Reproductive Health Behaviour of Young Europeans

Population studies, No. 42

Reproductive health behaviour of young Europeans

Volume 1

Nathalie Bajos, Agnès Guillaume, Osmo Kontula

Directorate General III – Social Cohesion

Council of Europe Publishing The views expressed in this study are those of the authors and do not necessarily reﬂ ect those of the Council of Europe.

Council of Europe Publishing F-67075 Strasbourg Cedex

ISBN 92-871-5310-8 © Council of Europe, September 2003 Printed at the Council of Europe Foreword The Council of Europe has a long tradition of producing population studies, and the work of the European Population Committee contributes to the understanding of the relationship between social policy and demographic issues in Europe. The fi ndings of this work are published in the series “Population studies”, where topics covered include migration fl ows, national minorities, demographic changes and the labour market, the ageing of European populations and the demographic consequences of economic transition. These publications provide essential background information for implementing the Council of Europe’s strategy for social cohesion: an integrated policy approach aimed at combating poverty and social exclusion through promoting access to social rights in areas such as employment and training, health, social protection, housing, education and social services. The report contained in the present publication examines the reproductive health behaviour of young Europeans. Reproductive health, and above all promoting healthy reproductive behaviour, are key priorities for the world community, in line with the programme of action of the International Conference on Population and Development. The analysis of differences between social groups provides an insight into which social indicators best describe the reproductive health of young Europeans. While the fi rst part focuses on contraceptive practices, the second one describes sexual and reproductive behaviour. Both parts provide an excellent background for research into the possible impact of legislation and government policy on the role of the welfare system, the institutional framework of reproductive health services and education. I should like to take this opportunity to thank the authors, Nathalie Bajos, Agnès Guillaume and Osmo Kontula, for their work, which has resulted in the comprehensive and thorough study contained in this volume. My sincere thanks go also to the European Population Committee whose careful discussion of successive drafts has guaranteed the high quality of the fi nal result.

Gabriella Battaini-Dragoni Director General of Social Cohesion

Table of contents

Page

Foreword ...... 3 Executive summary (Osmo Kontula and Nathalie Bajos) ...... 9

I. Contraceptive practices and use of abortion among adolescents and young adults in Europe (Nathalie Bajos and Agnès Guillaume)... 13

1. Introduction ...... 13 2. Available sources ...... 15 3. Contraceptive use by young people in Europe ...... 18 4. Abortion among young people in Europe ...... 30 5. Contraception and abortion: a complex relationship ...... 36 6. Consequences of abortion for women’s health ...... 43 7. Conclusions ...... 45

List of ﬁ gures 1. Prevalence of contraception use at ﬁ rst intercourse – central and eastern Europe ...... 19

2. Prevalence of contraception use at ﬁ rst intercourse – other countries ..... 20 3. Prevalence of contraceptive use at ﬁ rst intercourse, men and women born in the early 1970s in Europe ...... 21

4a. Prevalence of contraceptive use at ﬁ rst intercourse (years 1983-87)..... 21

4b. Prevalence of contraceptive use at ﬁ rst intercourse (years 1988-91)..... 22 5. Prevalence of contraceptive use at ﬁ rst intercourse according to women’s level of education (women 20-24) ...... 23

6. Contraceptive method used by couple (women <20 years) ...... 25

7. Contraceptive method used by couple (women 20-24 years) ...... 25 8a. Abortion rate for women aged <20 years in central and eastern Europe...... 34

8b. Abortion rate for women aged <20 years in other countries...... 34

5 Reproductive health behaviour of young Europeans

9a. Abortion rate for women aged 20-24 years in central and eastern Europe ...... 35 9b. Abortion rate for women aged 20-24 years in other countries ...... 35 10. Contraceptive prevalence and abortion rate (women <20 years) ...... 37 11. Contraceptive prevalence and abortion rate (women 22-24 years) ... 38 12. Pregnancy and abortion (women <20 years) ...... 40 13. Abortion ratio for women aged <20 years in Europe ...... 41

Appendices ...... 49 1. List of different national surveys in the Council of Europe member States ...... 49 2. Legislative conditions concerning abortion in different European countries ...... 50 3. Contraceptive status of couple (women <20 years) ...... 54 4. Contraceptive status of couple (women 20-24 years) ...... 56 5. Use of contraceptives by fecund, not pregnant women in sexual relationship: FFS results ...... 58 6. Trends in fertility rate (per 1000) for women aged 15-19 in Europe, 1990s ...... 59 7. Family planning programmes and access to contraception in different European countries ...... 60 8. Grounds on which abortion is permitted ...... 63 9. Rates of adolescent birth, adoption and pregnancy per year (per 1000 women aged 15-19) and abortion ratio (per 100 pregnancies), by European countries, for the most recent year available ...... 64 10. Estimate of maternal mortality, the number and rate of unsafe abortions and mortality due to these abortions in Europe in 1995 ..... 65

References ...... 66

II. Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe (Osmo Kontula) .... 77

1. Introduction ...... 77 2. Sexual behaviour among teenagers and young adults ...... 78 2.1. Age at ﬁ rst intercourse in European countries ...... 79 2.2. Contextual information trends in age at ﬁ rst intercourse ...... 87 2.3. Sexual activities among young adults ...... 89

6 Table of contents

3. Trends in teenage fertility and pregnancies in Europe ...... 91 3.1. Statistical data on teenage fertility ...... 92 3.2. Background for the great variance in European teenage fertility trends ...... 97 3.3 Disadvantages related to teenage pregnancies and young motherhood ...... 100 4. Sexually transmitted infections and HIV/AIDS among European teenagers ...... 101 4.1. The incidence of syphilis, gonorrhoea and chlamydia among young people in Europe ...... 103 4.2. HIV infection among young Europeans ...... 107 4.3. Background information on trends in sexually transmitted infections and HIV infections ...... 111 5. European policies for preventing unwanted pregnancies, sexually transmitted infections and HIV infections ...... 114 5.1. Sexual values and evaluation of sexual policy outcomes in Europe ...... 114 5.2. National sexual health policies ...... 116

6. Conclusions ...... 119 6.1. Summary of the European trends on teenage sexual behaviour, teenage pregnancies and teenage sexually transmitted infections and HIV/AIDS in Europe ...... 120 6.2. Need for sexual health surveillance and a data bank in Europe ...... 126 6.3. Sexual health policy implications in Europe ...... 127

List of tables 1. Live births per 1000 females in the age group <20 in Europe from 1990 to 2000 ...... 93 2. Annual reported rates per 100,000 for sexually transmitted infections among 15-19 year olds, by gender, and in total population, by type of infection and by country ...... 104 3. Sexually transmitted infections among individuals at age 15-19; newly registered cases of syphilis and gonorrhoea per thousand in the relevant population in 1989-1999 in CEE/CIS/Baltic States ..... 106 4. Number of HIV infections among teenagers in the age group 13-19 in Europe from 1990-2000 ...... 110

7 Reproductive health behaviour of young Europeans

List of ﬁ gures

1. Median age at fi rst intercourse, women by generation ...... 80 2. Median age at fi rst intercourse, men by generation ...... 80 3. Median age at fi rst intercourse, women by generation ...... 82 4. Median age at fi rst intercourse, men by generation ...... 82 5. Median age at fi rst intercourse, women by age group ...... 83 6. Median age at fi rst intercourse, in NEM surveys, men by age group ...... 83 7. Gender difference in the median age at fi rst intercourse in NEM surveys by age group ...... 84 8. Male singles who have had more than one partner during the last year in NEM surveys ...... 90 9. Female singles who have had more than one partner during the last year in NEM surveys ...... 91 10. Live births per 1000 women aged 15-19 ...... 94 11. Live births per 1000 women aged 15-19 ...... 94

References ...... 131

The authors ...... 138

Titles in the same collection ...... 139

8 Executive summary

Osmo Kontula and Nathalie Bajos

This study on teenage sexual and reproductive behaviour and its consequences in Europe includes fi ve main indicators: sexual behaviour, teenage fertility, contraceptive practices, abortion and STIs/HIV/Aids. The study data are based on national surveys on sexual behaviour and fertility conducted in European countries, statistics and results of the related European studies published in scientifi c journals. National sex surveys conducted in Europe in the late 1980s and in the 1990s show that the sexual initiation of teenagers has been in transition during recent years. This transition fi rst started in the Nordic countries and followed in most other western European countries. The mean age of women at the time when they fi rst experienced intercourse decreased after the 1960s by two to three years in all western European countries. Since the 1980s this age has remained stable. However, in the fi rst part of the 1990s there was a decrease in the mean age at fi rst intercourse. A similar transition started in central and eastern Europe one generation (twenty to thirty years) later. There is not any evidence that the HIV epidemic and related prevention campaigns have had any impact on the age of sexual initiation in Europe. Mean ages at fi rst intercourse are 17 to18 years for men and women in western Europe, and 20 years for women in some central and eastern European countries. In southern and eastern Europe a double sexual standard prevails: women’s sexual experiences before marriage tend to be met with disapproval, whereas this is not the case for men. In most western European countries the age at fi rst sexual intercourse was almost completely unrelated to marriage. In central and eastern European countries they were much more interlinked. Women had their sexual initiation later on, they married younger and they gave birth to the fi rst child fi ve years younger than in western Europe. The issue of contraception thus takes on a different aspect across Europe, in terms of both younger people’s access to it and its purposes (contraception prevents any pregnancy with a given partner, defers birth of the fi rst child, spaces births and prevents further childbearing).

9 Reproductive health behaviour of young Europeans

Teenage pregnancy rates were three to four times higher in central and eastern Europe than in western Europe. In the late 1990s the highest teenage pregnancy rates in Europe were 50 per 1000 and the lowest 5 to 6 per 1000. In most countries pregnancy rates decreased in the 1990s, but there were also countries where these rates were stable at a high level. All these transformations refl ect young people’s changing attitudes to family and sexuality, higher educational achievement among young women, a rise in the latter’s labour force participation rate and the striking spread of modern contraceptive methods. More precisely, the drop in fertility over the past few decades stems from the use of modern contraceptive methods in northern and western European countries, whereas in central and eastern European countries it is due mainly to the use of abortion, which, moreover, preceded the spread of modern contraception in these countries. Differences in contraception and abortion between eastern and western Europe have tended to diminish over time and to reveal the historical infl uence of the socio-political context. But differences between western and central and eastern European countries remain high with regard to contraceptive provisions and practices, abortions, and ill-health and mortality due to unsafe abortions. In countries where teenage access to contraception is the easiest and most legitimate, young people use more protection against unplanned pregnancies. Contraceptive coverage remains inadequate in many central and eastern European countries and considerable disparities in use of medical contraception are still observed when compared to western European countries. Con- traceptive methods are much less available in central and eastern European countries where medical staff are not always trained to deliver them. Women from these countries use the so-called “natural methods»” and condoms more often than western European women. In countries where access to abortion is most restrictive or where abortions are practised in unsafe conditions, resulting ill-health and mortality are highest. Although the practice of abortion has decreased in all European countries, it remains more prevalent in central and eastern European countries, especially among the 20 to 24 age group. In eight central and eastern Euro- pean countries and Italy the proportion of abortions for women aged 20 to 24 is 2.5 – four times higher than for those aged 15 to 19, whereas in other countries the differences are less marked. These data underline diffi culties in access to contraception, particularly medical contraception, but also reveal differences in the attitude towards abortion across European countries. It varies from country to country, depending on how long it has existed and on the ease of access to medical contraception. In countries where the latter is widespread, abortion tends to be used to counteract failure of medical contraception, whereas it is regarded more as a contraceptive method in countries where modern contraception is not widely used and where women have long used abortion to regulate their fertility.

10 Executive summary

The higher prevalence of abortion in certain social status groups refl ects fi rst and foremost a greater exposure to the “risk” of unplanned pregnancy that is associated with problems in gaining access to contraception. These problems are encountered above all by women from disadvantaged backgrounds. Disadvantaged environments do not, however, necessarily predetermine the grounds for using abortion. For some, a socially premature pregnancy may burden their chances of educational success or employment; for others it will, on the contrary, be a means of acquiring status and social identity through childbearing. Estimations on trends in teenage STIs were unsatisfactory due to missing data for certain parts of Europe. Information on teenage HIV infections was more reliable. Until the mid-1990s the STI problem was much less widespread in the transition countries than in western Europe, but the situation has since reversed. In most western European countries rates of syphilis and gonorrhoea had been on the decrease since the early 1980s. In the late 1990s there was some increase. In central and eastern Europe rates of STIs increased in the fi rst part of the 1990s but decreased dramatically in the second part of the 1990s. In Russia STIs were still on the increase in the late 1990s. The incidence was 100 times higher there than in the Nordic countries (for example gonorrhoea infected people 600 per 100,000 head of population). HIV infection is also 100 times more prevalent in eastern Europe than in western and central Europe. In several central and eastern European countries there was a heavy increase in STIs in 1999 and 2000. In Russia the rate was 124 per 100,0000. This was largely due to the increasing number of intravenous drug use among young men. In conclusion, the transition in sexual initiation started fi rst of all in the Nordic countries, then in many central and west European countries and fi nally, one generation later, in southern and eastern Europe. In this transition sexual initiation broke with marriage, and the age of women at fi rst sexual intercourse decreased by several years almost everywhere in Europe. In the meantime, contraceptive practices have increased and the number of abortions has decreased, but differences between central and eastern and western countries remain high. In western Europe decreasing trends in teenage pregnancies and STIs were due to the secularisation of sex and the liberalisation of attitudes. They made possible the distribution of relevant information on sexual issues, sex education and related public health services. HIV prevention campaigns in the 1980s were very important in providing the young generation with the knowledge and skills that they needed in order to protect themselves from health hazards. After the transition in central and eastern Europe in the early 1990s the new generation were freer to make personal choices but usually without the knowledge and means to protect themselves.

11 Reproductive health behaviour of young Europeans

In the late 1990s European teenagers and young adults were more sexually active than before. Thanks to reliable contraceptives and an increase in the level of education, teenage pregnancies also decreased. In central and eastern Europe syphilis and gonorrhoea were also more under control than before. In some countries there was an increase in teenage pregnancies and STIs. This is related to the decreasing use of condoms. In the late 1990s public sex education and HIV prevention campaigns were less active than ten years before and attitudes to condoms were less enthusiastic than they previously had been. This had dramatic consequences, especially in Russia, where the rates of teenage STIs and HIV infections were 100 times higher than in western Europe, and even in the late 1990s they were increasing steadily. Public opinion was not supportive of adequate sex education, and poverty brought increasing numbers of drug addicts to the streets. Due to insufﬁ cient investments in the public health sector teenagers and young adults were not equipped to face these risky situations. This led to serious problems in sexual and reproductive health among teenagers and young adults in Russia. There is a need for continuous sexual health surveillance in Europe and a European sexual health data bank. They could cover information on sexual initiation, use of contraceptives and sexual patterns among young adults. The European database could also include information on European sexual health policies and sexual and reproductive rights, based on harmonised sexual health indicators. European countries’ sexual and reproductive health policies should be considered globally, without disconnecting contraception and the prevention of STIs, especially the prevention of HIV infection. Due to the high prevalence of HIV infection in central and eastern European countries, the promotion of condom use associated with the promotion of emergency contraception, should be a priority. Governments should promote tolerance towards young people’s sexuality and ensure adequate dissemination of information on contraception, abortion and STIs through various channels (schools, the media, youth centres, health care centres, etc.). Poor sexual communication and low self-esteem could be improved by life skills education. There is a serious need for sexual health campaigns and related services in Europe. Fighting against poverty and the promotion of basic education would create more favourable conditions for the prevention of unwanted teenage pregnancies and teenage STIs and HIV infections. Teenagers also need more anonymous sexual health services at a lower cost. Distribution of free or low cost contraceptives would decrease sexual health hazards related to sexual activity. The prevention of STIs and HIV infections requires more effective marketing of condoms. It is also important to improve the training of medical staff so that better services to young people can be provided.

12 I. Contraceptive practices and use of abortion among adolescents and young adults in Europe

Nathalie Bajos and Agnès Guillaume

1. Introduction The changes affecting family and reproductive patterns in Europe over the past 30 years are so great that some authors have used the term “second demographic transition” to describe them (Leridon 1999). Whether looking at the drop in fertility or the increased age at fi rst birth, the decline in the marriage rate or the increased age at marriage, the rise in extra-marital births or the increase in divorce, all the demographic indicators have changed appreciably over the past few decades. It is the rate of change and the timing of the establishment of these new patterns of behaviour that differs between European countries rather than the nature of the changes observed (Leridon 1999). These changes, which are taking place against a background of a general decline in religious infl uence (Bozon and Kontula 1998), began as early as the mid-1960s in western and northern Europe and in the late 1980s in southern and central and eastern Europe (Philipov 2002). To these changes must be added a 1-3 year drop (depending on country) in the median age at fi rst intercourse for both men and women between generations born in the 1930s and those born in the 1970s, with the downward trend coming to a halt in the early 1980s (Bozon and Kontula 1998). All these transformations refl ect young people’s changing attitude to the family and sexuality, higher educational achievement among young women, a rise in the latter’s labour force participation rate and the striking spread of modern contraceptive methods (Bozon and Kontula 1998). As Creastas (1997) and Leridon (1999) emphasise, these various developments have resulted in a longer period between fi rst intercourse and marriage and an even longer interval between fi rst intercourse and birth of the fi rst child. This lengthening is different between central and eastern European countries and others. In most of western Europe countries age at fi rst sexual intercourse was almost completely unrelated to marriage whereas in central and eastern European countries they were much more interlinked; in in these latter countries women had sexual initiation older, they married younger and gave birth to their fi rst child fi ve years younger than in western Europe (see Part II, Kontula).

