Population Action International

We must smooth young women's transition through adolescence.

For biological, cultural and economic reasons, sexual and reproductive risk are higher among adolescent women. Pregnancy is the leading cause of death for young women aged 15 to 19 worldwide with complications of childbirth and unsafe abortion being the major risk factors.1 Teenage girls who are not physically mature are at greater risk of obstructed labor, pregnancy-induced hypertension and obstetric fistula (See Box on Obstetric Fistula). Girls aged 15 to 19 are twice as likely to die in childbirth as those in their 20s, and girls under 15 are five times as likely to die as those in their 20s.2 In almost all countries in sub-Saharan Africa, HIV/AIDS prevalence is higher among girls aged 15 to 24 than among boys of the same age.

Many relationships between older men and younger women that involve financial or material exchange both reflect and sustain girls' vulnerabilities. Studies on informal transactional sex in sub-Saharan Africa found that between 7 and 38 percent of unmarried adolescent girls surveyed report receiving money, gifts or favors within the last year in exchange for sex.3 Providing tuition scholarships to girls and heavily subsidizing all school-related expenses—including safe transportation where needed—would go a long way toward reducing girls' vulnerability and investing in their future, and that of society as a whole.

Death and injury rates are higher among infants born to young mothers. Young mothers are less likely to get prenatal care, and babies born to very young mothers are more likely to be premature or underweight. The risk of dying in the first year of life is typically greater by 30 percent or more among babies whose mothers are aged 15 to19 than among those born to mothers aged 20 to 29.4 In general, young mothers are less likely to have the means to safeguard the health of their infants.

The proportion of unplanned or unwanted pregnancies among adolescents varies widely within and between regions. The range of unplanned pregnancies among adolescent girls is highest in Latin America and the Caribbean, as well as in some sub-Saharan African countries where up to 50 percent of adolescent mothers reported that their pregnancies were unplanned.5 Overall, adolescent fertility rates are highest in middle and western Africa. Notably, the United States has the highest adolescent fertility rate of all developed countries, and 73 percent of 15- to19-year-olds giving birth report that their pregnancies were unplanned.6

Adolescence is a period of physical, social and emotional transitions and developments, mostly positive ones. However, lack of opportunities, knowledge and skills can complicate such transitions and have lifelong impacts. Sexual activity generally begins in late adolescence with, like other transitions, variations among regions and sexes. For girls in most developing countries, where one in seven girls marries before age 15 (excluding China),7 such very early sexual initiation primarily occurs within marriage.8 For boys, the relationship between age at marriage and sexual debut is not clear.

Education

Education is a potentially powerful tool for elevating women's status and improving their health. Better educated women are more likely to use maternal health services, including antenatal care and skilled delivery care.9 By way of factors such as consistent condom use, increased contraceptive use and a reduction in sexual partners, higher education can contribute to lower reproductive risk.10 Educated women also tend to develop a better understanding of formal institutions, including those related to health care provision, which in turn encourages health-seeking behaviors.

It is not certain that education always has a protective effect on women's risk of HIV infection.11 Still, a study in Zambia found that out-of-school adolescents were more vulnerable to infection with HIV than those attending school, and out-of-school girls had three to four times higher HIV prevalence than out-of-school boys in both rural and urban areas.12

Despite the many social and economic incentives for achieving education for all, 77 million children, 57 percent of whom were girls, did not attend school in 2004. While nearly two-thirds of countries have achieved gender parity in primary education, only one-third of countries have achieved gender parity at the secondary level.13 Sub-Saharan Africa remains home to half the world's out-of-school children, although the numbers have been falling.14 The share of rural children who don't attend school is at least double that of urban children in 24 countries.

Addressing the linkages between quality education and women's health and socio-economic development has synergistic effects. These effects contribute to meaningful investments in girls and women, and are often intergenerational: A child whose mother has no education is, on average, twice as likely to be out of school as one with an educated mother.15

In the next 10 years, 100 million young women will marry before they turn 18.16 The rate of marriage among girls younger than age 18 is greater than 40 percent in South Asia and Africa, and it exceeds 60 percent in parts of East and West Africa.17 There is a strong association between early marriage and early childbirth. Married young girls are often pressured to prove their fertility upon marriage and may suffer the health consequences of earlier, riskier births.18 Very young and first-time mothers disproportionately suffer from prolonged and obstructed labor, which can result in obstetric fistula. They may also be at a higher risk of contracting HIV than their unmarried, sexually active counterparts.19 Studies in Kenya and Zambia report that HIV infection rates among married girls are 48 to 65 percent higher than among sexually active unmarried girls.20

Early marriage can mark the end of investments in the education and development of girls, contributing to persistent poverty among women,21 and young married girls are more likely to experience domestic violence and sexual abuse.22 Among girls surveyed in India, those who married before age 18 reported twice the number of experiences of physical violence and three times as many sexually violent experiences as girls who married at later ages.23 Unmarried young girls are also at high risk of coercive sex. A study in South Africa found that 30 percent of pregnant adolescent girls reported forced sexual initiation, in most cases by their boyfriends.24

Intimate partner violence is the second leading cause of death in pregnancy (India). In Matlab, Bangladesh, pregnant adolescent girls were at three times' higher risk of death from violence than non-pregnant girls.25 A study on teenage pregnancy in North America found that more than a third of pregnant adolescents were coerced into sex or raped.26

Much of the sexual violence around the world occurs in the context of intimate relationships. In some countries, up to 52 percent of women report having been physically abused by an intimate partner at some point in their lives.27 A recent study of 10 countries found that women in abusive relationships were much more likely to report that their partner refused to use a condom and that they knew their partner had multiple other sexual partners.28

