For additional information, see RHO's Gender and Sexual Health key issue on child sexual abuse.

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Reducing service restrictions and biases

The age of consent for medical treatment varies considerably by region (for example, from a low of 14 years in Canada to a high of 18 years in South Africa). As a result, health departments, school boards, and other health facilities may limit the reproductive health services and programs they offer to young people. Parental and spousal regulations also affect adolescents' ability to obtain contraceptives or make decisions about their sexual health (McCauley and Salter 1995).

In countries where sexual intercourse for minors is illegal, it may be difficult for programs to guarantee confidentiality to adolescents. Requirements for spousal consent also can hinder confidentiality in the case of young married women. Many advocates for young people encourage adolescents to talk to their parents or spouses, but try to meet young people's health needs whether or not a parent or spouse can be involved. Laws and policies that allow adolescents and unmarried people to purchase contraceptives are important, as are programs that provide for other ways to distribute contraceptives if adolescents cannot find a place to buy them or cannot afford them (McCauley and Salter 1995; UNFPA/WHO/UNICEF 1999).

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Meeting the needs of married adolescents

In the 45 countries where DHS surveys have been conducted, more than 60 percent of sexually active adolescent girls are married. The majority of girls in developing countries are married by age 20. Marriage during adolescence is common among those who are poor, less educated, and who observe more traditional customs and rituals. Early marriage can be seen as a means to financial security both for the family and the married adolescent; to maintain economic, social, or political ties between families, castes, or tribes; or to protect young girls from (coerced or voluntary) premarital sex or pregnancy, both seen as dishonorable to the family (ICRW 2003).

Young adolescents tend to opt for early marriage because they have little or no opportunities for education or work. In addition, because of their low status in the new family, they often tend to become victims of domestic violence and abandonment, further contributing to limited options and poverty (ICRW 2003). Furthermore, research has shown a perpetuation of an intergenerational cycle of poverty as their children also tend to be less educated and less healthy. Research has shown that girls with school or work opportunities not only delay marriage, but also are less likely to live in poverty and more likely to have healthier and educated children later (ICRW 2003).

Married adolescents and are often pressured by their family and community to have their first child as soon as possible after marriage (Alauddin and MacLaren 1999). However, married adolescents are generally not more knowledgeable about reproductive biology or diseases than unmarried adolescents. Furthermore, because of their increased exposure to sexual intercourse and their physiological immaturity, married adolescents face greater reproductive health risks, including higher incidences of STIs, unwanted or poorly timed pregnancies, maternal mortality, and morbidity, than do their unmarried peers. Young girls have a higher risk of delivering babies with low birth weight and delivering prematurely. In addition, girls, aged 10 to 14 are five times more likely to die in pregnancy or childbirth than women who are 20 to 24 year old (ICRW 2003).

Adolescent girls may also be less experienced than their husbands in regards to sex and their bodies. Research from 16 countries in Africa show that the husbands of 15-19 year old girls are on average 10 years older and are more sexually experienced. In these marriages, young wives have little negotiating power and are at greater risk of contracting HIV and reproductive tract infections (Mathur 2003).

Programs for married adolescents can fill an unmet need for family planning services. Untrained health workers often turn away married adolescents who seek family planning because of the social expectation to have children at the early start of marriage (Sikes 1996). Instead, reproductive health services need to be tailored to young married girls and to provide basic health education about their changing bodies as well as routine screenings for RTIs and STIs. In addition, there needs to be more efforts to change societal attitudes towards early marriage and motherhood. Young girls need to have better options than early marriage—such as pursuing education and work skills—as the impact of early marriage has shown to have considerable impact on the livelihood and health of girls and their children (ICRW 2003; Save the Children 2004).

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