The Unmapped Journey:
Adolescents, Poverty and Gender
-Adolescence: Opportunities and Risks
-Reproductive Health in the Lives of Adolescents
-Young People and HIV/AIDS
-Young People and Employment
Reproductive Health in the Lives of Adolescents and Youth
International human rights agreements adopted over the last fifteen years uphold adolescents' reproductive health and rights. The 1989 Convention on the Rights of the Child, the most universally accepted human rights instrument, guarantees the rights of children and adolescents, including freedom from discrimination, abuse and exploitation; participation in decisions affecting their lives; privacy; and access to education, health information and services for their well-being. All of these rights have direct implications for adolescent reproductive health. In 1994, governments pledged for the first time to address the reproductive health needs and rights of adolescents at the International Conference on Population and Development (ICPD). At the 1995 Fourth World Conference on Women in Beijing, governments reaffirmed this commitment and placed special emphasis on the girl child. The 1995 World Programme of Action for Youth to the Year 2000 and Beyond cemented a global agenda for action in critical areas that directly affect progress toward the MDGs. The committees overseeing compliance with international treaties have also issued recommendations on adolescents' reproductive health and rights, and expressed particular concern for the situation of adolescent girls.(37)
Several countries have adopted policies and laws to address adolescent reproductive health. In Albania, reproductive health education and services for adolescents are free.(38) Kyrgyzstan protects the right of young people to reproductive health care.(39) Benin's law calls for separate reproductive health services for adolescents. (40) Panama recognizes the right of pregnant adolescents to health care, information on their rights and continued education.(41) Colombia now specifically protects the right of adolescents-including for those displaced by internal conflict-to contraception.(42) Many countries have established a minimum age for marriage, as called for by the 1962 Convention on Consent to Marriage, Minimum Age for Marriage and Registration of Marriages.(43) Antitrafficking and anti-violence policies and laws, such as those of Bangladesh, Niger and the Philippines, also prohibit child marriage and the forced marriage of women and girls in exchange for money or goods.(44)
In the last decade, a growing global youth movement and the AIDS epidemic have contributed to a surge in efforts to provide reproductive health education and services for young people. The pressing need to make reproductive health services more youthfriendly and youth-driven is widely acknowledged. Communities are being more effectively engaged, for example, through outreach efforts to remove the stigma associated with reproductive health services for adolescents. The important role of parents is being leveraged by educating them about the risks their children face and about their needs and rights to information that can affect their well-being and, in the case of HIV, their very survival. In a district in Ghana, "Time with Grandma" is an initiative operating from within the cultural framework to reach out to adolescent girls through traditional "queen mothers". These women, who are leaders in their communities and role models for young people, are now being trained to mentor the younger generation on reproductive health issues.(45)
A broad spectrum of government, civil society, youth groups and international partners is working to expand young people's access to reproductive health care. UNFPA helped initiate the first-ever youth-friendly reproductive health services in countries from Bosnia- Herzegovina to Lao PDR.(46) Its Reproductive Health Initiative for Youth in Asia, supported by the European Union, is empowering neglected groups in a region that is home to 70 per cent of the developing world's young people.(47) Using theatre, comic books, peer education, games and talk shows, the initiative has reached out to young people in rural areas, commercial sex workers, street children and factory workers. Influential adults, such as parents, community leaders and health providers have been enlisted to strengthen the impact of messages. In Cambodia, the initiative reaches more than 250,000 young people directly and 1.2 million more through the radio programmes it sponsors.(48)
The Y-PEER programme has coordinated and strengthened the efforts of nearly 200 peer education projects that reach some 1.7 million young people in 27 countries of Eastern Europe and Central Asia. Y-PEER uses Internet-based communications to share information, resources and lessons learned and has translated its peer education training manual into 15 regional languages.(49)
In the Arab States, UNFPA supported a successful regional initiative with Boy Scout and Girl Guide Associations to extend reproductive health education through their community development programmes. Over 4,000 girl guides and boy scouts were trained, and collaboration with ministries of health and education strengthened attention to young people's reproductive health needs.(50)
Full-blown national and regional programmes remain the exception, however. Most projects remain small in scale, leaving the reproductive health needs of most adolescents-especially the poorest and most marginalized-neglected.(51)
21 | SAVING YOUNG MOTHERS' LIVES IN BANGLADESH
In Manikganj, a farming community 70 km outside the capital of Bangladesh, UNFPA supports the Ministry of Health in making Mother and Child Welfare Centres accessible to poor women. Hamida, 25, gave birth to her second child last year in the UNFPA-supported local centre: "Before this centre upgraded its services, women with complicated pregnancies had to go to a hospital in Dhaka. Some of them didn't make it on time." She told of a school classmate, married at 15 and pregnant at 16, who bled to death in a horse cart on the way to the hospital. "If she had access to these services, she would still be alive today."