Obstetric Fistula

Young and poor women, due to physical immaturity and inadequate maternal health, are also disproportionately affected by obstetric fistula, one of the most devastating maternal disabilities. Obstetric fistula is a hole in the birth canal caused by obstructed labor without access to a Caesarean section when needed, and is also associated with the prevalence of births attended by untrained traditional practitioners.29 The prolonged labor usually results in stillbirth, and, if the mother survives, she is most often left incontinent. Fistulas can often be repaired with a simple and relatively inexpensive medical procedure, but most women who suffer from fistula cannot afford the $300 cost of the procedure and are thus condemned to a life of isolation and disability.30 It is estimated that 50,000 to100,000 women are affected by fistula each year, with the highest prevalence in Sudan, Ethiopia, Chad and Nigeria.31

Notes

  1. WHO. 2004. Maternal Mortality Update 2004: Delivering Into Good Hands. Geneva: WHO.

  2. Ibid.
  3. Luke, Nancy. 2005. “Investigating exchange in sexual relationships in sub-Saharan Africa using survey data.” In Sex without Consent: young people in developing countries, edited by Shireen Jejeebhoy, Iqbal Shah and Shyam Thapa, 114. New York: Zed Books.
  4. The Alan Guttmacher Institute (AGI). 1997. Issues in Brief: Risks and Realities of Early Childbearing Worldwide. Washington, DC: AGI.
  5. WHO. 2007. Adolescent pregnancy—Unmet needs and undone deeds: A review of the literature and programmes. Geneva: WHO.
  6. Ibid.
  7. Population Council. 2007. Transitions to Adulthood. Available from http://www.popcouncil.org/ta/mar.html; accessed on August 23, 2007.
  8. Dixon-Mueller, Ruth. 2007. Sexual and Reproductive Transitions of Adolescents in Developing Countries. Paris: IUSSP.

  9. Pande, Rohini, Anju Malhotra and Caren Grown. 2005. Impact of Investments in Female Education on Gender Equality. Paper prepared for presentation at Session 3: Schooling, XXV IUSSP International Population Conference, Tours, France.

     

  10. Michelo, Charles, IF Sandoy and K Fylkesnes. 2006. “Marked HIV prevalence declines in higher educated young people: Evidence from population-based surveys (1995-2003) in Zambia.” AIDS 20(7).

  11. Pande, Rohini, Anju Malhotra and Caren Grown. 2005. Impact of Investments in Female Education on Gender Equality. Paper prepared for presentation at Session 3: Schooling, XXV IUSSP International Population Conference, Tours, France.

     

  12. Michelo, Charles, IF Sandoy and K Fylkesnes. 2006. “Marked HIV prevalence declines in higher educated young people: Evidence from population-based surveys (1995-2003) in Zambia.” AIDS 20(7).

  13. UNESCO. 2006. Education For All Global Monitoring Report 2007. Paris: UNESCO.

  14. Ibid.

  15. Ibid.

  16. Population Council. 2007. Transitions to Adulthood. Available from http://www.popcouncil.org/ta/mar.html; accessed on August 23, 2007.

  17. International Planned Parenthood Foundation (IPPF) and the UNFPA. 2006. Ending Child Marriage: A guide for Global Policy Action. IPPF and UNFPA: London.

  18. Mathur S., M. Greene and A. Malhotra. 2003. Too Young to Wed: The Lives, Rights and Health of Young Married Girls. International Center for Research on Women (ICRW): Washington, D.C.

  19. Bott, Sarah and Shireen Jejeebhoy. 2005. “Non-consensual sexual experiences of young people in developing countries: an overview.” In Sex without Consent: young people in developing countries, edited by Shireen Jejeebhoy, Iqbal Shah and Shyam Thapa, 3-45. New York: Zed Books.

  20. Clark, Shelly. 2004. “Early marriage and HIV risks in sub-Saharan Africa.” Studies in Family Planning 35(3): 149-160.

  21. ICRW. 2007. New Insights on Preventing Child Marriage: A Global Analysis of Factors and Programs. Washington, DC: ICRW.

  22. Jensen R. and R. Thornton. 2003. “Early female marriage in the developing world.” Gender and Development 11(2): 9-19.

  23. ICRW. 2007. New Insights on Preventing Child Marriage: A Global Analysis of Factors and Programs. Washington, DC: ICRW.

  24. WHO. 2007. Adolescent pregnancy—Unmet needs and undone deeds: A review of the literature and programmes. Geneva: WHO.

  25. Ronsmans, Carine, and Wendy J Graham. 2006. “Maternal mortality: Who, when, where and why.” The Lancet 368: 1189-1199.

  26. WHO. 2007. Adolescent pregnancy—Unmet needs and undone deeds: A review of the literature and programmes. Geneva: WHO.

  27. Garcia-Moreno, Claudia, et al. 2005. WHO Multi-country Study on Women’s Health and Domestic Violence against Women: initial results on prevalence, health outcomes and women’s responses. Geneva: WHO.

     

  28. Ibid

  29. United Nations High Commission for Human Rights. “Fact Sheet No.23, Harmful Traditional Practices Affecting the Health of Women and Children.” Available at http://www.unhchr.ch/html/menu6/2/fs23.htm; accessed on July 18, 2007.

  30. United Nations Population Fund (UNFPA), Campaign to End Fistula. “Obstetric Fistula in Brief.” Available at http://www.endfistula.org/fistula_brief.htm; accessed on July 18, 2007.

  31. Hilton, P. 2003. “Vesico-vaginal fistulas in developing countries.” International Journal of Gynecology and Obstetrics 82: 285-295.