Growing up in cities, protecting sexual
and reproductive health
bing potrait

Teenage guidance centres like the one Maty visited are critical for empowering young women to exercise their right to a life free of violence; to protect themselves from unwanted, non-consensual sex; and to have access to information and services to prevent HIV infection and unwanted pregnancy. Staying healthy and delaying family formation is key for adolescent girls to live out of poverty. Compared to their rural counterparts, young people living in urban areas have better access to sexual and reproductive health services. Clinics, hospitals, voluntary HIV testing and counselling services, and other health care facilities are more often located in urban settings.

Births in urban areas are more likely to be attended by a skilled birth attendant. For example, 78.1 per cent of deliveries in urban settings in Bolivia, 60.6 per cent in Pakistan, 52.8 per cent in Angola and 46.9 per cent in Yemen are attended by a skilled birth attendant. In the same countries, deliveries attended by skilled personnel in rural areas are two to four times lower.(1) Young, educated city dwellers are also more likely to use contraception.(2) Surveys from Ghana, Kenya, Nigeria, Mozambique, and Tanzania suggest that condom use among urban young men aged 15 to 24 is considerably higher than among rural men of the same age.(3) This may also have to do with knowledge and availability: only about half of young men living in rural areas of Nigeria, Bolivia, Mozambique, and Vietnam knew where they could obtain condoms.(4)

At the same time, greater availability and closer physical proximity to health services in urban areas does not automatically translate into better sexual and reproductive health for young people: health services may simply be unaffordable; there may be no services in some neighbourhoods; and gender inequalities may make it harder for young women to protect themselves against infection, unwanted sex, and pregnancy.

The age of marriage is rising, and sexual activity outside marriage is increasing in urban areas. Young women find themselves at risk of forced sex, unwanted pregnancies, unsafe abortion, and sexually transmitted diseases, including HIV. Contraceptive use, though higher among urban youth than their rural counterparts, remains infrequent. Continued high levels of unwanted pregnancy and unsafe abortion indicate a considerable unmet need for family planning among young urban women.

Every year, some 14 million adolescent girls aged 15 to 19 give birth.(5) The highest rates of adolescent fertility are found in sub-Saharan Africa and South Asia.(6) Based on data from 56 countries, both urban and rural girls aged 15 to 19 from the poorest groups are three times more likely than their better-off peers to give birth in adolescence.(7) They bear twice as many children, and are two to five times more likely to die from pregnancy-related complications than women in their twenties.(8) Their babies are also less likely to survive. In every region of the world, rural girls have children earlier than urban girls,(9) yet in the cities of Namibia, Nepal, Nicaragua and Nigeria, one in every five girls gives birth before her eighteenth birthday.(10) In addition, girls aged 15 to 19 account for at least one-fourth of the estimated 20 million unsafe abortions performed each year. A study among 20 to 29 year olds in Yaoundé, Cameroon found that 21 per cent of urban young women reported ever having an abortion and 29 per cent of urban young men reported ever having a girlfriend who terminated a pregnancy for which they were responsible.(11) The study also noted that abortions obtained before the age of 20 were more likely to be self-induced or performed by an untrained person in unsafe circumstances than were abortions after the age of 20.

Research from around the world shows that young people still know alarmingly little about HIV/AIDS. Urban youth tend to know more than rural youth, and knowledge improves dramatically with increased education and economic status. A multi-country study in sub-Saharan Africa found that the proportion of young women and men aged 18 to 24 with knowledge of modern family planning methods was substantially higher in urban than in rural areas.(13)

Even if young people have the information they need, they may find it impossible to protect themselves. About half of all HIV infections worldwide, some 6,000 a day, occur in young people aged 15 to 24. Across the world, urban youth are more affected by HIV/AIDS than young people in rural areas. In Zambia, one of the countries most severely affected by the virus, the prevalence rate in young people aged 15 to 24
living in urban areas is 10.5 per cent, about twice as high as the HIV prevalence rate in rural youth in that age group.(14) Pervasive gender discrimination puts girls in urban settings at higher risk of HIV infection: 15.2 per cent of urban young women aged 15 to 24 in Zambia are infected with the virus, compared with 3.7 per cent of urban young men in that age group.(15) This trend is common throughout sub-Saharan Africa where,
on average, three young women are HIV-infected for every young man.(16)

UNFPA, the United Nations Population Fund, in collaboration with the Ministry of Health of Peru and the San Juan de Lurigancho VII Health Network, is implementing the project “Stronger Voices for Reproductive Health�, in San Juan de Lurigancho, a very poor community made up of rural indigenous migrants in metropolitan Lima. The project aims to improve the quality and friendliness of sexual and reproductive health services for young people, in particular adolescent girls. The project organizes information campaigns and direct partnerships with health care providers. Consultation with groups
of young people influences the way services are delivered, and makes them more attractive to young people. The initiative has enabled adolescent girls and boys to articulate their reproductive needs and exercise their right to a life without violence and with access to health services.

UNFPA employs a multisectoral approach that considers reproductive and sexual health issues as one aspect of personal development, with links to a range of other health and social services. In some cities, youth centres provide safe spaces for girls, offering recreational activities as well as counselling. Girls may find guidance about family issues; violence against women and girls; jobs; relationships; and reproductive health.

Young people need appropriate information, education, and health services. Promoting
knowledge of sexual and reproductive health and conflict resolution and negotiation skills can help young people protect themselves from non-consensual sex, unwanted pregnancies and STIs, including HIV. It can also help them make responsible and informed decisions about their lives. Education should also focus on issues of violence
against women and girls, to raise awareness and help avoid damaging experiences like Maty’s. It should also address the special needs of married girls, girls at risk of HIV, and girls and boys at risk of dropping out of school. Great importance should also be placed on non-formal education, which can reach marginalized and vulnerable youth who are not in school. Sexual and reproductive health services should be youth-friendly, honour confidentiality, offer convenient hours and locations, and keep fees affordable. But sexual and reproductive health is only one aspect of young people’s development; interventions should be linked to other programmes, including those that deal with employment and livelihoods programmes.