THE COSTS AND RISKS OF EARLY PREGNANCY. An estimated 14 million adolescents between 15 and 19 give birth each year.(52) Uncounted others have babies at even younger ages. One quarter to one half of adolescent girls in developing countries are mothers before they reach 18.(53) The highest rates of adolescent fertility are found in sub-Saharan Africa and South Asia.(54) Based on data from 56 countries, girls aged 15 to 19 from the poorest groups are three times more likely than their better-off peers to give birth in adolescence, and have twice as many children(55) (see Figure 4). High rates of early childbearing in many developing countries result primarily from the practice of child marriage.(56)
Figure 4: Childbearing Among the Poorest and Richest Adolescents
Source: Rani, M. and E. Lule, 2004, "Exploring the Socioeconomic Dimension of Adolescent Reproductive Health: A Multicountry Analysis" International Family Planning Perspectives 30 (3): 112.
22 | TEENAGE PREGNANCY AND NEWBORN SURVIVAL
Enabling adolescent girls to delay childbearing saves lives. Every year four million newborns die within the first month of life, many because their mothers were simply too young to give birth: babies with adolescent mothers are 1.5 times more likely than those with older mothers to die before their first birthday. Adolescents are at highest risk of premature delivery. Because their bodies are generally not fully developed and ready for childbirth, adolescent girls are also more likely to suffer obstructed labour. The risks are higher for poor girls whose growth was stunted due to malnourishment. In the absence of medical intervention, the infant usually dies. Access to life-saving emergency care when complications arise is fundamental to the survival of young mothers and their newborns-and to reaching the MDGs on infant and maternal mortality. See Sources
Adolescent girls between the ages of 15 and 19 are twice as likely to die during pregnancy or childbirth as women in their twenties. For those under 15, the risks are five times higher.(57) And for every girl who dies in childbirth, many more will suffer injuries, infections and lingering disabilities, such as obstetric fistula.(58) Fistulas are reparable if services are available, and UNFPA has led a global campaign to bring hope into these girls' lives (see Box 23).
23 | CAMPAIGN ON OBSTETRIC FISTULA:
RESTORING ADOLESCENT GIRLS' LIVES AND DIGNITY
Fatima was married at 14. Soon after, she became pregnant. After a gruelling six days of labour, the young Nigerian gave birth to a stillborn baby. For the following 10 years, Fatima explained, "the whole community rejected me. Anywhere I went, they laughed at me."
Fatima is a survivor of a devastating childbearing injury known as obstetric fistula- a preventable and treatable condition that affects at least two million women and girls worldwide. Caused by prolonged and obstructed labour, a fistula is a hole that forms between a woman's vagina and bladder and/or rectum, leaving her with chronic incontinence. In nearly all cases, the baby dies. Unable to stay dry, women with fistula are often abandoned by their husbands and families, blamed for their condition and ostracized by their communities. Fistula typically affects girls and young women living in poor and remote rural areas with inadequate or non-existent health services, as well as those who deliver at home without professional care.
Fatima is one of hundreds of girls and women who have received surgical treatment through the global Campaign to End Fistula, launched in 2003 by UNFPA and a large number of partners. The campaign works in more than 30 countries in sub- Saharan Africa, South Asia and the Arab States to prevent fistula and treat women and girls. It is also helping them reclaim their place in society by starting to expand their access to skills training, literacy classes and counselling in the post-operative healing process. After her surgery, Fatima smiled, pleased that now she is "being invited by friends and neighbours to weddings and naming ceremonies."
In Nigeria, the campaign supported a two-week project in February 2005 that treated 545 women and provided training to dozens of doctors, nurses and social workers in surgery and post-operative care. After participating in a health education session, a number of men who accompanied their wives and daughters to surgery are now committed to helping other girls and women. "Even if I have to use my own money, I will help other women come to the hospital," said Muhammadu Abubakar of Nigeria, who accompanied his niece.
UNPLANNED PREGNANCIES. Too many adolescents face the life-altering consequences of unplanned pregnancies. In Latin America and the Caribbean, for example, 35 to 52 per cent of adolescent pregnancies are unplanned.(59) The reasons vary. They include lack of knowledge about the basic facts of reproduction and lack of information about contraceptives, contributing to contraceptive failure. Some unplanned pregnancies are a consequence of rape, sexual abuse and incest, though these possibilities are often ignored, even when very young pregnant adolescents visit a clinic.
Unwanted pregnancies result in an estimated five million unsafe abortions among adolescents every year.(60) In sub-Saharan Africa, where 40 per cent of all unsafe abortions among adolescents in developing countries occur, data from seven countries revealed that 39 to 79 per cent of those treated for abortionrelated complications were adolescents.(61) Half of the 10,000 Nigerian women who die from unsafe abortions each year are estimated to be adolescents.(62) In Argentina and Chile, one third of maternal deaths of 15- to 19-year-olds were found to be abortion-related.(63)
Like adult women, adolescent girls encounter gender-related obstacles to informed choice about reproductive health, as discussed in Chapter 4. These obstacles are compounded by their low social status as young people. Adolescent girls are subject to sexual violence and coercion. They often hesitate to seek services because of stigma or mistrust until they are faced with an unintended pregnancy or life-threatening complications from an unsafe abortion. They also have little money to pay for services and transportation. Achieving the MDGs will require attention to the specific reproductive health needs of adolescent girls.(64)