© UNFPA/Wilton Castillo UNFPA/Rosa May DeGuzman

The illusion of choice: Adolescent pregnancy

EL SALVADOR/PHILIPPINES — When she was just 16, Yajaira was impregnated by her 18-year-old boyfriend the first time they slept together. They married soon after. “That was the start of a new stage in my life,” recalls Yajaira. “It was an abrupt change because I had to take responsibility for my pregnancy. I had only finished the ninth grade.”

Her situation is all too common. In El Salvador, where she lives, adolescents make up one quarter of all pregnancies (UNFPA El Salvador, 2021). This is a sign of overall disempowerment: teen pregnancies and early marriages are linked to cycles of domestic and sexual violence (UNFPA El Salvador, 2021), a scourge that was already common before it soared by 70 per cent in the COVID-19 pandemic (IRC, 2020). Sexuality education has only recently been added to the national curriculum, and abortion is strictly banned under all circumstances – with no exceptions for rape, incest or if the lives of the mother and baby are at risk.

One might assume, then, that most teen pregnancies are unintended. But in fact, over half of adolescent pregnancies in El Salvador, 58 per cent, were reported as intended by women, while 75 per cent of the men involved considered them intentional (Carter and Speizer, 2005).

When asked if she had made the choice to have a baby at 16, Yajaira does not answer directly. She says that she didn’t have any sexuality education, and that sex and pregnancy just seemed to happen. For her, and for so many young women – especially those marginalized by poverty and a lack of employment or educational opportunities – there is a certain inevitability to early pregnancy and marriage. More than one quarter of Salvadorian girls are married or in informal unions by age 18 (ECLAC, 2020).

While Yajaira did not make an affirmative choice to become pregnant, marriage was a different matter. “My mother didn’t want me to,” she says, “but I didn’t want to repeat my situation for my child, of being raised without a father, so I decided to get married and I went to live with my boyfriend’s parents. It was the most difficult stage of my life. As I was on my way to the city hall to get married, my classmates were at an event to mark the start of high school… It was a reality check. I thought, ‘What am I doing?’”

Her husband had promised she could continue her education, but the reality was different. In addition to caring for her infant son and helping with expenses by making and selling cheese, she attended school in the departmental capital every Saturday. Afterwards, she rushed home to prepare meals for her husband, a situation that irked her mother-in-law. “That nonsense about studying is over,” Yajaira recalls her saying.

On the other side of the world, in Maguindanao in the Philippines, Rahmadina was a typical school girl – until she finished sixth grade. At 14 years old, she fell in love with and married 16-year-old Morsid, giving birth to their first child soon after. These were her own decisions, she says. But she did not expect what followed.

“When we got married, I still managed to finish the first year of high school,” Rahmadinah says, cradling her second child, a newborn. Then her desire to continue school crashed into a harsh reality. After her husband travelled to Manila for work, “he told me to quit because he had stopped studying”.

Despite their financial hardships and the difficulties she sometimes faces raising two children so young, Rahmadinah loves being a mother. Still, she says she thinks about the life she would have had if she had made different choices.

Today, she wants to find work overseas “so that my children could have the things they need,” she says. “But my husband isn’t going to let me. He tells me I can’t. He’ll abandon me if I ever work abroad. So I just stay quiet; I don’t plan on going anywhere anymore.”

Yajaira, too, felt stuck. Though she had made the choice to get married, other life choices were beyond her control. Her husband was unfaithful and emotionally abusive. When Yajaira wanted to leave, he and his parents used her son as leverage: “They asked me to go and to leave my son, not to take him.” Finally, five years into the marriage, she reached a breaking point. She moved back to her mother’s home, taking her son with her. “I wasn’t going to leave my son there. Nobody was going to take my son away from me.”

Determined to chart a different course for herself, she finished her studies and joined the police force, supporting survivors of gender-based violence. She experienced another unintended pregnancy – this time she was using contraception, but it failed. When she told her partner she was pregnant, he left town.

These days, at 34, Yajaira exudes an air of confidence. She is happy with her career, proud of her 6- and 17-year-old boys, and excited about the degree in social work she is soon to complete. And she is raising her sons to be responsible men who reject gender-unequal norms and speak openly about issues like contraception: “It is very common for mothers not to open up and talk to their children about these issues. But it is good to talk to them so that they gain some confidence.”