13 Reproductive health behaviour of young Europeans

The question of contraception thus takes on a different aspect across Europe in terms of both younger people’s access to it and its purpose (contraception to defer birth of the fi rst child rather than to space births or prevent further childbearing), whilst having a wide range of historical origins (Philipov 2002). In this connection it should be pointed out that the drop in fertility over the past few decades stemmed from use of modern contraceptive methods in north and west European countries, whereas in central and eastern Europe it was due mainly to the use of abortion (Blayo 1991) which, moreover, preceded the spread of modern contraception in these countries (cf. Appendix 6 ). Hassoun and Jourdain (1995) put forward a number of hypotheses, which are taken up here, relating to socio-historical context as the explanation for low use of modern contraception in central and eastern European countries, some of which agree with the interpretations advanced by Philipov (2002). Women in central and eastern European countries, who were nevertheless among the fi rst to adopt the idea of fertility control (abortion being legalised in the USSR in the early 1920s), were shut off from women’s movements demanding contraception in western countries; similarly, doctors’ social and scientifi c isolation in central and eastern Europe perpetuated the idea that the risk associated with contraception was greater than that of abortion. Since health policy favoured termination rather than prevention of unintended pregnancies, there were no specialist services, trained staff or, above all, modern contraceptives. Only a few countries in central Europe (the GDR, Hungary and Czechoslovakia) manufactured these contraceptives, which, for the other countries facing serious economic diffi culties, represented an expensive import. In such circumstances, abortion was perceived as a routine procedure and modern contraception was considered unnecessary. When knowledge of these methods existed, they were felt to be “unnatural” and treated as evidence of the west’s declining morals. Modern contraception really started to spread from the 1980s onwards without, however, attaining the contraceptive prevalence rates recorded in other European countries. It was only from the early 1990s that widespread distribution was registered, as evidenced by the contraceptive prevalence now recorded for women aged over 20 (Philipov 2002, cf. Appendix 5). This resulted from a radical change in family planning, based on a marked growth in the activity of family planning organisations providing information and contraceptives (David 1999, cited by Philipov 2002); the latter are now widely distributed by pharmaceutical fi rms. This spread of modern contraception is nevertheless a long way from having reached all sections of the population and especially young people, as shown by data on teenage pregnancies and use of abortion (Unicef 2001), although

14 Contraceptive practices and use of abortion among adolescents and young adults in Europe it should be pointed out that most central and eastern European countries experienced a sharp decline in teenage fertility in the 1990s (cf. Appendix 6) linked to higher school enrolment. The fertility rate for women aged 15-19 is currently below 50 per 1000 (except in the Ukraine and Moldova), and in most of these countries fertility rates lie below 20 per 1000 and are even below 5 per 1000 in Slovenia and a few west European countries. In Bulgaria adolescent fertility fell from 70 per 1000 in 1990 to 49 per 1000 in 2000. It is estimated that 4.6 million women in Russia and 3.6 million in central and eastern European countries have unmet familyplanning needs (Ross and Winfrey 2002). The analysis of contraceptive practices and use of abortion among young people in Europe offered here is meant to shed light on current issues in fertility control upon entry into adult life. These issues must necessarily include the epidemic of HIV infection which is continuing to spread, especially in central and eastern Europe. Prevention campaigns have had the effect of encouraging use of condoms, especially among teenagers (Dubois-Arber 1998). This may expose women to unplanned pregnancies if they have difﬁ culty in negotiating with their partners the use of a preventive method which many men are still reluctant to employ. At the same time, it is the only method providing simultaneous protection against HIV infection and unplanned pregnancies. This publication ﬁ rst examines the characteristics of contraceptive use in the 15-24 age group. Then, after having analysed available data on abortion, focus is on the process connecting these two elements in order to underscore that the social factors determining attitudes to contraception are not necessarily the same as those determining attitudes to abortion, something which might not emerge from a general analysis.

2. Available sources Whether for contraception or abortion, data on use are very hard to compare owing to both the diversity of the populations concerned and the assorted sources of observation. The comparative study completed by the Alan Gutt- macher Institute (Singh, Darroch et al. 2001) on teenage pregnancies in ﬁ ve industrialised countries, which worked with experts in the ﬁ ve study countries over a two-year period to be able to produce comparable contextual and statistical data, bears witness to the size of the task. For contraception, our choice has been to work on surveys with similar procedures (FFS, CDC and DHS, cf. Appendix 5) in order to compare preva- lences. Some 30 countries have completed and published the results of either Fertility and Family Surveys (FFSs) conducted between 1988 and 1997 or CDC (Center for Disease Control and Prevention) or DHS (Demographic

15 Reproductive health behaviour of young Europeans and Health Survey) surveys. Since the FFS procedures are similar, the data obtained are relatively comparable. But the published data which used here is limited: percentage using contraception at fi rst intercourse by age and gender, current contraceptive coverage and method of contraception used, but only for couples. The FFS reports do not present their data in terms of social and demographic characteristics1. The DHS and CDC surveys are much more informative than the FFSs. They contain data on current contraceptive practices, methods used and recent developments. They also provide information on knowledge and opinions in the fi elds of contraception and abortion as well as problems arising from use of contraception – information not collected by the FFSs which cover the great majority of countries. The Center for Disease Control and Prevention (CDC) has published surveys for 7 countries: Romania 1993, 1996 and 1999; Ukraine 1999, Russia (3 sites) 1996; Czech Republic 19932, Armenia 2000, Georgia 1999-2000 and Moldova, 1997; lastly, a Demographic and Health Survey (DHS) was published for Turkey in 1993 and 1998. In addition, surveys covering population sub-groups have been published, and their fi ndings will be used for the study of variations in use of contraception in the light of social and demographic characteristics and barriers to use of contraceptives. As for available data on provision of contraception and the conditions on which it is prescribed for young people, they are extremely fragmentary. Only one publication was found, a summary of which is given in Appendix7. But these data, which cover only central and eastern Europe, do not make it possible to determine precisely under what conditions young people have access to contraception (parental consent, cost, distribution structures, information and education at school, etc.). For abortion, it should be noted that national surveys all suffer from considerable underreporting (Toulemon 1995), which considerably skews prevalence measurement but may also affect analysis of the associated social factors. Underestimation of abortion is bound up with the reluctance felt by some women to report a diffi cult event and to skewed survey coverage. National statistics will therefore be used, although under-registration may be proved or suspected for numerous countries, owing partly to the fact that abortions are carried out illegally when the legal time limit for the operation has been exceeded. In France, for example, the number of induced abortions is calculated on the basis of anonymous forms completed after

1. In connection with our work, we requested access to the FFS database in order to determine variations in contraceptive use at ﬁ rst intercourse in relation to level of education. 2. This means that two sources of data are therefore available for the Czech Republic: the FFS and the CDC survey.

16 Contraceptive practices and use of abortion among adolescents and young adults in Europe every termination of pregnancy, but there is a discrepancy between the number of forms received and the annual statistics from health facilities (Kafé and Brouard 2000). Thus for 1997 a 14% difference emerges when comparing the two sources, due in part to these facilities’ reporting abortions under a different classifi cation (miscarriage, for example). Moreover some abortions performed abroad, especially those outside the legal time limit in France, are not reported in these statistics. In Spain, where abortion was authorised only in 1985, women before then either had illegal abortions inside the country, without its really being possible to measure their prevalence, or they travelled to the Netherlands, England or Wales to obtain them (Peiro, Colomer et al. 2001); thus, for the 1974-85 period, 204,736 abortions were performed on women from Spain in these countries, a fi gure which has fallen to 34,895 since legalisation, while 340,214 abortions have been carried out in Spain. In some countries where abortion is legal, there are no statistics to measure its scale: the refusal to record abortion and keep statistics refl ects a wish to preserve a certain clandestinity that can observed in Europe, particularly Austria, Greece, Luxembourg and Portugal (Blayo 1998). In a comparative study of teenage pregnancies, Darroch and Singh (2001) estimate that, in Europe, abortion data are less than 80% complete in France, Georgia, Italy, Moldova, Northern Ireland, Romania, Russia and Spain. Abor- tion rates in Northern Ireland are for abortions on women resident in that country but performed in England and Wales; for Scotland, the rates also include abortions obtained in England and Wales by women in that country. In the Netherlands, abortion rates include only women resident in that country and exclude those obtained by women from other European countries. Abortion prevalence differences must therefore be treated with caution, and this study devotes more attention to time trends and socio-demographic variations. The data used here are those published by the Alan Guttmacher Institute. Adjustments have been made in order to make rates comparable for the reported age (at last birthday or at time of abortion) (Henshaw, Singh et al. 1999) but not to offset underreporting. Data on the statutory conditions for abortion are more plentiful than those on contraceptive provision. They have been collected in United Nations documents indicating the state of legislation in each country and in a summary produced by the IPPF. Appendix 2 shows the dates of legislation, the conditions under which abortion is authorised in each country (grounds and statutory time limit), the conditions under which young people have access to it, and the terms of payment for abortions (covered by the State, social insurance or the woman herself).

3. Contraceptive use by young people in Europe

17 Reproductive health behaviour of young Europeans

Substantial differences in provision According to the data from the IPPF (IPPF 2001) and the United Nations (United Nations 2002), the situation in Europe appears to vary considerably in terms of contraceptive provision for adolescents. The few characteristics available for central and eastern European countries are shown in Appendix 7. Some countries in central and eastern Europe have national family planning programmes, such as Armenia, Albania, Belarus, Bosnia, Bulgaria, Moldova, Poland, Romania, Russia, Slovakia, Slovenia and the Ukraine. However, this does not mean that family planning services are necessarily free (although they are in Albania, Bulgaria, Estonia, Hungary, Moldova, Romania, Russia, Slovakia and Slovenia) or that contraceptives are free of charge (which they are only in Albania and Slovenia), or even that they are available. Staff are not always trained. In central and eastern Europe, the price of contraceptives can be as high as a third of one month’s salary. Only ﬁ ve countries (Bosnia, Bulgaria, Lithuania, Russia and Slovakia) require parental consent for adolescents to have access to contraceptives. In some west European countries, conditions of access are restrictive without parental consent being required by law in every case. Thus in France, for example, until July 2001 adolescents could be issued with contraceptives in a family planning clinic whereas general practitioners were not permitted to prescribe them for teenagers.

Increasing protection for fi rst intercourse In all the countries studied, use of contraception at fi rst intercourse has been steadily increasing (cf. Figures 1 and 2). From generations born in the 1940s to those born in the very early 1980s, the trends are virtually the same in the various countries, and the hierarchy seen today differs little from that which prevailed 40 years earlier with a few exceptions such as Poland and Bulgaria. Hungary, which is one of the few central and eastern European countries to have actually manufactured contraceptives, has a profi le for contraception at fi rst intercourse which is similar to other countries in western Europe. Slovenia, a country where contraception is provided free of charge to minors without parental consent being required, and to a lesser extent Poland, are also distinguished by a higher prevalence. Conversely, Portugal is close to the central and eastern European countries recording the lowest contraceptive prevalence (Estonia, Czech Republic, Bulgaria and Latvia).

18 Contraceptive practices and use of abortion among adolescents and young adults in Europe Slovenia source : FFS Poland Lithuania Latvia Generations Hungary Estonia rst intercourse – central and eastern Europe (generation born in the 1945-80s)

Czech Rep. Bulgaria 40 45 50 55 60 65 70 75 80 85 0 90 80 70 60 50 40 30 20 10

100 % of contraception of % Figure 1 – Prevalence of contraception use at ﬁ

19 Reproductive health behaviour of young Europeans source : FFS Portugal Italy Greece Generations France Switzerland rst intercourse - other countries (generation born in the 1945-80s)

Belgium Spain 40 45 50 55 60 65 70 75 80 85 0 90 80 70 60 50 40 30 20 10

100 % of contraception of % Figure 2 – Prevalence of contraception use at ﬁ

20 Contraceptive practices and use of abortion among adolescents and young adults in Europe

Figure 3 – Prevalence of contraceptive use at ﬁ rst intercourse, men and women born in the early 1970s in Europe

100

Italy G73 Spain G73 Latvia G72 Greece G72 France G71 Poland G69Ukraine G79 Estonia G71 Belgium G68 Hungary G70Slovenia RomaniaG73 G79 Portugal G70 Lithuania G72Bulgaria MoldovaG70 G77 Switzerland G72 Czech Rep. G70

women men source : FFS et CDC

Figure 3 shows the prevalence of contraceptive use at fi rst intercourse for men and women born in the early 1970s. Attention is drawn to the large measure of agreement between the two sexes in their replies but it should be asked whether this agreement refl ects a widespread use of condoms (noted in a number of surveys, especially where campaigns have been run to prevent HIV infection) rather than men’s greater involvement in reproductive issues. First intercourse does not occur at the same age throughout Europe as Bozon and Kontula (1998) have demonstrated. Consequently, comparative genera- tional approaches may be skewed in a context where practices are changing fast. They can be usefully complemented by analysing data according to the year in which fi rst intercourse took place, information which is shown in fi gures 4a and 4b.

Figure 4a – Prevalence of contraceptive use at ﬁ rst intercourse (years 1983-87) 100 80 60 40 20 0

Latvia 86 Estonia 85 Poland Poland85 87 France 84 Belgium 83 LithuaniaBulgaria 87 84 Portugal 85 Slovenia 86 HungaryHungary 83 87 Belgium 87 Czech Rep. 83 Switzerland 86

21 Reproductive health behaviour of young Europeans

Hungary’s special position, arising from its manufacture of contraceptives is confi rmed, while the east/west difference is manifest, although in terms of a continuum rather than an antithesis. As far as public health is concerned, these data on trends in contraceptive use are encouraging, since it has been established that sexual and preventive conditions when fi rst entering into sexual relations foreshadow adult sexual lifestyles (Bozon 1998) and attitudes to prevention (Bajos, Ducot et al. 1997), at least in countries with easy access to contraceptive and preventive methods. It is known, however, that if sexual intercourse is not regular and if relationships are brief and far apart, which is often the case with adolescent sexuality (Lagrange and Lhomond 1997), it is far from easy to practise regularly contraception and prevention on a long-term basis. The consistency of contraceptive and preventive practices after fi rst intercourse is a crucial issue; the change from a condom to some other type of contraception is not always immediate, and teenage girls sometimes fi nd themselves in “in-between” situations which may expose them to unplanned pregnancies. This question is diffi cult to study with published data, since those on current use of contraception by young people are scanty and cover only women who have reported that they are living with a partner1. This restriction must be stressed, since young women who are not cohabiting are probably more affected by the feeling that their sexuality is socially unacceptable, and it is known that this discourages use of contraception (Singh, Darroch et al. 2001, Durand et al. 2002).

Figure 4b – Prevalence of contraceptive use at ﬁ rst intercourse (years 1988-91) 100 80 60 40 20 0

89 Italy 88 Spain 88 Italy 91 Spain 92 Latvia 89Estonia 91 France 90 Greece 91 Lithuania 91 Portugal 88Slovenia 91 Czech Rep.89 Switzerland

It must also be emphasised that there are considerable disparities in use of contraception at ﬁ rst intercourse according to young women’s level of education (Figure 5). Whatever the country studied, the more education the

1. Furthermore, it should be noted that the total numbers are small for these age groups and that data is not always available for 15-19 year olds.

22 Contraceptive practices and use of abortion among adolescents and young adults in Europe women have, the more they use protection during their fi rst intercourse. Such data undoubtedly refl ect the greater problems in gaining access to contraception encountered by women from the most socially disadvantaged backgrounds and possibly also a lesser social capacity to control their lives in general and reproductive matters in particular (Bretin 1995). In any case, these fi ndings underline the need for targeted reproductive health policies.

Figure 5 – Prevalence of contraceptive use at ﬁ rst intercourse according to women’s level of education (women 20-24) 100 90 80 70 60 50 40 30 20 10 0

Spain France Latvia Austria Bulgaria Hungary LithuaniaPoland Slovenia Belgium Czech Rep. Portugal Switzerland

low medium high

Contraceptive coverage is still inadequate The contraception situation changes according to age and period. Since there is no data to compare situations in a given country at different dates, the study at least compares prevalence for the same age groups in surveys conducted over the same period. Appendices 3 and 4 provide data on the current contraceptive situation of women aged 15-19 and 20-24 living with a partner; some ten years separate the latest published surveys (Armenia) from the oldest (Norway). These contraceptive prevalence data are not directly comparable, since it seems that some countries have recorded sexually active women not using contraception and not wanting children under the heading ‘Status unknown’. It is unlikely that contraceptive coverage is actually total in the Czech Repub- lic; similarly, the proportion of women aged 15-19 and living with a partner who apparently have no sexual intercourse seems particularly high in that country, as it does in Estonia for the 20-24 age group (men and women) and in Slovenia for women aged 15-19.

