Adolescent Reproductive Health

Key Messages

• Conflicts and natural disasters destabilize social infrastructure, leaving many children and adolescents, particularly girls, especially vulnerable to sexual violence, exploitative labor and trafficking.[1]
• Young displaced women are often forced to trade sex to meet their basic survival needs, which put them at greater risk of contracting sexually transmitted infections (STIs), including HIV.
• Adolescents affected by armed conflict are more likely than younger children to: be recruited into military service, miss out on an education, be sexually abused, abducted or held as sexual slaves and contract STIs, including HIV/AIDS.
• Because conflict tends to result in the disintegration of a community’s social fabric, conflict-affected adolescents may begin sexual relations at an earlier age, take sexual risks, such as having sexual intercourse without using a condom, and face exploitation in the absence of traditional socio-cultural constraints.
• Adolescents want and need accurate information about sexual and reproductive health, and they have a right to access reproductive health (RH) services.
• Comprehensive, youth-centered approaches to programming in conflict situations are critical to ensuring the protection, care and development of young displaced persons and their right to RH services.
• Refugee adolescents’ sexual and reproductive health relates directly to their well-being in other areas of their lives. It is important to identify and address the connections between programs that improve the lives of adolescents overall.
• It is necessary to develop sexual and RH programs that incorporate adolescents in the design and implementation process in order to better reach displaced youth and provide them needed services. Special efforts must be made to include girls in RH programs as their participation is often limited due to cultural attitudes and domestic responsibilities.
• The participation of youth in programming often increases their overall protection in conflict settings. In other words, participation equals protection.
• Not only should youth be made aware of RH services but so should parents and leaders in the community in order to ensure that youth are supported in their efforts to access beneficial programs and services.
• Female adolescents who want to educate themselves often have numerous obstacles to overcome such as: difficulty in accessing school, responsibility to care for their siblings or their own children, sexual harassment at school or lack of sanitary napkin supplies.
• Early pregnancy and early marriage often prevent girls from obtaining an education.

Overview

Like all young people, displaced adolescents have special needs during their years of development. However, due to forced displacement from their homes, exposure to violence, acute poverty and separation from their families and communities, displaced adolescents face additional difficulties that affect their reproductive health (RH). They often lack sufficient education, health care, protection, livelihood, recreational activities and friendship and family support. Furthermore, displaced adolescents may begin sexual relations at an earlier age and take more sexual risks, such as having sexual intercourse without using a condom. They are more vulnerable to sexual abuse and exploitation in the absence of traditional socio-cultural constraints.

These conditions may affect adolescents by limiting their access to information about their RH; escalating unsafe sexual practices, unwanted pregnancies and unsafe abortions; and increasing their exposure to sexually transmitted infections (STIs), including HIV/AIDS. In situations of conflict, the dearth of youth-friendly services is a significant barrier to ensuring young people’s right to a healthy and productive life. It is important to recognize that adolescents can be a part of the solution in addressing this gap. Their participation in the assessment, design and implementation of RH programs should be incorporated into relief efforts, as adolescents are creative, energetic and important agents for constructive change within their communities.

Facts

Global Statistics

• Nearly half of the world’s population (almost 3 billion) is under the age of 25, making it the largest youth generation in human history.[2]
• At least 80 percent of sub-Saharan African youth become sexually active by the age of 20.[3]
• Eighty-two million girls (ages 10 to 17) in developing countries marry before their 18th birthday. Over 70,000 teenaged girls are married each day and nearly 40,000 give birth.[4]
• Complications from pregnancy and childbirth are the two leading causes of death for 15 to 19-year-old girls worldwide.[5]
• Over 13 million adolescent girls give birth each year with 9 out of 10 of these births taking place in developing countries.[6]
• More than one million infants and approximately 70,000 of their adolescent mothers die each year in developing countries.[7]
• Girls under 16 are five times more likely to die in childbirth than women in their 20s, while teenage mothers are twice as likely to die as women in their 20s.[8]
• Only 13 percent of sub-Saharan Africa women aged 15 to 19 use contraception.[9]
• Every year, without the assistance of a midwife or traditional birthing attendant, 14 million adolescent girls aged 15 to 19 become mothers.[10]
• Of more than 4.4 million abortions occurring among 15 to 19-year-old girls every year, 40 percent take place under unsafe conditions.[11]
• Female education is one of the most effective ways to prevent high-risk pregnancy and neonatal deaths. Educated girls are more likely to grow up to be healthy mothers who provide better care for their babies. The more time girls spend in school, the later they marry and begin childbearing.[12]
• Over 30 percent of the 333 million new cases of curable STIs are found among people under the age of 25.[13]
• Every 14 seconds, a young person is infected with HIV/AIDS. At this rate, 6,000 youth are newly infected every day.[14] In developing countries, the number of new infections among young women is several times higher than that of young men.[15] In sub-Saharan Africa, two thirds of newly infected young people are female and 8.6 million youths are living with HIV/AIDS.[16]
• One-third of all women living with HIV are between the ages of 15 and 24.[17]
• Between 2 and 2.6 million children under the age of 15 is HIV positive with 640,000 children newly infected in 2004.[18]
• Caring for those with HIV-related illnesses or young children orphaned by AIDS is often expected of many young girls who sometimes must sacrifice their own education to do so [19]
• In Uganda, the risk of HIV infection doubles for girls 15 to 19 who have male partners ten or more years older.[20]  
• Nearly 2 million girls are at risk of female genital mutilation (FGM) each year.[21] A 2006 study found that women and girls who have undergone FGM are significantly more likely to have adverse obstetric outcomes than those without FGM. In addition, the risks appeared to increase the more extensive the FGM.[22]