As for Rahmadina, she too is making decisions to secure her future. She has learned about available contraceptive options and is about to receive her first contraceptive injection. She wants her daughter to have more choices, too. “I want her to finish school, not end up like me, and to achieve her goals before she marries,” she says.

© UNFPA/Michael Duff

Violence, coercion and the erasure of agency

FREETOWN, Sierra Leone — “I was not ready to get pregnant,” Mamusu, now 18, tells UNFPA in Freetown, Sierra Leone. “But when I started dating this man, I didn’t have anyone to take care of my education, someone who could assist me when I needed things for school… He was the one helping me.”

Mamusu describes her baby’s father as a “boyfriend”, “husband”, and “the man that impregnated me” – a sign that their relationship is many things, but it is not equal.

For one thing, Mamusu was a child, barely into her teenage years, when she met him. For another, she was desperate to stay in school, but poverty threatened that tenuous lifeline to a better future. “They were asking us to buy pens, books, to do everything, assignments, and I didn’t have money… He said he wanted us to date, and so I explained to him my problems.”

The help was short-lived: “When I realized that I was pregnant at age 14, I was not happy.”

She is not alone. Girls in Sierra Leone often struggle to navigate a maze of impossible choices. The country has some of the highest rates of teen pregnancy (UNFPA, n.d.) and maternal mortality (UNFPA, n.d.a) in the world. Sexual violence is rampant (UNFPA Sierra Leone, n.d.), with much of it directed at children and leading to dire circumstances. The most vulnerable girls can be attacked or propositioned by older boys and men when they venture out to fetch water, sell goods or even attend school. If these girls do consent to enter into a sexual relationship – whether it is romantic, transactional or a blurring of the two – they often do so from a position of disadvantage, or as a survival strategy. But if they become pregnant, they too often find themselves cast out of their homes, left to fend for themselves.

“Girls do not become pregnant because that is what they want,” says Mangenda Kamara, who co-founded and leads 2YoungLives, a mentoring project for pregnant girls. “But extreme poverty, as well as violence and many levels of coercion, including transactional sex, limit their options.”

Girls have little autonomy, but face full responsibility for these situations, even if they result from rape. “When someone is raped and falls pregnant, the options are very limited,” says Fatmata Sorie, a barrister in Freetown and chair of an organization of female lawyers, the Legal Access through Women Yearning for Equality, Rights and Social Justice. “The structures are not there to help rape victims,” she continues. “Police stations do not even have rape testing kits, for instance.”

Girls are often made to feel responsible for sexual activity, even when it results from pressure or coercion, and they receive little information about their rights or bodies. Until recently, sexuality education was largely unavailable and visibly pregnant girls were not allowed to return to school. (Ms. Sorie’s group and UNFPA lobbied for a law changing these rules, but implementation of this policy has only just begun.) More than 86 per cent of girls aged 15 to 19 years have never used contraceptives, according to FP2030, and 21 per cent of them will have a baby by age 19 (FP2030, 2020; Stats SL and ICF, 2020). Meanwhile, abortion is a prosecuted criminal offence in Sierra Leone. When an abortion does take place, Ms. Sorie says, “it happens in the most unsafe and unprofessional circumstances.”

These factors, together, are often fatal. “Before the quarantine, we did a survey and found that the maternal death rate for girls under age 18 [in East Freetown] was 1 in 10,” says Lucy November, a midwife and researcher from King’s College London (November and Sandall, 2018). Her research, conducted with Ms. Kamara, prompted the founding of the 2YoungLives.

Pregnant girls can be disowned and abandoned. That was the case for Dankay, also now 18. She, too, was propositioned by an older man who helped her get by: “When I accepted his proposals, it was him that was assisting me bit by bit. But when he impregnated me, he denied responsibility and started avoiding me. So my aunt sent me away, because she said it was disgraceful to become pregnant without a man claiming ownership.” She stayed with a friend, but often went hungry and slept on a cold floor on the porch.

“They get this stigma from the community, schools and the hospitals – everybody,” Ms. Kamara explains. Sometimes, “if there’s nobody to help them out, like by mentoring them or advising them, they end up losing either the baby or even both lives.”