23 Reproductive health behaviour of young Europeans

At all events, the data testify to the current inadequacy of contraceptive coverage in a number of countries, whether for women aged 15-19 or those aged 20-24. Hungary (n=27) is the only country in central and eastern Europe with such high contraceptive coverage. For the 20-24 age group the same trends have been recorded with the exception of the Czech Republic, which shows high contraceptive coverage, although with a high percentage of ‘status unknown’, and Hungary, where over 10% (Appendix4) of sexually active women do not use contraception even though they are not trying to become pregnant. According to the men’s responses, the contraceptive defi cit is considerable in Austria and Turkey (data not shown). It should be remembered that all these data cover only women in couples, and it may be supposed that women who are not in couples and who are sexually active fi nd it even harder to gain access to contraception. This lack of coverage cannot be simply put down to ambivalence on the part of the women and/or their partners regarding the desire for a pregnancy (Bajos, Ferrand et al. 2002). It also refl ects problems of accessibility and acceptability of contraceptive methods. Analysis of methods used also seems to reveal accessibility problems, especially in central and eastern Europe.

Considerable disparities in use of medical contraception It is in countries with the highest contraceptive prevalence the use of medical contraception is greatest (for the 15-19 age group: correlation coefﬁ cient (r) = 0.69, p=0.009; for the 20-24 age group: r=0.70 and p=0.002). Considerable disparities between European countries have been recorded for contraceptive methods used by couples (Figures 6 and 7). The percentage of medical contraception (pill or IUD) among women aged 15-19 living with a partner and using contraception thus ranges from 96% in the Neth- erlands to under 10% in the Ukraine. The highest percentages are recorded in west European countries together with the Czech Republic1 and Hungary, the only two countries in central and eastern Europe to produce medical contraception. The situation is slightly different for the 20-24 age group: the country hierarchy here does not entirely match that of the younger age group. Thus, for example, Portuguese women aged 20-24 make greater use of medical contraception than their younger counterparts, whereas Czech women use it less.

1. It should be noted that in the Czech Republic, medical contraception covers 86% of women using contraception, whereas the prevalence rate for contraception is only 55%; this feature is doubtless explained by the fact that oral contraceptives are manufactured in this country.

24 Contraceptive practices and use of abortion among adolescents and young adults in Europe

Figure 6 – Contraceptive method used by couple (women <20 years) 100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0% 3 97 va 97 Spain 95 Latvia 95 Turkey 98 Ukraine 99 Hungary 93Portugal 97 Slovenia 94 Bulgaria Romania 99Lithuania 95Armenia 00 Moldo NetherlandsCzech 9 Rep. 97

Pill IUD Condom Periodic abstinence Withdrawal Other method

Figure 7 – Contraceptive method used by couple (women 20-24 years) 100

Spain 95 France 94 Latvia 95 Greece Turkey99 Estonia98 94 PortugalAustria 97 Norway 96 Hungary 88 Slovenia 93 94 Romania 99 UkraineArmenia 99 00 Ukraine 1997 Lithuania 95 Netherlands Czech Rep. 97

Pill IUD Condom Periodic abstinence Withdrawal Other method

Recent data show that use of hormonal contraception is still growing among young people in France (Leridon, Oustry et al. 2002), Sweden (Oddens 1996b), Italy (Oddens 1996c), the Czech Republic (Weiss and Zverina 1997,

25 Reproductive health behaviour of young Europeans

Stembera, Velebil et al.(c) 2000) and Switzerland (Kunz and Bitzer 2000). In Romania, on the other hand, traditional methods still largely predominate (Serbanescu, Morris et al. 1995). Without prejudging the use effectiveness of the various methods of contraception, which differs appreciably from their theoretical effectiveness, the high use of intercourse-speciﬁ c methods (condom, withdrawal) in central and eastern Europe should be noted. These methods require genuine agreement between partners, which, it has been possible to demonstrate, is far from always being the case, especially when such intercourse is marked by male domination (Bajos, Ferrand et al. 2002) or heavy drinking. Emergency contraception to neutralise failures associated with these methods is still virtually unavailable in these countries, as shall be seen below.

Emergency contraception Emergency contraception play an important part in the event of failure, irregular use or total absence of contraception. It is estimated that of every 100 women that use them, three will end up becoming pregnant. This method is not yet available in all countries, and prescription terms and costs vary considerably. In central and eastern Europe emergency contraception is still virtually unavailable (see Appendix 7): in Estonia it is distributed free of charge by youth services. In some countries such as Belgium, France, Germany and the United Kingdom, a medical prescription is not required to obtain it; in France it is distributed free in schools and for minors. For adolescents, the literature on this subject covers only western and northern Europe. The studies on use of emergency contraception by adolescents show that it is already used by a not inconsiderable fraction of the population. In Switzerland, 20% of adolescents have used it (Ottesen Narring et al. 2002); in England and Wales, its highest rates of use are among women in the 20-24 and 15-19 age groups (Ineichen, Logie et al. 2000). In the east of Scotland, a study among pupils aged 14-15 revealed that 31% of them had already used emergency contraception (Graham, Green et al.1996); in Sweden, a survey of students underlined that 28% had already used such contraception (Haggstrom-Nordin and Tyden 2001). Reasons for using emergency contraception include condom breakage, oral contraceptive compliance failure, and unprotected intercourse (Ottesen Narring et al. 2002, Falk, Falk et al. 2001). Emergency contraception is particularly important in the context of preventing HIV infection, since it can counteract any problems arising from use of a condom. Numerous studies emphasise that conditions of access (cost and over-the-counter availability) are a determining factor.

26 Contraceptive practices and use of abortion among adolescents and young adults in Europe

Barriers to use of contraception, from women’s psychological characteristics to socio-political factors of supply Published surveys of contraceptive use in Europe, covering representative samples of young people or specifi c sub-samples (women using family planning services, women wanting an abortion, young people at university, etc.), make it possible to undertake an initial review of barriers to contraception, which are various in nature. It should be pointed out that only one comparative study, which can shed light on macro-social factors in the use of contraception, has been published (Darroch, Singh et al. 2001). The study covers three European countries (France, Britain and Sweden), Canada and the United States. Firstly, it is important to notice that knowledge of contraceptive methods and the menstrual cycle is still sketchy among many adolescents in central and eastern Europe (Dzepina and Prebeg 1991, Kapamadzija, Bjelica et al. 2001, Serbanescu, Morris et al. 1995) but also in western Europe (Oddens 1996c). Representations of contraceptive methods are often marked by a strong distrust of hormonal contraception, which is perceived as unnatural and potentially hazardous. These socially constructed representations refl ect the socio-historical background to the spread of medical contraception in central and eastern Europe as described in the introduction. They are also to be found, to a lesser extent, among young people in western Europe, reveal- ing the impact of ecological debate (particularly the artifi cial nature of the products) and the fact that these young women began to be sexually active in a situation where oral contraceptives had always been available: unlike the previous generation who fought to have access to them, young people today lay more emphasis on the constraints, the liberation issue in fact being overshadowed. Thus information campaigns cannot in themselves alter such representations, whose social anchoring extends well beyond information alone. It must be stressed that the question of contraception, which presupposes a certain social capacity to control the course of one’s life, may not arise in certain situations (Bretin 1995) where the issues of social survival are such that they undermine any use of contraception. Some studies show that women with the most education and women who are atheists are more open to contraceptive issues (Stembera and Velebil c 2000), as well as women from socially advantaged backgrounds (Weiss and Zverina 1997, Singh, Darroch et al. 2001). It should also be noted that contraception can be considered only if the woman – and man – feels concerned by contraceptive issues. This implies that she must feel free to have a sexual life, which is far from being the case in all societies. The comparative study of Britain, Canada, France, Sweden,

27 Reproductive health behaviour of young Europeans and the USA provides considerable food for thought in this respect. It is in those countries where social tolerance of young people’s sexuality is greatest (France and Sweden) that contraception rates are highest and abortion rates lowest. Countries attempting to introduce prevention policies based on delay- ing the age of fi rst intercourse, thereby adopting an extremely mechanistic view of human sexuality (Short 1998), run the risk of discouraging sexually active young people from using contraceptives. The same conclusion, this time at the micro-sociological level, emerges from recent research on adolescents in France (Durand et al. 2002). Similarly, a review of the international literature shows that the spirit of tolerance apparent in the way in which sex education is delivered (whether at school or in the home) appears to be more decisive than the content itself (Health Education Authority 1999). Young men’s involvement is a very important issue. Young men and young women experience sexuality in a very different way (Bozon 1998, Narring, Wydler et al. 2000): men focus much more on physical pleasure, whereas women are more concerned with the affective and emotional aspects. These ways of experiencing, which produce and reproduce social gender relationships, has an impact on how contraception is regarded and managed (Bajos, Ferrand et al. 2002). Virtually all the studies, whether they deal with young men directly or record their attitudes as reported by young women, underline young men’s lack of involvement in contraception, both in western Europe (Moreau-Gruet, Ferrond et al. 1996, Durand et al. 2002) and in central and eastern Europe (Kubba, Guillebaud et al. 2000). The high prevalence of intercourse-specifi c methods (such as withdrawal or condom) in central and eastern Europe raises the question of young men’s involvement and relationship issues in risk-taking (Bajos Ferrand et al. 2002, Manning, Longmore et al. 2000), about which, admittedly, very little is known, especially concerning teenage boys. Some studies have shown that risk-taking is greater when young women have their fi rst intercourse very young and with older partners (Narring, Wydler et al 2000, Wellings, Nan- chahal et al. 2001, Creastas 1995). As to the psychological profi le that would predispose some young people to expose themselves to the risks associated with sexuality, the literature seems to disagree. Some authors stress that impulsive personalities are more at risk (Kahn, Kaplowitz et al. 2000) or that there exist multiple-risk personalities (Hidalgo, Garrido et al. 2000). Others report survey fi ndings which show that the risks taken in the sphere of sexuality depend on issues very different from those determining risks in other fi elds such as road safety, alcohol and drugs (Rees, Argys et al. 2001, Flisher and Chalton 2001).

28 Contraceptive practices and use of abortion among adolescents and young adults in Europe

The conditions of access to contraception remain an issue of prime importance, especially, but not solely, in central eastern Europe. The atypical profi le of Hungary, a contraceptive-manufacturing country, illustrates the importance of the socio-political context. Local production of contraceptives cannot be the only criterion affecting the nature of contraceptive provision. A number of studies emphasise that contraception cost, anonymity, confi dentiality and the accessibility of clinics issuing contraceptives are all determining factors in use of contraceptives by young people (Singh, Darroch et al. 2001, Zimmer-Genbeck, Doyle et al. 2001, Donovan, Mellanby et al. 1997, Serbanescu 1995, Morris et al., Bender 1999). Fear of a gynaecological examination also inhibits attendance, especially among young women (Peremans, Herman et al. 2000). In some cases, family planning clinics are reserved for young couples (Riveira, Cabral de Mello et al. 2001), thus excluding a population that is all the more closely concerned in that its members specifi cally experience their sexuality as socially stigmatised. In other cases, the facilities available are not really accessible to certain population groups such as migrants, who already face confl icting tensions between the norms concerning sexuality and legitimacy of contraception in the home country and those in the host county (Hendricks, Lodewijckx et al. 2002, Turki et al. 2002), or young people in particularly diffi cult social and economic circumstances. Some studies also stress the need for the health system to overcome the lack of communication in many families on matters of sexuality and contraception (Hassan and Creastas 2000, Sundby, Svanemyr et al. 1999, Crosby 2001). According to a study conducted in Switzerland, communication within the family seems to be easier for young women than for young men (Moreau-Gruet, Ferrond et al. 1996). The health system must also make up for the limitations of sex education at school recently highlighted in a meta- analysis by DiCenso et al. (2002). Among the features of the health system, it must be stressed that staff training is also essential, since normative attitudes can discourage young people from having any inclination for contraception (Durand et al. 2002). The question also arises of ensuring that the method used is suitable for young people’s lifestyles (Talfelski and Boehm 1995). Prescribers often disregard the latter in order to follow prescription rules based on pursuit of maximum effectiveness. This unsuitability of the method used for young people’s lifestyles is often a source of contraceptive failures (Rivera, Cabral de Mello et al. 2001, Bajos, Ferrand et al. 2002, Stevens-Simon, Kelly et al. 2001, Sundby, Svanemyr et al. 1999). For example the pill is not necessarily the most appropriate method for young women who have an irregular sex life. The medical literature, moreover, disagrees about the most appropriate contraceptive methods for adolescents: whether implants and injections that

29 Reproductive health behaviour of young Europeans are supposed to counteract young people’s “irresponsibility”, or the pill, whose theoretical effectiveness is highest. Besides, medical attitudes vary according to country, often depending on the available methods most used in a given country (Cromer, Berg-Kelly et al. 1998). In any case, helping those concerned to choose the best method for their lifestyle means listening carefully and taking time (Bender 1999). There is still little available information about how contraception and prevention are managed together, although the AIDS epidemic has probably altered the contraceptive practices -. Some studies show that the interaction appears to be considerable (Crosby, DiClemente et al. 2001, Durand et al. 2002, Stigum, Magnus et al. 1995, Narring Wydler et al. 2000). Nevertheless the two issues are often separated in prevention work. A number of authors have emphasised that it is worth stressing the contraceptive issue - as pregnancy affects a larger number of people than HIV infection - with the exception of homosexual relationships of course. These factors do not all work in the same way in the various countries studied. They combine in speciﬁ c proportions according to the historical, social and cultural contexts. The factors associated with use of contraception do not necessarily coincide, statistically speaking, with those associated with abortion. Thus, for example, women with social, cultural or economic capitals are better able to resort to contraception. But, in the event of contraceptive failure, this same capital would come together to lead these women, especially young women, to terminate a pregnancy which if taken to term would run counter to socially programmed integration into the education system and entry into employment. The next chapter studies the use of abortion among young people in Europe in relationship to the features of contraceptive use.

4. Abortion among young people in Europe The Cairo International Conference on Population and Development in 1994 and the Beijing Women’s Conference in 1995 dealt extensively with various aspects of reproductive health and reproductive rights and emphasised that individuals must be able to lead risk-free sex lives and decide on the number and timing of their children. Considerable attention was devoted to the question of abortion and especially how to reduce unsafe abortions, which are common where abortion is illegal. However, it was emphasised that abortion should not be used as a method of contraception as was still the case in countries where access to contraception was limited. Have the commitments on abortion made at these conferences been followed by revision of abortion legislation in European countries?

30 Contraceptive practices and use of abortion among adolescents and young adults in Europe

Legislation: a mixed picture Abortion laws in Europe have evolved over time (Appendix 2 and Appendix 8). The Soviet Union was the fi rst country in Europe to legalise abortion, as early as 1920, and in the other central and eastern European countries such legalisation occurred during the 1950s. Since then, laws have been alternately tightened and relaxed. Abortion in these countries was the main method of fertility control in the absence of access to modern contraception. In Romania abortion was alternately prohibited and legalised in order to increase or reduce fertility: these measures resulted in a rise in maternal mortality due to illegal and therefore back-street abortions (Johnson and Horga 1996). In other European countries, laws were gradually introduced from the 1970s onwards and were often further relaxed from the 1980s, except in Poland, where the 1993 law prohibits abortion on the grounds of economic distress. At present, abortion is available on request in 33 out of the 47 countries of Europe, including the whole of central and eastern Europe and the former Soviet Union with the exception of Poland (Appendix 8). In Iceland, Luxembourg, Finland and the United Kingdom it is theoretically authorised only on social and economic grounds, but in practice access is more permissive, at least in the latter two countries. In fi ve countries – Cyprus, Liechtenstein, Poland, Portugal and Spain – statutory access to abortion is conditional on the woman’s having physical or mental health problems or (apart from Liechtenstein) on foetal malformation, rape or incest. Abortion is authorised only to save a woman’s life in Andorra, Ireland, Monaco and San Marino and is totally prohibited in Malta. Access to abortion is always subject to legal gestational limits and sometimes to parental consent for minors. The legal gestational limit for the operation is 12 weeks in most European countries, extending to a maximum of 24 weeks. It may be exceeded in certain circumstances: on medical grounds relating to a woman’s physical or mental health or to the fœtus (especially if there is a risk of foetal malformation); for social or economic reasons; in the event of sexual abuse, rape or incest; and on account of a woman’s age. The cost of abortion and its payment by the government or social insurance systems differs considerably from country to country. Abortion is charged for in 18 countries, mostly in central and eastern Europe; some governments cover its cost if it is carried out for medical reasons or if a women is facing social, economic or other diffi culties. In the other countries, the cost is fully or partly covered by the government. Abortion is performed within the public system subject to compliance with the statutory conditions, but it is also provided by the private sector, often at higher cost and in varying health and safety conditions.

31 Reproductive health behaviour of young Europeans

Welsh McCarthy et al. (2001) in a study of abortionists in the Netherlands, Sweden and Britain, have highlighted differences in teenagers’ access to abortion: in the Netherlands abortion is free of charge; in Sweden it costs less than use of the pill; in Britain, the abortion referral system is very effective, abortion clinics are numerous, and the cost of an abortion will depend on where it is performed and by whom, as well as parental involvement.