Refugee/Internally Displaced/Conflict-affected Statistics

• Of the 33 million refugees and internally displaced persons around the world, approximately half are children.[23]
• Since June 2002, the Lord’s Resistance Army (LRA), a rebel group in northern Uganda, has abducted 8,400 children, the highest rate of child abduction since the beginning of the 17-year war.[24]  UNICEF estimates that 80 percent of the LRA are abducted adolescents, many of whom were forced to attack their own families, neighbors, and villages.[25]  A Belgian study of abducted child soldiers in Uganda found that 35 percent of girls had been “given as a wife” to rebel fighters.[26]
• In Afghanistan, 40 per cent of girls are married before they reach the age of 18. Girls under the age of 15 are five times more likely to die in childbirth than women in their twenties.[27]
• A study of 575 adolescents in a refugee camp in northern Kenya found that 70 percent were sexually active and engaged in unplanned and unprotected sexual intercourse.[28]
• A survey of adolescent Bhutanese refugees in Nepal revealed that 22 percent of boys and 46 percent of girls “did not know anything” about sexual contact, while only 41 percent of all respondents knew that condom usage prevented STIs.[29]
• Twenty percent of urban refugee girls in South Africa faced sexual violence and exploitation and 60 percent of urban refugee children had limited information on the transmission and prevention of HIV/AIDS.[30]
• Seventy-three percent of all Liberian women ages 15 to 19 have had intercourse while 49 percent of Ugandan women have become sexually active.[31]
• A study of adolescent pregnancies in Congolese refugee camps in Tanzania found that almost 30 percent of all births were by girls between the ages of 14 and 18, putting them at high risk for death and disability.[32]
• A survey by Colombian NGO Profamilia found that displaced girls and young women aged 13 to 19 had the highest rate of pregnancy and child bearing in the country for their age group (30% versus 19% for their non-displaced counterparts).[33]
• Although RH programs for adolescents in conflict settings in place, many more are needed that are designed specifically to meet adolescents' needs.[34]
• Girls comprised 25 per cent of soldiers in Sierra Leone. The majority was recruited as soldiers, cooks, cleaners and forced sexual partners, otherwise known as “bush wives”.[35]
• From the beginning of the conflict in Uganda, an estimated 25,000 children have been abducted in the northern region. Of those abducted, 30 percent were girls, of whom 1,000 conceived during captivity.[36]
• In response to queries regarding allegations of sexual exploitation or sexual abuse by UN Peacekeeping Operations, the UN Secretariat received 105 reports of allegations. Forty-five per cent of those allegations involve sex with minors and 15 percent involved rape or sexual assault.[37]
• Only 26 percent of adolescent girls in Somalia have heard of HIV/AIDS, and only one percent knows how to protect themselves against contracting HIV.[38]
• Violence against conflict-affected children in Sudan is rampant.  One in every three rapes reported in the region was committed against a child.[39]  
• A report by Amnesty International about the Central African Republic (CAR) exposes the physical and psychological trauma, and in some cases death, suffered by women and girls in late 2002 and early 2003 at the hands of combatants in the armed conflict.  Girls as young as eight years old were raped. Sources in CAR report that some child combatants, who were among the suspected perpetrators of rape and other abuses, appeared to be under 10 years old.[40]

Case Studies

Reproductive health workshop educates youth in Sudan
In 2003, Francis Tabuley, a 19-year-old student from southern Sudan, attended his first RH workshop sponsored by the American Refugee Committee. Although he had heard about STIs and HIV from his friends, he thought these diseases were contracted through contact with animal shelters. After attending the workshop, he learned that STIs are contracted through unprotected sex with an infected person and that condoms offer protection against STIs. He now advocates for RH programming and teaches his fellow villagers how to use condoms in order to avoid STIs.