But this is also a place where a little support goes a long way, she said. Mentoring, social support, child-care assistance, factual information, kindness – these are making a world of difference. Through 2YoungLives, Mamusu started her own small business and proved to be an excellent student. She is committed to making the most of what she has, not only for herself and her child, but for her community. “After I have taken my exams and graduate from college, I want to become a nurse,” says Mamusu. “Because when I visit the hospital I see the way nurses take good care of people.”

Dankay, too, is getting help balancing school and motherhood. Their resilience and determination to create a better life for their children are examples decision makers would be wise to follow. Theirs is a potential to be celebrated, not squandered – and they know it.

“To be a mother at this age is not really easy,” she says, “but it will enable me to become stronger.”

© Shutterstock

When contraceptives fail

UNFPA — Contraceptives have changed history: for decades, modern methods have fortified women’s agency over their reproductive lives and helped countries meet their development goals. But they don’t always work.

After Mukul, in India, experienced life-threatening labour complications at age 24, she opted to use an IUD. Yet less than a year later, she was shocked to discover she was pregnant again – and five months along, too late to consider an abortion. She gave birth to a second daughter. “We welcomed our second child and continued rearing both,” Mukul says. “It worked out well, and she was loved by all my family and friends.”

Mukul had no reason to expect she would become pregnant. The IUD, a long-acting method, is considered one of the most reliable forms of contraception. Yet no contraceptive is infallible – not oral contraceptives, implants, injectables or even vasectomies. When used consistently and correctly, these methods all have failure rates lower than a single percentage point, and sometimes far lower, but they do fail. In the United Kingdom, for example, one in four abortions is attributed to failure of hormonal contraception (BBC, 2017), a figure that nearly doubles when other methods, including condoms, diaphragms and withdrawal, are added to the mix.

Several years later, while still using contraception, Mukul found herself pregnant again. She was certain she did not want another child, even though her father had been pressuring her to try for a boy. (Despite Mukul’s own successes – she is an accomplished academic – her family continued to harbour a strong preference for boys.) “I chose to have an abortion so I could meet my responsibilities to my two daughters, which would have been divided with the birth of a third child,” she says. “I have no regrets about that.”

Dalila*, in rural El Salvador, had a very similar experience. Soon after her wedding, a family planning counsellor paid her and her new husband a visit. But she held off on using contraception. “I wanted to have a child,” Dalila explains. “Then my daughter came along and I was happy.”

Like Mukul, she started using contraception after her first child was born. And also like Mukul, she learned she was pregnant well into her second pregnancy. “I realized the contraceptive hadn’t worked when I got the result at six months. I was in shock and thought, ‘What happened?’”

These stories are no surprise to Dr. Ayse Akin, a medical doctor in Türkiye whose career in reproductive and public health spans half a century. She has witnessed many breakthrough pregnancies, both in individuals with IUDs and in those using other methods. “Sometimes people don’t recognize their pregnancy until much farther along, because they’re not expecting it,” she explains.

But contraceptive failure does not affect all women the same way – or even at the same rates. A 2019 study found that, for certain methods, the youngest contraceptives users had failure rates up to 10 times higher than older women (Bradley and others, 2019). There are many possible explanations: younger women may be more fecund, more sexually active, have less experience using contraceptives, or face worse access to quality contraceptive counselling. The poorest women also experienced significantly higher contraceptive failure rates. These findings indicate that those least able to cope with an unintended pregnancy – the youngest and the poorest – are more likely to experience one, even when they are doing their best to prevent it.

The consequences can be dire, Dr. Akin explains. She helped many patients who arrived after undergoing a clandestine and unsafe abortion. They would arrive bleeding, anaemic or septic; many had lasting complications, or didn’t survive. “It was terrible,” she says. One month, out of four women admitted after unsafe abortions, “three of them died. Only one was saved.” The situation improved after 1983, when abortion was legalized in Türkiye, but even now safe abortions are not available in many hospitals, she said, and many doctors do not have the time or inclination to provide contraceptive counselling.

Dalila and Mukul continued to rely on contraception, even after experiencing contraceptive failure. Mukul’s husband underwent a vasectomy to keep their family at their desired size. Dalila – who says her surprise second pregnancy left her “filled with joy” – also decided her family was complete with two children.