Adolescents’ reproductive rights There may be derogations or and restrictions regarding conditions of access for adolescents (Boland 1993; Whitty 1993; Wise 1997; Kero, Hogberg et al. 2001; Rey 2002). In 27 countries1 abortion is subject to authorisation from the young woman’s parents or legal guardian. It is necessary: under the age of 14 in Austria; under the age of 16 in Croatia, the Czech Republic, Estonia, Georgia, Greece, Iceland, Lithuania, Netherlands, Norway, Switzerland, Ukraine, United Kingdom, and Slovakia (in the latter country, if the girl is aged between 16 and 18 the parents must simply be notifi ed by the doctor); under the age of 18 in Bulgaria, Denmark, Hungary, Latvia, Moldova, Turkey and Italy (if the parents refuse in the latter country, a judge is then consulted); if the woman is a minor in Portugal or Yugoslavia. Parental consent is no longer required for women over 16 in Bosnia-Herzegovina or for minors in Slovenia and “the Former Yugoslav Republic of Macedonia” if they are fi nancially independent. In France, since July 2001, parental consent for girls under 18 is no longer mandatory but is recommended. In certain circumstances, abortion law for minors may be relaxed. The statutory deadline for abortion can be extended in fi ve countries: it may exceed 12 weeks in Austria if the woman is under 14 and can run to 18 weeks for teenagers under 16 in Norway, 20 weeks in Finland for women under 17, 21 weeks in Estonia for women under 15, and 22 weeks in Georgia for adolescents under 16. Access to abortion is facilitated legally or fi nancially for minors in three countries: in Iceland, where abortions can be carried out at the woman’s request only if she is unable to look after a child because of her youth or lack of maturity; in Liechtenstein if the woman is under 14, the birth would be ille- gitimate and she is unable to marry the man responsible for the pregnancy; in Bulgaria the abortion is performed free of charge. Abortion laws provide a theoretical framework for the conditions under which abortion should be performed, but these conditions are not always respected: some women get round their country’s laws by travelling abroad for

1. This matter of authorisation has not been clariﬁ ed for the other countries.

32 Contraceptive practices and use of abortion among adolescents and young adults in Europe abortions. There is also the question of illegal abortions, often performed in conditions of hygiene that jeopardise the woman’s health, for which no data are available. Lastly, it must be emphasised that many private-sector abortions in central and eastern Europe are not recorded in the statistics. However, these abortions are performed in satisfactory conditions of hygiene. Conditions for legal access to abortion differ greatly in Europe. These legislative differences affect use of abortion, measurement of its prevalence, available statistics, and the health consequences of abortion.

Trends in use of abortion: falling in central and eastern Europe and stable elsewhere Abortion trends for young people are studied in the light of abortion rates. The data presented here are based mainly on the comparative studies published by the Alan Guttmacher Institute (Singh and Darroch 2000, Alan Guttmacher Institute 2001) and show only legal abortions. Of the 7.7 million abortions performed in Europe (all ages), it is estimated that 12% are carried out illegally, this percentage being between 12 and 13% for southern and central and eastern Europe, 8% for northern Europe and under 0.5% for western Europe (Alan Guttmacher Institute 1999). A long-standing division is apparent in Europe with a higher prevalence of abortion in the countries of central and eastern Europe and the former Soviet Union in comparison with other countries: abortion has long been practised there, since it was legalised very early and used as a substitute to contraception. Abortion rates between 1985 and the end of the 1990s have followed different patterns according to country and the women’s age (Figures 8 and 9). For women aged 15-19 they have shown a decline in central and eastern Europe, with the exception of Bulgaria and Hungary. In Slovenia, Yugoslavia and the Czech Republic the rates have fallen by about 20 per 1000 to 10 per 1000. In other European countries, the trend is more stable: in most countries the variation in the abortion rate does not exceed 2 per 1000, these rates are less than 10 per 1000 in Belgium, France, Netherlands, Italy, Spain and Germany. For the 20-24 age group, the changes are more marked: there is an appre- ciable decline in abortion rates throughout central and eastern Europe, although levels still remain very high in Bulgaria, Estonia and Belarus. The drop is particularly sharp in the Czech Republic, Slovakia and Slovenia, and in Croatia, where rates have halved, whereas in Hungary, the rates remain practically constant at around 40 per 1000. In the other European countries, the changes are less pronounced, with rates falling in northern Europe since the 1990s with the exception of Iceland.

33 Reproductive health behaviour of young Europeans

Figure 8a – Abortion rate for women aged <20 years in central and eastern Europe p. 1000 45

0 1984 1986 1988 1990 1992 1994 1996 1998 Belarus Bulgaria Croatia Estonia Hungary Slovak Rep. Slovenia Yugoslavia Czech Rep.

Figure 8 b – Abortion rate for women aged <20 years in other countries p. 1000 45 40 35 30 25 20 15 10 5 0 1984 1986 1988 1990 1992 1994 1996 1998

Italy Denmark England-Wales Finland France Iceland Ireland Netherlands Norway Scotland Spain Sweden Germany

34 Contraceptive practices and use of abortion among adolescents and young adults in Europe

Figure 9 a – Abortion rate for women aged 20-24 years in central and eastern Europe p. 1000

140

120

100

0 1984 1986 1988 1990 1992 1994 1996 1998

Belarus Bulgaria Croatia Estonia Hungary Slovak Rep. Slovenia Czech Rep.

Figure 9 b – Abortion rate for women aged 20-24 years in other countries p. 1000 45

0 1984 1986 1988 1990 1992 1994 1996 1998

Belgium Denmark England-Wales Finland France Iceland Ireland Netherlands Norway Scotland Spain Sweden Italy Germany

35 Reproductive health behaviour of young Europeans

The decline in abortion in central and eastern Europe may be partly due to a larger number of abortions being carried out in the private sector and therefore not recorded. It is nevertheless consistent with the change in contraceptive use at ﬁ rst intercourse analysed above. The complex relationship between contraception and abortion will be discussed in greater detail subsequently.

A marked difference between the 20-24 age group and teenagers in central and eastern Europe Singh and Darroch (2000) have classifi ed countries into fi ve groups according to their abortion levels for the 15-19 age group: very low (under 10 per 1000), low (between 10 and 20 per 1000), moderate (between 20 and 35 per 1000), high (between 35 and 50 per 1000) and very high (over 50 per 1000), (see Appendix 9 for details). Only one country, Russia, comes into the latter category1, and in three countries (Belarus, Estonia and Bulgaria) the rates are high. They are moderate in eight countries, the majority in central and eastern Europe (including Romania, where they are greatly underesti- mated). The rates are low in twelve countries and very low in seven (mainly in northern and western Europe), but data are incomplete for fi ve countries. For women aged 20-24, abortion rates are still higher than for adolescents aged 15-19 and higher in central and eastern Europe than in western Europe. All in all, prevalence differences are much more pronounced between east and west for the 20-24 age group than for the 15-19 age group. For the 20-24 age group, rates vary between 14 per 1000 in Croatia and 110 per 1000 in Belarus, and for the 15-19 age group the maximum recorded range runs from Croatia (4.7 per 1000) at one end of the scale to Bulgaria (35 per 1000) at the other. In western Europe differences between teenagers and young adults are much smaller. Rates do not exceed 30 per 1000 for the 20-24 age group and are, at most, twice as high as for the 15-19 age group.In eight central and eastern European countries and Italy the proportion of abortions for women aged 20-24 is approximately 2.5 and 4 times higher than for those aged 15-19, whereas in other countries differences are less marked.

5. Contraception and abortion: a complex relationship Available data show that there is a statistical link between use of contraceptives and the level of abortion. It should nevertheless be remembered that published data on contraception are only for women living with a partner and cover only eight countries for women aged 15-19 and nine countries for those aged 20-24.

1. But these rates are higher than those published by the Health Ministry.

36 Contraceptive practices and use of abortion among adolescents and young adults in Europe

Overall, it can be noted that the higher the prevalence of contraception, the lower that of abortion1. This tendency is signifi cant for both the 15-19 age group (r=–0.64, p=0.08) and the 20-24 age group (r=–0.83, p=0.06) (fi gure 10 and 11). When distinguishing according to the type of contraception used, it seems that this relationship holds only for medical contraception (pill and IUD). Thus, the higher the prevalence rate for medical methods, the lower that for abortion: the correlation coeffi cient is –0.68 (p=0.07) for women aged 15-19 and –0.75 for those aged 20-24 (p=0.02). On the other hand, this tendency is inverted if the prevalence of natural methods (withdrawal and periodic abstinence) are taken into account: the correlation is positive for the 20-24 age group (r=0.80, p=0.09), i.e. the higher the prevalence of these methods, the higher the abortion rate2.

Figure 10 – Contraceptive prevalence and abortion rate (women <20 years) 50 45 40 35 30 25 20 15

abortion rate (p.1000) 10 5 0 020406080100 contraceptive prevalence

all methods pill+IUD Linear (all methods) Linear (pill+IUD)

The prevalence of abortion thus drops when women use medical methods of contraception: conversely, use of natural methods, whose use effectiveness is lower, tends to maintain high levels of abortion, as is the case in central and eastern Europe.

1. Correlation coefﬁ cients have been calculated by relating contraceptive prevalence for the survey year to the prevalence of abortions recorded for the same year. 2. This correlation has not been calculated for the 15-19 age group since in two countries the natural contraception rate is nil.

37 Reproductive health behaviour of young Europeans

Figure 11 – Contraceptive prevalence and abortion rate (women 20-24 years) 100 90 80 70 60 50 40 30 20 abortion rate (p.1000) 10 0 020406080100

contraceptive prevalence

all methods pill+IUD Linear (all methods) Linear (pill+IUD)

For all that, contraceptive prevalence alone cannot account for the level of abortion in a given country. Three countries – Norway, Slovenia and the Czech Republic – have abortion rates verging on 30 per 1000 but with different prevalence rates for contraception: in Norway contraceptive prevalence is high (76%) and 78% of this is medical contraception; in Slovenia and the Czech Republic contraceptive prevalence rates are around 55% but medical contraception represents 49% of methods among Slovene women and 86% of methods among Czech women. These few data clearly illustrate the com- plexity of the relationship between contraception and abortion and the need to take account of other elements to explain use of abortion.

Recourse to abortion: a multi-stage process The factors which determine recourse to abortion are various and equally concern sexuality, use of contraception, decision processes in the event of an unwanted pregnancy, and the conditions of access to the health care system, as the diagram below illustrates.

Different stages of recourse to abortion

Contraception Decision process Access to abortion Sexuality Pregnancy Decision to abort Abortion

38 Contraceptive practices and use of abortion among adolescents and young adults in Europe

The factors associated with sexual activity are not necessarily the same as those determining contraceptive prevalence or use of abortion; moreover, these factors do not necessarily work along the same lines. It is therefore necessary to analyse the successive links of this chain leading to abortion to reach a better understanding of the ins and outs of this practice. The different stages of this process, which are not separate from each other, are explored focusing on those for which data is available.

Sexuality and contraception Analysis of obstacles to contraception (see above) show that the links between sexuality and contraception are complex and involve both the issue of societies’ recognition of sexuality and sexual social relations. Even in countries where, thanks to medical contraception, sexual intercourse is dissociated from reproductive issues, the links between sexuality and contraception remain strong, whether for choosing a method or for managing it on a daily basis (Bajos, Ferrand et al. 2002). In addition to the contraceptive used, the characteristics of the population’s sexual activity will determine the period and intensity of exposure to the risk of pregnancy. This study does not cover sexual activity which is examined in Part Two. It should be noted, however, that a comparative study of teenage pregnancies in industrialised countries led its authors to emphasise that data on sexual activity were less of a determining factor for pregnancy rates than use of contraceptives (Darroch, Singh et al. 2001).

Contraception and pregnancy A pregnancy may occur if a women does not use contraception or if the method used fails. There are multiple barriers to regular use of contraception, as has been seen above. The relationship between the pregnancy rate among women aged 15-19 and contraceptive prevalence is marked (r=–0.73, p=0.04); contraceptive prevalence covers only women living with a partner, whereas the pregnancy rates are compiled for all women. As in the previous case, this relationship depends on the type of contraception used: the more women use an medical contraceptive method, the lower the pregnancy rate ( r= –0.67, p=0.07). On the other hand, if they use only a natural method (withdrawal or periodic abstinence), the correlation approaches zero (r= –0.06, p=0.89), demonstrating a very low use effectiveness for these methods. They are difﬁ cult to use, since they assume not only that young women have a good understanding of their fecund periods but also that they are able to negotiate use of such methods with their partners. These ﬁ ndings underline the importance of availability of medical contraception in preventing pregnancies, contraception which is not always easily obtainable in central and eastern European countries. It must also be stressed that there is a strong correlation between pregnancy rate and level of education for women aged 15-19: the greater the percentage

39 Reproductive health behaviour of young Europeans of women with no education, the higher the pregnancy rate (r=0.52, p=0.03); similarly, the greater the proportion of women with primary or secondary education, the lower the level of pregnancy (r=–0.58, p= 0.01). These differences show that women from disadvantaged backgrounds may have problems with use of contraception, as indicated previously, but they could also reﬂ ect a greater tendency to continue with the pregnancy if contraception has failed.

The decision to abort It must ﬁ rst of all be emphasised that pregnancies among adolescents are not necessarily all unplanned pregnancies. Teenage childbearing, regarded as socially premature, is not automatically evidence of contraceptive failure and/or the impossibility of obtaining an abortion. It may represent a means of acquiring status and social identity, even if it is likely to handicap the young mother’s future (Unicef 2001) and have consequences for the young woman’s health. In countries such as France where access to contraception is relatively easy, a large proportion of births to teenage mothers arise from intended pregnancies (Toulemon and Leridon 1992). The decision whether to continue or terminate a pregnancy seems to depend largely on young women’s living conditions (Unicef 2002). It is closely associated with these women’s family status, their relationships with their partners and their dependency on them or their parents (Singh, Darroch et al. 2001), social norms and the young people’s educational and employment prospects. For adolescents aged 15-19, the higher the pregnancy rate, the higher the abortion rate as well (r=0.88, p=0.00 ) (cf. Figure 12). However, no correlation has been recorded between the pregnancy rate and the proportion of pregnancies ending in abortion (ratio) (r=0.06, p=0.78).

Figure 12 – Pregnancy and abortion (women < 20 years) 120

100

abortion rate 40

0 020406080100 120

pregnancy rate source : AGI

40 Contraceptive practices and use of abortion among adolescents and young adults in Europe

The highest ratios (over 50%) are found among adolescents in northern Europe (Sweden, Denmark, Norway, Finland and Iceland) and in Hungary, Russia and France (abortion being, however, under-reported in the latter two countries). Thus the contrast between central and eastern European countries and the rest, which was noted when analysing abortion rates, is less apparent when looking at abortion ratios (Figure 13). These high ratios also exist in countries where access to contraception (especially medical contraception) is easy and widespread among adolescents; in Norway and France, for example, abortion ratios are over 50%, whereas the prevalence of contraception is high and over 90% of it is medical.

Figure 13 – Abortion ratio for women aged <20 in Europe

80 70 60 50 40 30 20 10 0 y Italy Spain Latvia GeorgiaIreland Belgium Bulgaria Belarus Estonia Iceland France Sweden Moldova Scotland Romania Slovenia Hungary Finland NorwayDenmark N-Ireland GermanSlovak Rep. Czech Rep. Netherlands Russian Fed. England Wales

source : AGI Women with the most education in the 15-19 age group are more likely to have an abortion in the event of an unplanned pregnancy than those with the least education: the correlation between the abortion ratio and the proportion of women with primary or secondary education is 0.43 (p=0.08)1. The more education women have, the more they will reject unplanned pregnancies. This ﬁ nding agrees with a similar ﬁ nding in numerous studies that women with high social and cultural capital will postpone parenthood, which may be a barrier to achievement of their educational or occupational plans (Bankole 1999; Singh, Darroch et al. 2001).

Do conditions of access inhibit use of abortion? These differences in abortion ratios also raise the question of conditions of access to the health care system. Although legality of abortion has a strong inﬂ uence on recourse to abortion and its consequences in terms of morbidity and mortality, as the history of Romania shows (Johnson and Horga 1996), legislative restrictions (parental consent, procedures which are not free of charge), on the other hand, do not seem in themselves to explain the differences in use of abortion. Thus it has been seen that in central and eastern Europe where abortion is legal but hard to access owing to cost, abortion

1. Eurostat data, International standard classiﬁ cation of education (based on ISCED 1997).

41 Reproductive health behaviour of young Europeans rates are particularly high. This point clearly merits closer consideration than any study so far published can help to provide. The conditions under which abortions are performed will in any case have consequences for the health of the women concerned.

The purpose of abortion The purpose of abortion varies from country to country, depending on how long it has existed and the conditions of access to medical contraception. In countries where the latter is widespread, abortion tends to be used to counteract failure of medical contraception, whereas it is regarded more as a contraceptive method in countries where little use is made of modern contraception and where women have long used abortion to regulate their fertility (Wielandt, Boldsen et al. 2002). This is the case in central and eastern Europe: abortion has long been legalised there and for decades was the main means available to women to manage their fertility, together with traditional contraceptive methods (withdrawal and abstinence), in the absence of modern contraception (Bru- yniks 1994, Santow and Bracher 1999). Information, especially at school, and contraceptive provision are often lacking in these countries. The choice of methods is limited and their cost high (sometimes higher than that of an abortion), and supply is often irregular and inadequate (Kovacs 1999). The training of service providers (doctors and non-doctors) is not suffi cient to provide counselling and high-quality medical treatment, which explains why some women have a negative perception of contraception and contributes to unsatisfactory conditions of use. It could be asked whether there is not a confl ict of interest among the service providers, who might prefer the easy task of performing an abortion (also a source of income) to the anticipated diffi culties of prescribing contraceptives. For their part, gynaecologists in the Czech Republic and Russia explain the persistence of high abortion rates by a lack of sex education, failure to use contraceptives or use of traditional methods, which women prefer and which are better understood than modern methods (Visser, Uzel et al. 1993). As for the purpose of abortion for the individual, it is the factors determining the abortion decision which will shed light on this. The higher prevalence of abortion in certain social status groups refl ects fi rst and foremost a greater exposure to the risk of unplanned pregnancy associated with problems in gaining access to contraception – problems encountered above all by women from disadvantaged backgrounds. This high prevalence in disadvantaged environments does not, however, necessarily predetermine the grounds for using abortion.