Behavior change in Liberia
Momoh, a 19-year-old refugee in Liberia, had initially denounced the community’s adolescent RH peer counselors. He refused to attend any of the youth programs because he felt that the organization hosting them did not want young people to have sexual intercourse. Upon the recommendation of a peer counselor, Momoh was invited to attend a youth RH workshop. During the pre-test, given at the start of the workshop to measure participants’ RH knowledge, Momoh stated that gonorrhea could be contacted through riding a bicycle and engaging in other strenuous exercises. When tested again at the end of the workshop, Momoh scored the highest grade. He commented that his confusion about STIs had been cleared. After attending the workshop, Momoh became one of the regular participants of the youth shows and users of condoms. He also encouraged many of his peers to participate in the show and to use condom as well.

Peer educator avoids forced early marriage
Kadiatou, a 16-year-old our peer counselor in Liberia, was arranged to be married by her brother who did not consult her. One night, Kadie’s brother informed her that she would have to move in with her new husband the next day. He warned that if she refused, she would be beaten and her things thrown out of the house. Kadie, who was never in the habit of refusing her brother’s demands, did not comment but quietly went in her room and started to pack her things. Early the next morning, Kadie left the house and sought out the church pastor’s wife and explained the situation. The pastor’s wife sent for Kadie’s brother and counseled him against forcing the child’s hand in marriage. She also explained the negative effects of early marriage. At the end of the discussion, he understood and paid back the dowry the next day. Kadie later returned home and was happy because she had succeeded in protecting herself against gender-based violence and early and forced marriage to a man she did not know or love.

Peer educators teach reproductive health in Liberia
Massa, 18, lives in a village five kilometers from Sinje, Liberia. She and two friends usually watch kickball games sponsored by a local NGO that works with refugees. She also enjoys the NGO’s health talks and receives her supply of condoms from the NGO. One day on her way home from the game with her two friends, they were stopped by three boys in the middle of the road. The boys advanced, each going toward the girl of his choice, expressing their desire to have sex with them. Massa’s friends became furious and wanted to fight the boys. Massa calmed them down and told the boys that she understood they were in love, but explained that rape does not show love. As she had learned from the peer educators, Massa explained some of the consequences of rape, such as injury, STI/HIV infection, unwanted pregnancy and stigmatization. She also stressed the importance of using condoms and the agreement of both partners before sex to avoid all these problems. The boys became interested in what she was saying, changed their minds, and asked Massa’s forgiveness for their sexual harassment. The three boys were referred for peer counseling and later joined the NGO’s football team.

Lack of family planning leads to unsafe abortion and often death
Yatta, 17, was confused about family planning methods due to misinformation she received from her friends. Her friends told her that the prolonged use of any family method could lead to infertility, vaginal discharge and eventually death. Yatta explained that based on these assumptions she did not use a family planning method and became pregnant. As a result, she had an unsafe abortion and consequently nearly lost her life. Afterwards, Yatta was invited to attend the Saturday evening youth RH show by a local NGO’s peer counselors. The health talks and discussions on the importance of family planning helped Yatta understand that family planning was aimed at preventing unwanted pregnancies, contrary to what her friends had explained to her. Yatta was referred for family planning counseling the following week. She is now using contraceptive pills and has also joined the NGO team of peer counselors.

Teen survivor of abuse makes a new life for herself
Claudia is a young woman from Colombia who lives with her mother, six brothers and her baby. When Claudia was 11-years-old, her stepfather tried to sexually abuse her. After being threatened by paramilitary groups, her stepfather abandoned the family. Soon after, her mother left her children with their grandmother and traveled to Cartagena looking for a place to settle. Claudia followed her mother to Cartagena at the age of 13, where she lived with the father of her son for eight months. During this time she was mistreated, humiliated, beaten, insulted and was involved in crimes with her partner, who was a drug addict. When she was three months pregnant, she was beaten and almost lost her baby. At that time, she returned to her mother.

Today her baby is three months old and Claudia has not heard from the child’s father. She sells mangos and sometimes accompanies her mother to sell trash bags. She takes care of her son most of the time and occasionally leaves him with her grandmother. Since Claudia became pregnant, she has received medical care and psychological counseling and has taken part in teaching activities promoted by the counselor of Profamilia, the main RH service agency in Colombia. Currently, she is using a quarterly injectable (so as not to interfere with breast feeding), even though she does not have a steady partner, "since we never know…” She is thinking of studying again and is happy with the program at Profamilia. She says: "Life is changing…"

Resources

Click here for more resources on adolescent reproductive health.

Updated September 2006