These days, Dalila’s daughters are teens, and she advises them to find partners who are supportive of them and their ambitions – and to consider family planning. She is firm that each of her girls will be in command of their own future: “Nobody is going to demand that she brings a baby into the world if she doesn’t feel ready to be a mother.”

*Name changed for privacy and protection

© Jay Directo/AFP via Getty Images

Planning for change

THE PHILIPPINES, 2021 — After her sixth birth, Rahma Samula, 40, in Maguindanao in the Philippines, was exhausted. She had already seen her mother raise eight children. “Seeing my mother struggle to care for my seven siblings helped me decide to try family planning, which my husband and I have both agreed to do.

”Most of her children were born just a year apart, but with the help of an injectable contraceptive, Rahma was able to delay her last pregnancy until 2021 – five years after her previous child was born. Rahma is quite sure that without the injections, there would have been two more in between. She and her husband are grateful to their local health workers, who advised them on the various family planning options available. In good health and with only some welcome weight gain as a side effect, she says birth spacing and using the contraceptive was better for her body and family, “so that the children don’t have a hard time.”

A generation ago, Rahma’s story would not have been so simple.

Government policy on family planning and reproductive health has fluctuated in the Philippines. Policies in the 1980s centred on limiting population growth through quotas and contraceptive incentives, then later aligned with Catholic teachings that prohibit modern methods of contraception. For decades, the tensions between pro- and anti-contraception camps led the country down a rocky middle road, in which family planning was largely promoted as a maternal health and child survival intervention, an approach that marginalized adolescents and unmarried women (Alvarez, 1993). It wasn’t until 2012, and the passage of the Responsible Parenthood and Reproductive Health Law, that the government settled on its current client- and reproductive-health-centred approach, committing the government to providing free family planning services for poor families. Still, influential religious leaders continue to oppose the use of any form of contraception other than so-called natural methods (fertility awareness methods).

Yet, for years, it was actually religious and community leaders, alongside non-profit organizations, who helped to provide contraceptives in remote areas and to families who could not afford to feed extra mouths. As one mother in an impoverished remote fishing village explained to UNFPA in 1998, “We have a parish priest who comes by, and he is the one who gives us access to [birth control pills]. We don’t know where to get them.”

The 2012 law and grassroots efforts, such as those by non-governmental groups, women’s rights organizations and individuals like that parish priest, have had an enormous and positive cumulative impact on the state of contraception access in the Philippines. No single effort – by the health system, legal system or broader society – carried the momentum of this shift by itself. Rather, it was holistic and across-the-board work, over years, that brought about change.

The law helped to spur investment in clinics and reproductive services, and a health insurance programme now covers more than 90 per cent of municipalities in the country (FP2030, 2020a). Heated rhetoric around contraception has cooled, and a new conversation has emerged, one about choice and rights and long-term goals for individuals and families. Health workers, family planning counsellors and even religious leaders are proactively dispelling contraceptive misinformation.

“My husband and I agreed to use contraceptives because of how hard life is right now,” says Theresa Batitits, a 36-year-old nutrition counsellor in a northern village. They want to spend their stretched resources on educating the four children they already have. Theresa had previously avoided hormonal contraceptives, partly out of fear over side effects, but when a local health worker talked about long-acting implants, she decided to try them. “Before they provide family planning to each woman, they offer information on what the methods are, how they work and how they are used, what are the side effects of the contraceptives, things like that,” Theresa says.

Anisa T. Arab is one of 15 siblings in Maguindanao. She has always been strong-willed; she left home at age 20 rather than accept her father’s plan for her to marry and curtail her education. She initially opposed family planning, believing it went against Islamic teachings, but “when I studied Islam, I saw in the community that our traditions regarding women were too far from what Islam actually says,” Anisa explains.

Now 57, Anisa is a radio show host and teacher of Islamic studies (or Uztazah), and a vocal supporter of women’s education and their rights to marry if, when and whom they want and to plan their families. She teaches her followers about the Fatwa on Family Planning, a legal opinion endorsed by Islamic scholars that clarifies contraception is not forbidden. Family planning is not bad, she says. Instead, “when our women learn to take care of their bodies, that is where the best family will emerge”.