42 Contraceptive practices and use of abortion among adolescents and young adults in Europe

National surveys (CDC and DHS) show that in both Romania and Georgia abortion rates among women aged 15-19 and those aged 20-24 are higher in rural areas than in urban areas and in populations from the most disadvantaged social classes, whose socio-economic status is low and/or average and who are facing diffi cult living conditions. For these women, the wish to limit their fertility in an uncertain socio-economic context seems to underlie their decision to have an abortion. In Moldova, 60% of young women reported having had an abortion on account of their socio-economic diffi culties. Other surveys on teenage pregnancies in fi ve developed countries, including Sweden, France and Britain, show that young women in diffi cult social circumstances become parents earlier. In Britain this applies to young women who have family problems, in France to those with diffi culties at school and in Sweden to those from separated families and with low socio-economic status (Singh, Darroch et al. 2001, Bajos and Durand 2001). Similarly, other studies of central and eastern European countries emphasise the fact that the young women with the most education will more often terminate an unplanned pregnancy in order to be able to complete their education or gain occupational experience before starting a family (Bankole, Singh et al. 1999). For some, a socially premature pregnancy may thus burden their chances of educational success or employment; for others, it will on the contrary be a means of acquiring status and social identity through childbearing.

6. Consequences of abortion for women’s health The consequences of abortion in terms of ill-health and mortality are largely contingent on the conditions in which abortions are performed: the health environment, the method used, the type of anaesthetic employed and the length of pregnancy at the time of abortion. Legalisation of abortion and an improvement in the conditions of hygiene in which it is performed have helped to bring about a steep decline in mortality due to post-abortion complications, as was seen in Romania. The risks of abortion for women’s health are very limited provided that statutory procedures for access to abortion are simple and affordable and medical treatment is provided in satisfactory conditions. But some women continue to run the risk of back-street abortion if they are unable to comply with the statutory requirements or if there are serious restrictions on access to the health care system. Little information is available on complications and mortality relating to teenage abortions.

Which methods of abortion are used? Abortion methods differ according to country. In northern, western and southern Europe abortion is performed by aspiration, with use of anaes- thetics varying considerably from country to country. In central and eastern Europe and Russia, abortion is usually by curettage with or without a general

43 Reproductive health behaviour of young Europeans anaesthetic. Medical abortion procedures (mifepristone coupled with pros- taglandins, marketed under the name of RU486 in some countries) have been available on the market for over 10 years now in certain countries of western and northern Europe – especially France, Britain and Sweden. It has only recently been licensed in Europe and is still little used; it has just been approved in Russia and the Ukraine. In some central and eastern European countries menstrual regulation (or mini-abortion) has become widespread over the past decade or so: this aspiration procedure is often carried out by means of a syringe. Thus in Georgia and Moldova, 39% of abortions on women aged 15-24 have been performed using this method and 31.4% in the Ukraine, a country, moreover, in which 1.7% of abortions are performed by the women themselves (Serbanescu, Friedman et al., 2000, Serbanescu, Morris et al., 1998). These terminations of pregnancy by “menstrual regulation” are often not recorded as abortions, which tends to distort the registration statistics.

Frequent complications? Complications subsequent to abortions depend on length of pregnancy, hygiene conditions within the country and the abortionists’ skills. In northern and western Europe, ill-health following an abortion is low and mortality virtually nil; such data are more difﬁ cult to obtain for central and eastern Europe. Taking a study conducted in Denmark which covered over 56000 abortions in public hospitals, Zhou emphasises that only 5% of cases were recorded as having complications (haemorrhaging, infection or re-evacuation) but that they were more frequent among adolescents (Zhou, Nielsen et al. 2002). In surveys conducted in Georgia, Moldova, Romania and the Ukraine between 1997 and 1999 (Serbanescu, Friedman et al., 2000, Serbanescu, Morris et al. 1998) this question of post-abortion complications was studied, but the ﬁ ndings have still not been published with reference to the women’s age. In Georgia, 10% of abortions for all women were followed by complications, 8% by immediate and 2% by longer-term after-effects; in Ukraine, 14% of women reported complications immediately after abortion and 6% in the longer term. In Romania, 8% of women aged 15-24 had immediate post-abortion complications and 2% had subsequent complications; in Moldova, 9% had immediate complications and 5% had later problems. The most frequently reported complications were pelvic pain, severe or prolonged haemorrhaging, high temperatures, pelvic infection and, in a few cases, per- foration of the uterus. In these four countries, the frequency of complications increased with the length of pregnancy.

44 Contraceptive practices and use of abortion among adolescents and young adults in Europe

Is abortion still a cause of maternal mortality? A comparison of maternal mortality rates for women aged 15-49 in Europe shows that mortality is higher in the countries of the former Soviet Union than in other European countries. In 1995 this mortality was estimated to be 28 per 100,000 live births for Europe as a whole, but with considerable regional disparities ranging from 50 per 100,000 in central and eastern Europe to 12-14 per 100,000 in other regions (Appendix 10). Of course these deaths are not all attributable to abortion (United Nations Population Division 2002). Unsafe abortion ratios1 (number of unsafe abortions per 100 live births) are nil in western Europe and 4 to 10 times lower in southern and northern Europe than in central and eastern Europe. The proportion of maternal deaths due to unsafe abortion is 17% for the whole of Europe, but the same disparities are found when comparing central and eastern Europe, where this ratio reaches 24%, with southern Europe, where it is only 10%, and northern and western Europe, where it is 2 to 0% (World Health Organi- zation, Maternal and Newborn Health 1998). The three countries where the number of post-abortion deaths is highest are Romania, Bulgaria and the former USSR (Ivanov and Vasilev 1993). These ﬁ ndings raise the question of the conditions in which these abortions are performed in central and eastern Europe. Although abortion is legal in most of these countries, the cost of the operation may prevent some women from having it performed in a hygienic environment.

7. Conclusions Analysis of the data on contraception and abortion among young people has revealed the limitations of this information, either because in some countries the data does not exist or is incomplete and/or it does not enable us to follow changes over time. In particular, it should be remembered that published data on contraceptive methods used at ﬁ rst intercourse are not available; the same applies to contraception by persons not living with a partner, and published benchmark statistics do not provide indicators of social afﬁ liation2. As for contraceptive provision, no comparative data are available and country-by- country information which have been published are scanty. Data on abortion are incomplete for a number of countries, even when the operation is legal, and some countries publish no data at all. Moreover, there are no estimates for illegal abortions, especially in countries where statutory conditions of

1. The WHO deﬁ nes unsafe abortions as procedures by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both. 2. More detailed data on contraceptive practices exists in some surveys, in particular the method of contraception used during the ﬁ rst encounter and contraception used by women not in a couple. Also, social variables are available such as education levels and work. But this information is not published in the summary reports upon which this study is based.

45 Reproductive health behaviour of young Europeans access are restrictive and where access to abortion services is diffi cult. All in all, published data are approximate and do not allow detailed analysis of this phenomenon (profi le of women, methods used, actual provision, etc.). In such circumstances, it is diffi cult to carry out comparative analysis. Despite these limits, the data presented in this report show that the differences between central/eastern and western Europe have tended to diminish over time and reveal the historical infl uence of socio-political context. However, the recorded differences remain wide with regard to contraceptive practices, abortion and health risks for women due to abortions carried out under inexistent or inadequate conditions of hygiene. In countries where teenage access to contraception is easiest and most legitimate, young people use more protection against unplanned pregnancies. In countries where the conditions of access to abortion are most restrictive, the ill-health and mortality resulting from its practice are highest. Major disparities exist between central and eastern Europe and the rest of Europe regarding the prevalence of contraception and the methods used: contraception is used less frequently in the east and also women use more frequently natural methods (withdrawal, abstinence) and condoms whilst in other European countries contraception is mostly based on medicalised methods. The barriers revealed in many studies already open up numerous courses of action. These barriers arise from various processes of social reasoning that go far beyond the ambivalence which some women may feel towards wanting a pregnancy or their lack of knowledge in this fi eld, and seem particularly to affect young people from the most disadvantaged social backgrounds. Government responses to reproductive health should promote social tolerance of young people’s sexuality and ensure proper dissemination of information on contraception, especially among young people and through a range of channels (school, media, youth centres, public entities, etc.). But they should also involve developing contraceptive provision, training of sexual and reproductive health personnel and setting up structures to receive and handle demands for contraception and abortion that meet the needs and expectations of young people and which take into account the fi nancial constraints they face. The prevalence of abortion also distinguishes central and eastern Europe from other European countries. Although the abortion rate in central and eastern Europe is decreasing, it remains higher than in the rest of Europe, in particular for women aged between 20-24 years. In eight central and eastern European countries and Italy the proportion of abortions for women aged 20-24 is approximately 2.5 and 4 times higher than for those aged 15-19, whereas in other countries differences are less marked. These differences highlight the diffi culties of access to contraception, in particular medicalised contraception, but also the different use made of abortion. This still seems to

46 Contraceptive practices and use of abortion among adolescents and young adults in Europe be used as a method of contraception in central and eastern Europe where abortion was liberalised very early on and for a long time was the only accessible way of regulating fertility, modern contraception being inacces- sible or of limited access in these countries. The differences observed of access to contraception and abortion, but also the different rates of maternal mortality, in part due to unsafe abortions, highlight the need to develop health policies to reduce differences between countries and to improve the sexual and reproductive health of adolescents. Sexual and reproductive health policies must think globally, without disso- ciating contraception and the prevention of sexually transmitted infections and in particular HIV infection. Given the HIV epidemic in central and eastern Europe, promoting the condom, linked with emergency contraception in cases of need, should be a priority axe. Over and above legal measures per se, all action aimed at improving young people’s education, men’s involvement in contraception, and increasing women’s empowerment and respect for women will encourage proper attitudes to, and use of, contraception and prevention and will help indirectly to change social norms regarding sexuality. Allowing young Europeans genuine freedom to time their parenthood seems to be a key social and public-health challenge at the beginning of the 21st century, especially for young people from the most disadvantaged backgrounds. This objective must not be approached from a normative angle with the aim of systematically preventing all teenage pregnancies. Of course, many studies show that young mothers are much more likely to encounter social and economic difﬁ culties. But do young mothers bring their schooling to an end because maternity prevents them from continuing their education, or do they become mothers because they are already failing at school? For some young women, socially premature childbearing represents a means of acquiring status and social identity, which they have had little opportunity to acquire otherwise. Nonetheless, caring for a baby in often difﬁ cult social and economic circumstances does not help to alleviate any of these young women’s problems. However, a drop in teenage pregnancies cannot automatically relieve the poverty in which some young women are living. It is rather an increase in school enrolment among these young women and the spread of contraception which underlie the fall in teenage pregnancies observed in Europe over the past few decades.

Appendices

Appendix 1 – List of different national surveys in the Council of Europe member States Albania Andorra Armenia CDC 2000 Austria FFS 1996 Azerbaijan Belarus Belgium FFS 1996 Bosnia and Herzegovina Bulgaria FFS 1997 Croatia Cyprus Czech Republic FFS 1997– CDC3 Denmark FFS 1994 Estonia FFS 1994 Finland FFS 1989 France FFS 1994 Georgia CDC 1999-2000 Germany Greece FFS 1999 Hungary FFS 1992-93 Ireland Iceland Italy FFS 1995-96 Latvia FFS 1995 Liechtenstein Lithuania FFS 1994-1995 Luxembourg Macedonia* Moldova CDC 1997 Norway FFS 1998 Netherlands FFS 1993 Poland FFS 1991 Portugal FFS 1997 Romania CDC 1993 - CDC 1996 - CDC 1999 Russian Federation CDC 1996 (3 cities) Spain FFS 1995 Slovak Republic Slovenia FFS 1994 Sweden FFS 1994-1995 Switzerland FFS 1993 Turkey DHS 1993, DHS 1998 Ukraine CDC 1999 United Kingdom United Kingdom Yugoslavia

FFS: Family and Fertility Survey, DHS: Demographic an Health Survey, CDC: Center for Disease Control and Prevention * The use in the tables of the term “Macedonia” is for descriptive purposes and the convenience of the reader.

49 Reproductive health behaviour of young Europeans - - asons or if woman Cost Paying Paying Paying Free if for medical Free re <18 years is criteria Ireland, the Holy See, is criteria Ireland, -- - - 1 for minors Parental up to 14 Parental years Parental or guardian or guardian Parental if woman under age except if >16 years or earning her living Parental up to 18 Parental years if or guardian Parental <16 years Conditions for exceeding maximum period Authorisation authorised by a medical committee No limit if medical reason under 14 years if risk of congenital illness or mental the child of rape or incest is the result pregnancy >20 weeks if life or health of the woman is seriously threatened No limit if incurable illness of fœtus or serious risk to the health woman’s Up to 20 weeks for medical reasons if risk of congenital illness or mental the child of rape or incest is the result pregnancy Legal maximum period * 12 weeks >12 after medical consultation - - 12 weeks Up to 28 weeks for medical and social or personal reasons 10 weeks or >10 weeks if the life or health of woman is threatened 10 weeks or >10 weeks if the life or health of woman is threatened legislation 1936-1955 1982-1987 19961950 12 weeks Up to 22 weeks if rape, sexual abuse or social reasons 1974–1975 12 weeks 12 weeks >12 weeks if life or health of woman in danger for minors 1936-1955 Up to 22 weeks if medical or social reasons 1982-1987 - Paying 1952-1969 1974-1977 1990 12 weeks Up to 12 weeks if medical reason 1990 12 weeks Up to 16 weeks for social reasons 1952-1969 1978 Country Date of Belarus Albania Armenia Austria Azerbaijan Bosnia and Herzegovina Belgium Bulgaria Croatia Appendix 2 – Legislative conditions concerning abortions in different European countries Appendix 2 – Legislative conditions concerning abortions in different 1. th To Abortion is completely forbidden in Malta. In Andorra it except when the life of mother danger. Monaco and Lichtenstein also make an exception if the physical or mental health of woman is in danger.

50 Appendices ee if low income, ee if woman has r r Social security up to 80 % 100% women <18 years or living in poverty State medical reasons, rape, sexual crime; if not, social security in part Free Paying in private sector rights to health cover if medical reasons State State and the woman State and the woman -F -F - Parental authorisation authorisation Parental only recommended since 2001 Parental up to 16 Parental years up to 16 Parental years Parental if < 16 yearsParental for all women Free up to 16 Parental years Parental up to 18 Parental years >12 weeks if risk to the health or life of woman fœtal malformation No limit if medical reasons or foetal malformation No limit if medical reasons of the woman or rape other sexual crime fœtal mal- or girl <16 years >40 formation or social reasons woman with AIDS by a special medical but approval >22 weeks same reasons committee of the woman or rape other sexual crime up to 24 weeks in case of serious fœtal abnormalities If risk to physical or mental health of the woman fœtal malformation or rape other sexual crime fœtal malformation or rape other sexual crime Up to 21 weeks if woman <15 years or >45 for of the Minister (illnesses listed by decree medical reasons social affairs) mental health or rape other sexual or risk to the woman’s crime health Up to 20 weeks if risk the woman’s life or risk of fœtal Up to 24 weeks if risk the woman’s malformation risk of severe fœtal malformation risk of severe ed 12 weeks* 12 weeks Up to 12 weeks if rape or sexual crime speciﬁ 12 weeks life or risk of or risk to the woman’s >12 if medical reasons 11 weeks and 6 days 12 weeks or socio-economic Up to 12 weeks if socio-medical reason 2000 12 weeks 12 to 22 weeks if risk the physical or mental health From 1992-1995 1993 1986 12 weeks Up to 20 weeks if risk for the physical or mental health life 1974-1986 Limit not 1986–1987 1993 1973-1999 12 weeks1955–1992 life is at risk or >12 weeks if medical risk or the woman’s 1993-1998 1970– 978 1985 1975-2001 Georgia Germany Greece Cyprus Czech Republic Denmark Estonia Finland France

51 Reproductive health behaviour of young Europeans easons, women Paying Paying Social security State Free Paying Paying Paying Paying if medical Free r in poor health or prisoners Social security State - - Parental (written) up Parental to 16 years years (or guardian) Parental up to 16 years or agree- Parental ment of a judge if woman<16 years for under Parental age women up to 18 Parental years Parental up to 18 Parental years up to 16 Parental years up to 18 Parental years, possibility of by a being replaced magistrate rmed by a to 22 weeks for special medical and/or social reasons Parental up to 18 quarter if risk to the woman’s life or serious fœtal quarter if risk to the woman’s nd public prosecutor) 2 of the woman or fœtal malformation >12 weeks if risk to the physical or mental health life of the woman or fœtal malformation rape other sexual crime of distress or mental health of the woman fœtal malformation rape or other sexual crime if woman <16years malformation woman Up to 16 weeks if rape or other sexual crime Up to 24 weeks if risk of foetal malformation Up to 28 weeks if socio-medical or socio-economic reasons other sexual crime or in a serious crisis health of the woman is in danger or fœtal deformity rape or inability to look after the child >90 days if risk to the physical or mental health life of woman or risk of fœtal malformation rape other sexual crime quarter Up

st 12 weeks Up to 22 weeks if risk for the physical or mental health life 1 1955-1987 1990 1978 12 weeks1981-1984 Up to 12 weeks for medico-social reasons 13 weeks1975-1978 to be in a state Up to 24 weeks if the woman is recognised 12 weeks or risk for the life physical Up to 18 weeks if social reasons 1993-1997 12 weeks Up to 12 weeks if rape or sexual crime (conﬁ 1984-1997 12 weeks Up to 12 weeks if risk the life or mental health of 1956-1982 12 weeks Up to 25 weeks upon decision of a special committee 2000 12 weeks >12 weeks if serious risk for the life of woman or rape 19751975-1978 12 weeks 90 days or if the life Up to 12 weeks if medical and social reasons Up to 90 days if social, medical or economic reasons 1991-1993 2000 Lithuania Luxembourg Netherlands Norway Poland Portugal Moldova Hungary Iceland Italy Latvia

52 Appendices - cult easons Free if medical Free r Social security Major part by social security - Paying Free Paying in private sector Social security Paying in private sector - difﬁ circumstances gislation in Europe (update October gislation in Europe Parental or guardian if or guardian Parental woman under age Parental up to 16 Parental years, and informa- (after tion to parents abortion) if woman 16-18 years if woman under age except if she earns her living - Legal authorisation if under age <16 years if woman under age except if she earns her living or guardian Parental or legal authorisation if under age <18 if under age Pparental <16 years <16 years -Free quarter if risk to the woman’s life or fœtal malformation quarter if risk to the woman’s - life or risk of fœtal malfor- quarter if risk to the woman’s for women in Free nd nd socio-economic reason socio-economic reason no limit if risk to the life or health of woman mation or rape other sexual crime life No limit if risk to the woman’s health of the woman malformation social or medical reasons agrees) or medical reasons agrees) 10 weeks >10 weeks if risk to the health or life of woman or guardian Parental 10 weeks >10 weeks if authorised by a commission medical, legal or 1977 1991-1992 19851974-1995 12 weeks1942 -2001 18 weeks Up to 22 weeks if important reasons Up to 22 weeks if risk of foetal malformation 12 weeks no limit (12-14 weeks) if risk to the life or physical mental 1977 10 weeks1983 >10 weeks if authorisation given1953 10 weeks - >10 weeks if risk to the life of women or fœtal 1967-1990 12 weeks 12-28 weeks if risk to the physical health of woman or 24 weeks Up to 24 weeks if social or medical reasons1974-1977 1979-1995 or guardian Parental Social security if or guardian Parental 19891955-1993 12 weeks 12 weeks 2 Up to 22 weeks for social (without limit if the woman 1986-1987 12 weeks 2 ugoslavia urkey Slovenia Spain Sweden Switzerland Macedonia T Ukraine United Kingdom Y Romania Russian Fed. Slovak Rep. Source: United Nations: World Abortion Policies 1999, Abortion Policies: a global review, vol. I to III; IPPF 2001: Abortion le Abortion Policies 1999, Policies: a global review, United Nations: World Source: 2001) - not informed, * duration of pregnancy

53 Reproductive health behaviour of young Europeans 25.5 28.6 53.5 77.874.5 42.9 35.7 43.2 0.0 63.9 3.7 14.3 10.8 ithdrawal 7.5 0.0 3.5 11.1 5.7 10.8 23.0 ear 2000 1997 1997 1992-93 1995 1994-95 1997 otal 100 100 100.0 100.0 100.0 100.0 100 PillIUD 2.8DiaphragmCondom 7.1Periodic abstinenceW Other method 5.5% of CM 2.1 had sex, Fecund, not pregnant, 0no contraceptive method used 2.6Status unknown 3.7T 7.1 10.5 0.0 0Base 14.3 2.9 19 40.7 0.0 - 0.0 0.0 0.0 5.4 48.1 50 3.8 3.7 14.3 0.0 11.1 25.8 99 14.3 86 0.0 0.0 11.2 20.0 0.0 5.4 14 67 0.0 0.0 2.7 18.9 2.7 23 0.0 40 10.4 14.3 0.7 27 1.3 8.1 25 35 - 45 37 769 CountryY CohortAge had sex, Fecund, not pregnant, used contraceptive method Armenia BulgariaRep.Hungary Czech 81-85 Latvia 15-19 78-79 Lithuania 18-19 78-82 Moldova 15-19 73-74 18-19 s75-77 18-19 75-77 18-19 73-82 15-24 Appendix 3 – Contraceptive status of couple (women <20 years)

54 Appendices 55.5 92.0 85.7 33.68.1 47.4 7.0 NC* 7.1 46 - - NC - ithdrawal 20.3 21.6 17.3 13.8 4.4 31.1 ear 1994 1993 1995 1998 1999 1997 1999 otal 100.0 100.0 100.0 100 100 100.0 100 PillIUD 0.0DiaphragmCondom 0.0Periodic abstinenceW Other method 7.6% of CM 27.1 0.0 had sex, Fecund, not pregnant, 0.0no contraceptive method used 8.0Status unknown 7.4 88.0T 4.0 0.0Base 0.0 3.4 44.4 49 0.0 6.7 0.0 12.1 1.9 0.7 96 0.5 0.0 6 1.2 1 13 61 6.4 0.5 0.0 20.8 54.7 138 28 1.9 39.1 8.2 14.0 10 0.2 1.1 1.9 262 55 4.2 121 20 29 116 CountryY CohortAge had sex, Fecund, not pregnant, used contraceptive method Slovenia Netherlands Spain 76-80 Turkey 15-19 74-73 Ukraine 18-19 75-77 Portugal 18-19 Romania 79-83 15-19 79-84 15-19 77-82 15-19 80-84 15-19 Source FFS and CDC DHS surveys Source

55 Reproductive health behaviour of young Europeans 55.3 69.2 35.7 59.4 56.5 80.844.7 53.4 35.1 63.3 4.7 61.8 8.0 5.9 28.4 13.5 11.3 ithdrawal 31.4 0 8.9 6.0 9.3 1.7 19.0 4.9 3.2 ear 2000 1996 1997 1997 1994 1994 1999 1992-93 1995 otal 100 100 100 100 100 100 100 100 100 CountryY CohortAge had sex, Fecund, not pregnant, used contraceptive method PillIUD 5.9 Armenia AustriaDiaphragmCondom 2.2 Bulgaria Czech Rep.Periodic abstinence Estonia 20-24W 3.6 FranceOther method 72-76 20-24% of CM 10.3 Greece 73-77 0.8 20-24 had sex, Fecund, not pregnant, 1.8 HungaryNo contraceptive method used 73-77 Latvia 20-24 7.6 17.6Status unknown 53 2T 69-73 7.8 6.3 20-24 10.5Base 6.0 69-73 4.8 20-24 10.7 1.5 3.4 12 0.6 75-79 30.5 20-24 - 0.0 12.5 68-72 1.2 4.9 0.0 20-24 80 5.3 70-75 22.6 20-24 11.6 21.9 0.0 14.5 26 68.3 10.1 511 0.3 4.2 68 3.7 5.2 16.5 297 0.0 2.6 23.3 0.0 43.1 50 - 168 8.4 0.0 1.5 21.5 0.0 147 92 19.4 0.5 2.2 3.7 0.0 0.0 16 326 0.0 0.5 177 75 4.2 116 12.4 58 406 186 Appendix 4 – Contraceptive status of couple (women 20-24 years)

56 Appendices 47.4 76.3 86.0 NC* 62.1 6525.6 7.8 74.7 52.9 4.0 63 - - 9.2 13.5 - 37 ithdrawal 4.9 2.3 2.7 32.5 5.4 7.5 21.6 24.2 ear 94-95 1988 1993 1997 1999 1994 1995 1998 1999 otal 100 100 100 100 100 100 100 100 100 CountryY CohortAge had sex, Fecund, not pregnant, used contraceptive method PillIUD 9.1 Lithuania NorwayDiaphragm NetherlandsCondom 5.0 Portugal 70-75Periodic abstinence Romania 1968 Slovenia 20-24W 1.0 SpainOther method 73-68 20% of CM Turkey 5.6 0.5 0.4 had sex, Fecund, not pregnant, 6.7 72-77 Ukraine 20-24No contraceptive method used 20.4Status unknown 54.8 5.0T 20-24 13.7 0.0 78.0Base 9.6 20-24 71-75 - 5.0 0.5 31 20-24 77.1 3.2 70-75 6 20-24 2 78 17.8 9.8 16.3 20-24 0.5 9.4 33.7 12.9 20-24 91 1.9 - 2.3 285 9.2 33.6 3.2 78 138 5.8 4.8 29.0 0.0 85.7 0.0 23 138 0.0 8.8 4.3 0.9 - 0.0 66 0.3 258 15.8 0.3 5.9 0.8 4.9 49 664 0 0.8 190 39 - 156 10 924 - 737 Source: survey FFS and CDC DHS Source:

57 Reproductive health behaviour of young Europeans

Appendix 5 – Use of contraceptives by fecund, not pregnant women in sexual relationship: FFS results (in percent)

20-24 25-29 30-34 35-39 40-44 Poland -using modern method 36 41 32 34 33 -using traditional method 52 49 55 53 55 -not using any method 12 10 13 12 11 100 100 100 100 100 Latvia -using modern method 77 74 74 71 62 -using traditional method 7 12 13 19 19 -not using any method 15 15 13 10 19 100 100 100 100 100 Hungary(1) -using modern method 74 82 78 75 67 -using traditional method 8 7 10 13 15 -not using any method 18 11 12 12 18 100 100 100 100 100 Estonia -using modern method 55 56 61 58 49 -using traditional method 32 28 24 23 23 -not using any method 12 16 15 19 28 100 100 100 100 100 Slovenia -using modern method 73 71 71 69 72 -using traditional method 15 17 18 18 13 -not using any method 12 12 12 13 15 100 100 100 100 100 Lithuania -using modern method 49 51 49 47 37 -using traditional method 16 24 24 19 27 -not using any method 35 25 27 33 36 100 100 100 100 100 Netherlands (1) -using modern method 93 95 89 79 73 -using traditional method 2 3 3 8 15 -not using any method 4 3 8 13 13 100 100 100 100 100 Italy -using modern method 47 51 56 56 50 -using traditional method 33 24 22 21 24 -not using any method 19 25 22 23 26 100 100 100 100 100

Source: estimations based on tables 19 in the corresponding FFS country reports. (1)The last age group in Hungary is 40-41, and in the Netherlands, 40-42. Modern methods include clinical and commercial methods. Traditional methods include periodic abstinence and withdrawal. Table from Dimiter Philipov in “Demographic consequences of economic transition in countries of central and eastern Europe”: Population studies No.39, Council of Europe Publishing, 2003.

58 Appendices

Appendix 6 – Trends in fertility rate (per 1000) for women aged 15-19 in Europe, 1990s

Country 1990 Most recent estimation 1997-2000 Albania Andorra Armenia Austria 20.2 13.1 Azerbaijan Belarus 43.8 39.5 Belgium 11.3 9.1 Bosnia and Herzegovina Bulgaria 69.9 49.1 Croatia 27.4 16.1 Cyprus Czech Republic 44.7 10.7 Denmark 9.1 7.7 Estonia 53.6 19.0 Finland 12.4 6.7 France 12.2 9.4 Germany 17.8 12.8 Georgia Greece 21.6 12.5 Hungary 39.5 19.4 Ireland 16.8 19.8 Iceland 30.6 19.1 Italy 9.0 6.9 Latvia 50.0 18.7 Liechtenstein 4.8 2.0 Lithuania 41.6 32.2 Luxembourg 14.1 2.3 Macedonia 43.1 30.8 Malta 11.2 16.5 Moldova 58.7 53.2 Norway 17.1 12.7 Netherlands 6.4 5.1 Poland 31.5 19.5 Portugal 24.1 17.6 Romania 51.5 24.3 Russian Federation 55.6 29.5 Slovak Republic 45.5 19.4 Slovenia 24.6 5.4 Spain 11.9 6.4 Sweden 14.1 7.2 Switzerland 4.6 4.2 Turkey United Kingdom 33.1 30.0 Ukraine 57.4 54.3 Yugoslavia 41.0 30.1 Source: United Nations Population division: World population monitoring 2002: table II.8 p. 46

59 Reproductive health behaviour of young Europeans 20 clinics functioning gions Free in some Free re yes - - yes existing)(hardly yes noyes (gynaecologist only) no yes -no (information - only) yes Estonia Latvia Lithuaniano Armenia Azerbaijan Georgia no yes for students Free months after for three abortion for one year after yes birth no in young peo- Free ples’ services no yes no - - Family planning programmes and access to contraception in different European countries Family planning programmes and access to contraception in different vailable for the whole Family planning clinics Location of distribution Maternity hospitalPrivate gynaecologistFamily planning counselling yes yes of chargeFree Contraceptive freeOther no yes yes yesParental autorisation for adolescents - yes no no yes yes no no - - no ------National family planning programme OtherEmergency contraception A population ------Appendix 7 –

60 Appendices - yes (but no data) no nono yes - - no -gynaecological depart. - no (information only) no (except IUD and oral cont) up to 16 years olds - up to 18 years old no yes - Albania Bosnia Bulgaria CroatiaRep.Hungary Czech Poland yes yesyes (gynaecologist only) yes yes yesno - yesyes (private sector) yes yes yes - - - vailable for the whole Free of chargeFree Contraceptive free yes yesOther no no yes no - - no no no National family planning programme Family planning clinics Location of distribution Maternity hospitalPrivate gynaecologistFamily planning counselling - -Other yes yes Parental autorisation for adolescents yes yesA - -population no yes yes yes - - Emergency contraception Appendix 7 (cont. )

61 Reproductive health behaviour of young Europeans yes (gynaecologist and mid-wives) For certain of groups population yes (consultations only Except for abortion Except diaphragms and condoms free = oral free contraception/ IUD not expensive Romania Slovak Rep.yes Slovenia yes Macedonia Belarus MoldovaFed. Russian Ukraine yes yes yes - yes yesno yes - yes yesyes - yes no no yes yes - yes no - no yes yes no no - vailable for the whole National family planning programme Family planning clinics Location of distribution Maternity hospitalPrivate gynaecologistFamily planning counselling of chargeFree yes yesContraceptive free yes -Other yes noParental autorisation -for adolescents yes yes noOtherEmergency contraception - yesA population yes yes yes yes - no yes yes yes yes no - Up to 15 years yes no yes yes no yes no - Appendix 7 (cont. )

62 Appendices

Appendix 8 – Grounds on which abortion is permitted

Country To save the To preserve To preserve Rape Fœtal Economic On woman’s physical mental or impair- or social request life health health incest ment reasons (1) Albania X X X X X X X Armenia X X X X X X X Austria X X X X X X X Azerbaijan X X X X X X X Belarus X X X X X X X Belgium X X X X X X X Bosnia and Herzegovina X X X X X X X Bulgaria X X X X X X X Croatia X X X X X X X Czech Republic X X X X X X X Denmark X X X X X X X Estonia X X X X X X X France X X X X X X X Georgia X X X X X X X Germany X X X X X X X Greece X X X X X X X Hungary X X X X X X X Italy X X X X X X X Latvia X X X X X X X Lithuania X X X X X X X Netherlands X X X X X X X Norway X X X X X X X Moldova X X X X X X X Romania X X X X X X X Russian Federation X X X X X X X Slovak Republic X X X X X X X Slovenia X X X X X X X Sweden X X X X X X X Switzerland X X X X X X X Macedonia X X X X X X X Turkey X X X X X X X Ukraine X X X X X X X Yugoslavia X X X X X X X Finland X X X X X X - Iceland X X X X X X - Luxembourg X X X X X X - United Kingdom X X X - X X - Cyprus X X X X X - - Poland X X X X X - - Portugal X X X X X - - Spain X X X X X - - Liechtenstein X X X - - - - Andorra X ------Ireland X ------Monaco X ------San Marino X ------Malta ------

Notes: An X indicates that abortion is permitted. A hyphen (-) indicates that abortion is not permitted. Source: World Abortion Policies 1999 Table of Contents, United Nations publication, (ST/ESA/SER.A/178) and IFPP 2001.