© Getty Images/Canopy

The next male contraceptive: what’s taking so long?

UNFPA — “The hard part about reproduction should be deciding if and when to have children,” says Logan Nickels, a researcher at the Male Contraceptive Initiative (MCI) in the United States. “Once that decision is made, the tools should be available to everyone to ensure that they’re able to carry out their life plan easily and effectively.”

Two male-driven methods – condoms and withdrawal – currently make up about 26 per cent of worldwide contraceptive use. But male condoms, as commonly used, have a failure rate of about 13 per cent, and withdrawal is one of the least effective forms of contraception (WHO, 2018). Vasectomy, on the other hand, is noted as being one of the most effective methods (WHO, 2018), but fewer than 3 per cent of couples rely on it for protection (Pile and Barone, 2009).

Promising possibilities for new male methods abound: pills, topical creams, microneedle patches, biodegradable injectables and a device that acts like a vasectomy but is designed to be reversible. More than 40 methods are listed in a database of contraceptive methods under exploration or development (Calliope, n.d.). So why aren’t there better male contraceptive options out there yet? “I think the societal assignment of reproduction to women has played a big part in that – it’s women who bear the burden of pregnancy,” says Logan.

Cultural attitudes often assign women responsibility for contraception. This can stand in the way of progress. “Men are often thought of as secondary in the equation because it’s kind of a pervasive opinion that they have all the rights that they need,” Logan says. “So I think that [contraceptive development] has been focused on providing rights to women and girls rather than bringing men into the equation in a way that’s productive and helpful.”

Research shows that men in many countries are interested in male-driven contraceptive methods. In a 2002 survey of 9,000 men in nine countries, more than 55 per cent of respondents said they’d be willing to use a new product (Heinemann and others, 2005). And in the United States, a 2019 study of some 1,500 men found that, of those who wanted to prevent a pregnancy, 60 per cent wanted to see a new male contraceptive method (Friedman and others, 2019). Yet the global pharmaceutical industry has not advanced in this arena. “They just don’t have the incentive, because the products they have [for women] work and are safe,” says Rebecca Callahan, who works in product development at the United States-based health and wellbeing non-profit FHI 360.

A new male contraceptive would have to be at least as effective as the best women’s products on the market in order to compete. Meanwhile the safety thresholds for a novel contraceptive – male or female – are the highest of any pharmaceutical product, Rebecca says, “because you’re giving it to young, healthy people to prevent a condition”. And these standards are even higher for a new male method, as for women the risks of contraceptive side effects are weighed against the potential risks of a pregnancy – which can, after all, be deadly.

One study found that weekly hormonal injections in men were very successful at preventing pregnancy, with generally minimal side effects (Behre and others, 2016). There were some cases of acne, weight gain and mood swings – the kind of problems women often endure with hormonal contraception. But when one man developed severe depression and another attempted suicide, the study was cut short, even though depression is a known risk among female users of hormonal contraceptives (Skovlund and others, 2016).

Challenges extend beyond pharmaceutical research. New contraceptive methods require funding and extensive field-testing, marketing and distribution. Without support, even effective and desired methods can falter. Dr. Demet Güral saw this in the 1990s when she worked on a project to introduce non-scalpel vasectomies in Türkiye.

“Our project demonstrated that men would accept the method in a heartbeat,” she says. Of more than 2,000 vasectomies performed within a three-year period in four Turkish hospitals, over 60 per cent of the potential clients accepted the procedure after just one counselling session. But without long-term support from the donor, she says, the method never took off. Vasectomy has remained rare in the country (UN DESA, 2021a).

Yet any improved forms of male contraception will not, by themselves, be enough. For all people to be able to make responsible reproductive choices, they will also need accurate information about benefits and drawbacks of contraceptive methods, the ability to articulate their desires when it comes to reproduction, and a healthy respect for the needs and views of their partner.

In this area, too, there are signs of progress. Martha Brady, a global health expert in contraceptive development, says she has seen attitudes shifting: “[Younger men] see the world is changing dramatically. Norms have shifted for everyone from the US to Africa… I think there will definitely be young men who are willing to try things that maybe 50-year-old guys of a different era wouldn’t,” she says.

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