63 Reproductive health behaviour of young Europeans

Appendix 9 – Rates of adolescent birth, abortion and pregnancy per year (per 1,000 women aged 15–19) and abortion ratio (per 100 pregnancies), by European countries, for the most recent year available

Country Year Birth rate Abortion rate Pregnancy rate Abortion ratio Albania 1990 15.4 u U U Armenia 1995 56.2 u u U Austria 1996 15.6 u u U Belarus 1995 39.0 34.3 73.3 47.5 Belgium 1995 9.1 5.0 14.1 35.6 Bosnia and Herzegovina 1990 38.0 u u U Bulgaria 1996 49.6 33.7 83.3 40.4 Croatia 1996 19.9 u u U Czech Republic 1996 20.1 12.3 32.4 38.1 Denmark 1995 8.3 14.4 22.7 62.6 England and Wales 1995 28.4 18.6 46.9 40.2 Estonia 1996 33.4 32.8 66.2 49.7 Finland 1996 9.8 10.7 20.5 52.9 France 1995 10.0 10.2* 20.2* 51.2* Georgia 1994 53.0 13.4* 66.4* 20.2* Germany 1995 12.5 3.6 16.1 23.0 Greece 1995 13.0 u u U Hungary 1996 29.5 29.6 59.1 50.3 Iceland 1996 22.1 21.2 43.3 51.1 Ireland 1995 15.0 4.2* 19.2* 21.9* Italy 1995 6.9 5.1* 12.0* 42.9* Latvia 1996 25.5 29.0 54.5 47.6 Lithuania 1996 36.7 u u U Moldova 1996 53.2 11.6* 64.8* 18.1* Netherlands 1992 8.2‡ 4.0‡ 12.2‡ 33.8‡ Northern Ireland§ 1995 23.7‡ 4.8*,‡ 28.4*,‡ 17.0*,‡ Norway 1996 13.5 18.7 32.3 59.2 Poland 1996 21.1 u u U Portugal 1996 20.9 u u U Romania** 1995 42.0 32.0* 74.0* 42.9* Russian Federation†† 1995 45.6 56.1* 101.7* 56.1* Scotland‡‡ 1995 27.1 14.5 41.6 37.2 Slovak Republic 1995 32.3 11.1 43.3 25.5 Slovenia 1996 9.3 10.6 19.9 49.2 Spain 1995 7.8 4.5* 12.3* 36.7* Sweden 1996 7.7 17.2 24.9 69.6 Switzerland 1996 5.7 u u U Macedonia 1995 44.1 u u U Ukraine 1995 54.3 u u U Yugoslavia 1995 32.1 u u U *Abortion data are less than 80% complete. †Abortions are for women younger than 20, not just 15–19. ‡Birth data are for women younger than 20, not just 15–19; abortions are those for residents only. §Abortion rates refl ect abortions obtained by Northern Ireland residents in England and Wales. **Data are from the 1993 National Fertility Survey. ††Abortion data are from Soskomstat. The totals are higher than those from the Ministry of Health. ‡‡Abortion rate includes abortions obtained by Scotland residents in England and Wales. Notes: The abortion ratio is the proportion of pregnancies (excluding miscarriages) that are resolved as abortions. All data refl ect “age in completed years.” The following adjustments were made when age was defi ned as “age attained during year”: abortion data—Finland, France, Germany, Iceland Source: based on Singh et Darroch 2000.

64 Appendices Proportion of Proportion maternal deaths (% of maternal deaths due to unsafe abortion) Mortality ratio (deaths due to unsafe abortion per 100,000 livebirths) Estimated number of deaths due to unsafe abortion Incidence ratio (unsafe abortions per 100 live births) Incidence rate (unsafe abortions per 1 000 women 15-49) Estimated number of unsafe abortions (000s) per 100,000 Maternal mortality ratio (maternal deaths livebirths) in Europe 1995 Estimate of maternal mortality, the number and rate of unsafe abortions mortality due to these Estimate of maternal mortality, estern Europe 14 ° ° ° ° ° ° Region EUROPEEastern EuropeNorthern Europe 50 28 12Southern Europe 12W 800 900 <30 <90 10 5 1 2 25 12 2 6 500 500 <20 <20 15 6 0.2 1 24 2 17 10 Appendix 10 – Source: World population monitoring 2002 – United Nations 2002 (table V.2, p.105) and Unsafe Abortion, WHO, table 2. population monitoring 2002 – United Nations (table V.2, World Source:

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II. Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

Osmo Kontula

1. Introduction The European Population Committee (CAHP) took a decision on 7 December 2001 to draw up a study entitled “Sexual and reproductive behaviour”, within the framework of the activity “Reproductive health behaviour of young Europeans: trends and implications”. In the ﬁ rst part of the project, a descriptive analysis will provide an overview of current patterns and trends in adolescent sexual and reproductive health behaviour for the European countries where this information is available. The goal of the project is to study trends in sexual behaviour, fertility and STIs/HIV/AIDS in the 15-25 age-group from the 1980s to the late 1990s. Sexual and reproductive behaviour, and the outcomes of that behaviour, will be treated in the framework of sexual and reproductive health. At the 1994 International Conference on Population and Development in Cairo (ICPD), and at the Fourth World Conference on Women in Beijing in 1995, the focus was shifted from population control to sexual and reproductive health. The programme of action of the Cairo conference states that reproductive health “implies that people are able to have a satisfying and safe sex life and that they have the capacity to reproduce and freedom to decide if, when and how to do so” (United Nations 1996, 1). The document goes on to say that the purpose of sexual health “is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases”. In the new approach, agreed upon by 184 governments, sexual health is considered as a vital part of a person’s physical and psychological well-being. A long-time consultant for the IPPF, Evert Ketting advocated a separation of sexual and reproductive health areas (1996). Ketting deﬁ nes reproductive health problems as “medical problems related to pregnancy, childbearing and infancy”, whereas sexual health involves “helping people to gain full control of their own sexuality and enabling them to accept and enjoy it to its full potential. It is not primarily about diagnosis, treatment, or medical care

77 Reproductive health behaviour of young Europeans but about lack of knowledge, self-acceptance, identity, communication with a partner and related issues”. Sexual health is an essential component of general health, and includes the avoidance of unintended pregnancies and sexually-transmitted infections. The notion of reproductive health encompasses the rights of men and women to make informed choices concerning the number, timing and spacing of their children and to fulﬁ l their reproductive aspirations, ensuring that women’s sexuality and childbearing poses no risk to the health and well-being of the mother. Reproductive health is the prerequisite and the result of sexual and reproductive behaviour (World population, 2002.) In this report, trends from the 1980s to the late 1990s in sexual behaviour, in fertility/pregnancies and in STIs/HIV infections will be presented. The focus is on teenagers; additional information is available on young adults. The results of the study will be summarised and discussed in the context of relevant European social and sexual policies.

2. Sexual behaviour among teenagers and young adults Sexual activity includes any individual or mutually-shared activity involving stimulation of the sexual organs for the purpose of enjoying the eroto-sexual pleasure that comes from such stimulation (Francoeur et al., 1991). Sexual activity refl ects a need for intimacy, support and exchange, confi rmation of one’s identity, sensation-seeking, and self-enhancement through sexual gratifi cation (Choquet and Manfredi, 1992). Sexual initiation includes variant and individual desires, feelings and behaviour patterns. It has always had different standards and defi nitions from country to country. However, the fi rst sexual intercourse has been generally adopted as a turning-point in the intimacy experiences and as fi nal evidence of the completion of the sexual initiation. The age at fi rst intercourse is an important indicator of sexual behaviour, both individually and culturally, and of its variations among teenagers and young adults. Traditionally, female sexual initiation has been closely linked with marriage. Women were supposed to be initiated into sex by their husbands, especially in southern European countries. The spread of reliable birth control methods, the rise in women’s level of education, women’s rapidly growing participation in the labour force and more tolerant standards in sexual issues have caused a notable increase in female sexual autonomy. As a consequence, the age at fi rst intercourse has decreased in Europe. At the same time, the period from the fi rst intercourse to cohabitation or marriage has increased. Modern teenagers and young adults have less committed sexual experiences than the

78 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe generation of their parents, and thus young people face more risks in their sexual encounters.

2.1. Age at fi rst intercourse in European countries Information on fi rst sexual experiences and other sexual habits is available only from national and other large-scale local surveys. Unfortunately, most member states of the Council of Europe have not conducted any surveys on sexual habits. The motivation and resources for sex-related surveys have varied considerably across Europe. The boost for national sex surveys came in the late 1980s and early 1990s in many western European countries after specifi c resources related to the AIDS epidemic became available, making possible European collaboration in the fi eld. One of the outcomes was a summary of the western European sex survey, “Sexual initiation and gender in Europe: a cross-cultural analysis of trends in the twentieth century”, authored by Michel Bozon and Osmo Kontula (Bozon and Kontula, 1998). The study was based on twelve European national sex surveys carried out between 1989 and 1993. The trends in the age of fi rst sexual intercourse were analysed in each country by looking at differences between generations, defi ned by year of birth. Among males, the age at fi rst sexual intercourse did not vary much from country to country in western Europe. The average age at fi rst intercourse declined somewhat from the older generation to the younger in several European countries, but much less so than among women. Particularly in southern countries, male sexual initiation was very stable for the different generations in their teenage years from the 1950s to the 1990s. Regarding older and younger female generations, the age at fi rst intercourse fell from the 1960s by at least two years in all western European countries where surveys were conducted, in all of which there was a dramatic fall in the percentage of women who had had their fi rst sexual intercourse at or after the age of twenty. In the north, the changes started in the 1960s, whereas in the south the new trend dates back only to the 1980s. This is not a general international trend because in the developing world a similar decrease in the age of sexual initiation ceases after the 1960s (Kontula, 2000). From a gender perspective, there are two distinct profi les, namely, the double standard of the south and the egalitarianism of the north and of some other countries. The average age at fi rst intercourse was much higher among women compared to men. In southern Europe, female premarital intercourse was still strictly controlled. On the other hand, in nordic countries the age at initiation tended to be slightly earlier for women than for men in the youngest cohorts.

79 Reproductive health behaviour of young Europeans

Figure 1 – Median age at ﬁ rst intercourse - Women by generation Years 25

24 Athens 90 Belgium 93 23 Denmark 89 22 Finland 92 21 France 92 Germany 90 20 Great Britain 91 19 Iceland 92 Netherlands 89 18 Norway 92 17 Portugal 91 Switzerland 92 16

15 1922-31 1932-41 1942-51 1952-61 1962-66 1967-71 1972-73 Generations

Figure 2 – Median age at ﬁ rst intercourse - Men by generation Years 22

Athens 90 21 Belgium 93 Denmark 89 20 Finland 92 France 92 19 Germany 90 Great Britain 91 18 Iceland 92 Netherlands 89 17 Norway 92 Portugal 91 16 Switzerland 92

15 1922-31 1932-41 1942-51 1952-61 1962-66 1967-71 1972-73 Generations

On the whole, the sexual initiation in the 1980s and the early 1990s was characterised in western Europe by a relative stagnation of the age at ﬁ rst intercourse. This trend had already started before the onset of AIDS. The overriding impression was that AIDS did not affect the timing of sexual initiation.

80 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

An interesting exercise regarding the differences in sexual initiation between western European countries (nordic) and eastern European countries (the two geographical areas of the former Soviet Union) was conducted in a study entitled “FINSEX study and the related sex surveys in the Baltic area”, authored by Osmo Kontula and Elina Haavio-Mannila (Kontula and Haavio- Mannila, 1995; Haavio-Mannila and Kontula, 2001). The Swedish survey was originally conducted by Bo Lewin et al. (1998). The study covers six national sex surveys and one local sex survey (St. Petersburg) in the Baltic area: Finland 1971 (N=2188), 1992 (N=2250), and 1999 (N=1496); Sweden 1996 (N=2810), St. Petersburg 1996 (N=2085), and Estonia 2000 (N=1031). The age groups vary from 18-54 years to 18-81 years. According to the typology by Ira Reiss (1967), permissiveness with affection suggests that premarital sex is appropriate in stable, affectionate relationships. This seems to be the new trend in the values related to sexual initiation in the aforementioned surveys. Particularly in Finland in the 1990s, the most common answer to the question about the appropriate time for young people to have sexual intercourse was “when they are going steady” (men 75%, women 62%). In St. Petersburg this proportion was for both genders about 40%. Only from 3-8% of the respondents expected chastity until marriage. This shows that in value judgements, sexual initiation was very seldom related to marriage. However, in Russia female sexual chastity was still a cultural value even though most Russians did not apply these ideals to their actual sexual initiation. Women’s age at fi rst intercourse decreased by around four years from older generations (born 1917-1931) to younger generations (born 1967-1980). Almost identical decreases were found in Finland, Sweden, Estonia and Russia (St. Petersburg) but the timing was twenty to thirty years later in the former parts of the Soviet Union. Among males the decrease observed was only two years. The trend found in Estonia and St. Petersburg resembles that observed in southern Europe. On average, the declining trend has been observed there one generation later than in the other western countries. Sexual behaviour of young people varied by area, gender and generation. Age at fi rst intercourse was much higher in the east than in the west. Men started to have coitus at an earlier age than women according to surveys conducted in Finland in the early 1970s and in St. Petersburg in the 1990s. In the other populations the gender differences were small. Young people had begun having intercourse earlier than older people, and gender gaps in the age at fi rst intercourse were wider in the older than in the younger age groups. An interesting fi nding was that in Finland in 1999 and in Sweden in 1996, young women had started sexual intercourse at an earlier age than young men. This fi nding is in line with studies conducted in other nordic countries, namely Denmark, Iceland and Norway. It contrasts with the available data from Athens in Greece and from Belgium, France, Germany, Great Britain, The Netherlands, Portugal and

81 Reproductive health behaviour of young Europeans

Switzerland. In these areas, young men started to have intercourse at an earlier age than young women (Bozon and Kontula, 1998). The latest example of collaboration at European level in sexuality-related national surveys is “the New encounter module” (NEM) for following-up HIV/AIDS prevention in general population surveys”. The project is funded by the EU “Europe against AIDS” programme. The aim of the project is to follow up, ﬁ rstly, the way HIV/AIDS prevention is or is not taken into account in new relationships, and secondly, key indicators of sexual behaviour and HIV/AIDS prevention. The co-ordinator of the project is Michel Hubert in Brussels.

Figure 3 – Median age at ﬁ rst intercourse - Women by generation Years 25 24 23 22 Finland 92

21 Finland 99 20 Sweden 96 19 Estonia 00 18 17 St. Petersburg 96 16 15 14 1917-21 1927-31 1937-41 1947-51 1957-61 1967-71 1977-80 1922-26 1932-36 1942-46 1952-56 1962-66 1972-76 Generations Figure 4 – Median age at ﬁ rst intercourse - Men by generation Years 22

20 Finland 92

19 Sweden 96

Estonia 00 18 St. Petersburg 96 17

15 1917-21 1927-31 1937-41 1947-51 1957-61 1967-71 1977-80 1922-26 1932-36 1942-46 1952-56 1962-66 1972-76 Generations

82 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

The following national surveys were conducted in western Europe in the late 1990s in the 18-49 age group: Norway 1997 (N=3704), England 1998 (N=2935), Germany 1997 (2594), Germany 1998 (N=2583), France 1998 (N=1614), Portugal 1999 (N=1000), Switzerland 1997 (N=2777), Spain 2001 (N=2935), Italy 1998 (N=2603), and Greece 1998 (N=2000). These surveys were based on a common questionnaire: “Sexual behaviour and risks of HIV infection in Europe”. These surveys provide the latest information concerning trends in sexual behaviour in these countries.

Figure 5 – Median age at ﬁ rst intercourse - Women by age group Years 22

England 98 20 France 98 Greece 98 19 Italy 98 Norway 97 18 Portugal 99 Spain 01 17 Switzerland 97

15 20-24y 25-29y 30-34y 35-39y 40-44y 45-49y Age groups

Figure 6 – Median age at ﬁ rst intercourse in NEM surveys - Men by age group Years 22

England 98 20 France 98 Greece 98 19 Italy 98 Norway 97 18 Portugal 99 Spain 01 17 Switzerland 97

15 20-24y 25-29y 30-34y 35-39y 40-44y 45-49y Age groups

83 Reproductive health behaviour of young Europeans

Figure 7 – Gender difference in the median age at ﬁ rst intercourse in NEM surveys by age group Years 5

England 98 3 France 98 Greece 98 2 Italy 98 Norway 97 1 Portugal 99 Spain 01 0 Switzerland 97

-1

-2 20-24y 25-29y 30-34y 35-39y 40-44y 45-49y Age groups

NEM- surveys confi rm the earlier fi ndings of the European sex surveys (Bozon and Kontula, 1998): that is that before the outbreak of the HIV infection in the second half of the 1980s, the average age at fi rst sexual intercourse was fairly stable in western Europe for both genders. Among men the average age at fi rst intercourse was slightly increasing. In the late 1980s and early 1990s the average age slightly decreased for both genders (0.2-0.3 years). The campaigns for preventing HIV infections did not seem to have much impact on teenage sexual initiation. However, one can assume that the decrease of age at fi rst intercourse would have been more pronounced if it had not been for the AIDS prevention campaigns in the late 1980s. In the fi rst part of the 1990s, teenage sexual initiation took place, on average, a half-year younger than before. This was true for both genders. Because there are still many inexperienced men and women in the 20-24 age group (around 10%), the fi nal decrease from the older cohort to the younger is be actually smaller than presented here. The lowest mean age of sexual initiation in the 20-24 age group was for women in England (16.2 years) and for men in Portugal (15.9 years). The highest ages were for women in Italy (18.3 years) and for men in Italy and Switzerland (17.7 years). In all eight countries participating in the NEM project the age at fi rst intercourse declined in the early 1990s among women. In Portugal the decline was greatest. This may have been due to the low number of women respondents in this age group in Portugal (only 39). In

84 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

Greece the mean age at fi rst intercourse was increasing for men; for women it was stable. Standards in sexual initiation can be different for men and women in many western European countries. With regard to gender differences in the median age at fi rst intercourse, these standards have remained fairly equal for young men and women in England, Switzerland and Norway. In Norway girls have been allowed to have their fi rst intercourse at a younger age than has been the case for the boys in the same age group. These girls usually go steady with boys who are older than them. In Italy, Spain, and France boys have had their fi rst experience around a year younger than girls. In Portugal this age difference has been as much as two to three years. In these cases there is evidence of a strong double standard in favour of young men. This double standard decreased in the youngest generation (in the 1990s) in all western European countries except France. The early age at fi rst intercourse in the UK was signifi cantly associated with pregnancy under eighteen years, but not with the occurrence of STIs. Low educational attainment was associated with motherhood before eighteen years, but not with abortion (Wellings et al., 2001). In another survey in the UK, 20% of thirteen-years-olds reported that they had already had either full or oral sexual intercourse with a partner (Burack, 1999). In a survey among adolescents (aged fourteen to nineteen years) the rate of sexual activity was low in Barcelona compared with that in both European and American studies. Boys had their fi rst experience at a signifi cantly earlier age than girls. After sexual initiation, girls participated in sexual intercourse more often than boys. Sexual activity ranged from 11% to 15%, which is much lower than the rate among European students, which oscillates between 31% and 54% (Parera and Suris, 1997). Centres for disease control and prevention in Atlanta have co-ordinated CDC surveys in eastern Europe in collaboration with several national organisations. These surveys are available from Ukraine (1999), Romania (1999), Moldova (1997) and the Czech Republic (1993). City-level CDC surveys are also available in Ivanovo Oblast, Ekaterinburg City and Perm City in Russia. In Armenia (2000), a DHS-survey was conducted. In the CDC survey conducted in the Czech Republic in 1993, the median age at fi rst intercourse in the 20-24 age group was for women 17.7 years. In this group only 8% had fi rst intercourse before age 16, but 60% before age 18. Over 99% of sexually experienced women fi rst had intercourse before they were married, and 84% of these women said their fi rst relations were with their “boyfriend”. About two thirds fi rst had sexual intercourse less than four months after their relationship began.

85 Reproductive health behaviour of young Europeans

In Ukraine (1999), the average age at fi rst intercourse was higher than in western Europe, but was decreasing in line with western fi gures, especially among the youngest cohort, aged 20-24. In the survey conducted in 1999, female median age at fi rst intercourse was, in the cohort aged 20-24, 17.9 years, while a generation ago it was still 20.1 years (age group 40-44). In the 20-24 age group, half of the women had had their fi rst sexual intercourse before age 18. There was thus a decrease of two years, which had acceler- ated in the cohort that had its teenage years after the transition in the 1990s. This development was fairly similar in urban and rural areas of Ukraine. In Romania (Serbanescu et al., 2001) the median age at fi rst intercourse was for women close to 20 years, and for men around 18 years. Median age at fi rst intercourse was fairly stable from one generation to the other. The rate of sexual activity is extremely low among teenagers in relation to rates in the west, and the double standard is strong (Women of the world, 2000.) In the survey among the 15-19 age group (Serbanescu and Young, 1998), only 11% had had intercourse before they were 16. In this study group, altogether 20% of women and 41% of men had had sex. Of all teenage women, 25% – or about half of those who were sexually experienced – had had premarital sex. Men were more than twice as likely as women to have had premarital intercourse. Almost all the young men’s fi rst sexual experiences had been premarital. In the CDC survey in Moldova in 1997 (Serbanescu et al., 1997), the age at fi rst sexual intercourse was quite high for women. Before the age of 18, only 21% had experienced intercourse and before the age 20, 50% of women. In the 15-24 age group, these proportions were 29% and 63% respectively. This shows that there had been some decrease at the average age of the fi rst intercourse. The level of sexual experience was similar among various ethnic groups and in urban and rural areas. Young women with low socio-economic status and with fewer years of formal education were more likely to be sexually experienced at a given age. Among Armenian women in the DHS survey conducted in 2000 (Armenia demographic, 2001), the age at fi rst marriage and age at fi rst intercourse correspond almost exactly. By age 20, 44 % have married and 45% percent have had sexual intercourse. By age 25, these proportions are 82% percent and 81% percent, respectively. The median age of both fi rst marriage and fi rst intercourse decreased slightly from just over 21 among women aged 45-49 to just under 20 among women in the 25-29 age group. These median ages varied little by region. The median ages increased steadily with better education. The tendency towards earlier sexual initiation among males compared to females has been observed throughout all the eastern European countries.

86 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

The following fi gures are examples of teenage sexual experience by gender: Russian (Saratov) males 54%, females 32%, Ukrainian males 65%, females 34%, and Romanian males 45%, females 25%. Moreover, casual sex is on average twice as common among males than females. One in fi ve of those having sex with casual partners reported paying for sex (Unicef, 2000 ). There have been several WHO cross-national surveys carried out in schools among 11, 13 and 15-year-old pupils by using a standardised questionnaire (Currie et al., 2000). This collaborative project is called “Health behaviour in school-aged children” (HBSC). The seven European countries that conducted the survey in 1997-1998 are Hungary, Scotland, Northern Ireland, Latvia, Finland, France and Poland. According to the HBSC surveys conducted in 1997-1998, the sexual experiences of adolescent boys do not vary much from country to country. Around 30% of 15-year-old boys report having had sexual intercourse. In Hungary this proportion was for boys exceptionally high: 47%. Among teenage girls, variation was much more pronounced: in Scotland 37%, in Hungary 34%, in Finland 30%, and in Northern Ireland 26% of 15-year-old girls had experienced sexual intercourse. These proportions were 20% in France, 19% in Latvia, and 13% in Poland. In Latvia and Poland, gender differences were signifi cant: boys were twice as often sexually experienced than girls. This is evidence of the double standard that still exists among teenagers in eastern European countries.

2.2. Contextual information trends in age at fi rst intercourse National sex surveys have shown that since the 1960s the age at fi rst sexual intercourse has declined around western Europe, more among women than men. After stabilisation in the generation that had its teenage years in the 1980s, there was another decreasing trend in western Europe in the 1990s. An even more pronounced decrease was found in some eastern European countries in the 1990s. However, there were exceptions, such as Moldova and Norway, where the average age at fi rst intercourse has been stable over the last twenty years. In several countries, the average age of male initiation has also been fairly stable over recent decades. In this sub-chapter, some contextual information and determinants of these sexual patterns will be provided. Marriage used to be the institution that strongly determined sexual initiation. In older generations, it was common for a woman to be initiated sexually by her husband. In the 1990s, even cohabitating with the fi rst partner become an exception. Three out of four women married or started cohabitating the year they had fi rst intercourse in Portugal, but only one French or Athenian woman in three, one British woman in four, and only 7% of Finnish women.

87 Reproductive health behaviour of young Europeans

First intercourse is generally part of a steady relationship. This characteristic is always more pronounced among women, and, more signifi cantly, more women than men report being in love with their fi rst partner. The time between fi rst intercourse and marriage or cohabitation was much longer in Finland in the 1990s than in 1971. In the 1990s, this period of “playing the fi eld” was for men about six years and for women about four years. Estonian men married fi ve years after their coital initiation and women three years afterwards. Russian men in Estonia married or moved in with their partner some four years after their fi rst intercourse, and men in St. Petersburg fi ve years afterwards. Russian women in both research areas married about two years after their fi rst coitus. This corresponds to the behaviour of Finnish women twenty-fi ve years earlier. People starting coitus at a young age had a longer period of “playing the fi eld” in their life than those beginning intercourse later. In Ukraine only 15% of sexually experienced young women reported that their fi rst sexual partner was their husband, and about equal numbers of women said that their fi rst partner was a fi ancé or boyfriend (altogether 36%). Rural women were far more likely than urban women to report that their fi rst sexual experience was after marriage or with a fi ancé (64% 46%). In Romania (Serbanescu et al., 2001), among women it took on average only one to two years to commit to union after fi rst sexual intercourse, whereas among men it took around six years. Median age at fi rst union and also at fi rst live birth was increasing for women. In the youngest generation, the interval from intercourse to fi rst live birth was fi ve years. In the older generation this interval was only two years. In Moldova, more than half of all women had intercourse before they married: this was much less common in rural areas. This is related to the fact that women in rural areas are more likely to marry at a younger age which may be related to the fact that they are more likely to grow up in families with strong traditional values. Stronger family ties, parental control of dating, a stricter upbringing and a higher emphasis on virginity at fi rst marriage are more common in rural areas. Young women in rural areas are also more likely to be infl uenced by community and religious restraints than those who grow up in urban areas, and are less likely to work outside the home, which may contribute to less independence compared with urban women, and control of their reproductive lives. All over Europe, men and women graduates have their sexual initiation later than early school-leavers (Bozon and Kontula, 1998). The gap between the proportions of early school-leavers and graduates who had intercourse before the age of eighteen was more marked (a difference of 20% or more) in Finland, Greece (Athens), Great Britain and among Dutch and German

88 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe women. The difference was smaller in France, Norway and among Dutch and German men. Portugal was the only country studied where graduates did not behave differently from non-graduates. Early sexual initiation may be related to a preference for union and raising a family rather than a career. The future graduates have an attitude and a lifestyle in which sexual initiation is not a priority, at least during secondary education. On the other hand, early school-leavers are in a position to take independent decisions and initiatives much earlier, free from parental control and from the constraints of school. The Choquet and Manfredi study (1992) confi rmed a relationship between smoking, drinking and/or illicit drug taking, and sexual activity. For some authors these are manifestations of problem behaviour (problem behaviour theory), while for others they are simply lifestyle indicators, with no reference to normality, or are an expression of sensation-seeking. These adolescents are undoubtedly in a risk-taking situation with regard to smoking (respiratory disease), drinking (accidents), drug taking (dependency and problems with the law), school absenteeism (getting expelled from school,) as well as with regard to sexual activity (pregnancy and/or STDs). Emotional distress, more than the need to take risks per se, appears to be the crux of the problem. The results of Kontula’s study (1991) illustrate that the most important individual variables, which have an impact on the age of sexual initiation, are a steady relationship (a suitable situation and a partner), alcohol use (a lifestyle choice, avoidance of inhibitions and responsibility), sexual experience of friends (observed behaviour of the reference group), a high value attached to sex (change in values relating to sexual development), popularity with the opposite sex (self-image, positive image of one’s capacities and performance, suffi cient confi dence in sex role) and sexual maturity (rate of sexual development, being “old enough”). Educational goals (goal-orientation, time perspective, sex being something close or distant) are also important in the development of values.

2.3. Sexual activity among young adults Relationship status is a very important indicator of sexual activities. Young people who are married or who cohabit have regular intercourse but they usually do not have extra partners. On the other hand, singles who do not cohabit may have many occasional and also simultaneous sexual relationships. In this population, unwanted pregnancies and STIs are the most prevalent. Cohabitation is not common in western Europe in the 16-19 age group. In NEM surveys the proportion of cohabitation is 2-5% among males and close to 10 % among females. In the 20-24 age group, these proportions vary considerably. In Greece, Italy, Portugal and Spain the incidence of cohabitation is for men 10%

89 Reproductive health behaviour of young Europeans maximum. In France it is close to 20% and in England and Norway close to 30%. In northern Europe men cohabit younger – this decreases the number of young men who rely on more occasional sexual relationships. Among women similar differences were found: in the 20-24 age group, women in Mediterranean countries cohabited more seldom than women in western and northern Europe. In Spain only close to 10% of women cohabited, but in Norway more than 40%. Most of the singles who do not cohabit are sporadically sexually active. On average, around 90% of singles in the 20-24 age group have had at least one sexual partner during the last year. Multiple partners are also fairly common. The proportion of women who have had more than one partner during the last year was in the 1990s around 15% in Norway, Portugal and Spain. In France and Greece it was close to 25%. In Italy this proportion was only 3%. This means that in Italy young women have fewer sexual partners than in other NEM survey countries. Compared to women, men report multiple partners more often. On average, one in three men in the 20-24 age group had had more than one partner during the last year. The highest proportion (50%) was found in Norway and the lowest in Italy (10%). This ﬁ nding goes against the stereotypes of the potential and actual stance on multiple partners in southern and northern Europe. It also provides evidence that young men have signiﬁ cantly more sexual partners than young women in all European countries where this information is available.

Figure 8 – Male singles who have had more than one partner during the last year in NEM surveys % 60

16-19 years 30 20-24 years 20

0 France Greece Italy Norway Portugal Spain

90 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

Figure 9 – Female singles who have had more than one partner during the last year in NEM surveys % 40

16-19 years 20 20-24 years

0 France Greece Italy Norway Portugal Spain

In northern Europe multiple partners are much more common than in those countries where NEM surveys have been conducted. According the Baltic surveys, in Estonia 39%, in Sweden 40%, and in Finland 55% of single women in the 20-24 age group had had more than one partner during the last year. Among men the corresponding ﬁ gures were in Estonia 63%, in Sweden 44%, and in Finland 46%. Among the sexually-experienced women (women aged 15-24) in Romania, 81% had had only one partner in their lifetime. On the other hand, 60% of sexually-experienced men had had four or more partners, while only 13% reported a single partner. Multiple partnerships were generally allowed for males but quite seldom for females (Serbanescu and Young, 1998.) In Ukraine, of the sexually-experienced women in the 15-24 age group, around 15% had had more than one sexual partner during the last year.

3. Trends in teenage fertility and pregnancies in Europe Worldwide, the mean age at fi rst marriage has increased by 1.6 years among women and 1.2 years among men over the past decade. In Europe the regional average age for women at marriage is 26.1 years, and for men 28.8. In the countries of central and eastern Europe, the mean age of entry into fi rst marriage varies between 21.0 and 24.8 years (in most cases it is between 23 and 24; World population, 2002). The age at which women have their fi rst child rose on average two years from 1980 to 1998. Fertility decline in countries of Europe and North America

91 Reproductive health behaviour of young Europeans has been associated with the rising age at marriage, increasing divorce rates and widespread cohabitation. In eastern Europe births to unmarried women often result in single motherhood, whereas in northern Europe they often occur within relatively stable consensual unions which are not legalised. Before the transition, youths in central and eastern Europe tended to marry young and have a ﬁ rst child relatively young. During the transition years, the picture changed substantially. Youths are now less likely to marry, but more likely to have sex at a younger age; teen birth-rates have fallen across the region overall, but more of these births are occurring outside marriage and to very young teenage mothers (Unicef, 2000).

3.1. Statistical data on teenage fertility Teenage pregnancies can be divided into planned and unplanned pregnancies. Usually the ratio of abortions to live births can be used to predict the rate of unwanted pregnancies. There are also some surveys that give estimations of unplanned pregnancies. The Alan Guttmacher Institute (Jones et al., 1989) found that more than 50% of pregnancies are unplanned. NEM surveys in France, Greece, Italy, Norway, and Switzerland asked whether the last pregnancy was wanted or unwanted. In the 16-19 age group, the proportion of unwanted pregnancies was practically 100%. Italy was the exception, where all three respondents who had been pregnant had wanted to become pregnant. In the 20-24 age group, unwanted pregnancies were around 50% per cent in France, Greece, Norway, and Switzerland. In Italy they were 19%. This gives some evidence that unwanted pregnancies are less prevalent in Italy. In Europe the information on teenage fertility is mostly based on national birth-registration statistics (Recent demographic developments in Europe, Council of Europe Publishing). Some additional information is available from The European Community household panel (ECHP) survey (Berthoud and Robson, 2001) and from the review by Singh and Darroch (2000). It is estimated that about 14 million women aged 15-19 worldwide gave birth each year in the period from 1995 to 2000, when the adolescent fertility rate was 54 births per 1000 women for the world as a whole. In the more developed regions, the rate was 29 per 1000, while in the less developed regions the adolescent fertility rate was nearly twice as high, with 58 births per 1000 women. In eastern Europe, more than three quarters of the total fertility (79%) is contributed by women below the age of 30, whereas in western Europe, the corresponding percentage is 56% (World population, 2002). Births to adolescents make up a smaller proportion of births now than in 1980 in most industrialised countries (Singh and Darroch, 2000).

92 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

Table 1 – Live births per 1000 females in the age group < 20 in Europe from 1990 to 2000

Live Births 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Albania 25 ...... Armenia 70 77 83 77 68 56 53 44 43 31 29 Austria 20 22 22 21 19 17 16 15 14 13 13 Azerbaijan 26 32 36 39 42 38 37 42 38 33 30 Belarus 44 45 46 43 43 39 36 33 30 30 28 Belgium 11 11 11 10 10 9 ...... Bosnia & H. 38 ...... 31 36 26 .. .. Bulgaria 74 75 71 67 60 53 51 44 44 48 47 Croatia 29 25 22 20 19 18 21 20 16 16 16 Cyprus 34 31 32 24 21 18 16 14 13 13 11 Czech Rep. 50 51 46 42 32 24 19 17 15 14 13 Denmark 9999 98 88888 Estonia 50 48 50 43 39 36 34 30 27 26 26 Finland 12 12 12 11 10 10 10 9 10 10 10 France 12 12 11 11 10 10 10 10 9 .. .. Georgia 60 62 53 61 74 72 66 61 58 51 39 Germany 15 16 16 15 14 13 13 13 13 13 .. Greece 20 18 17 15 14 13 12 12 12 11 .. Hungary 43 42 38 35 33 30 29 27 25 23 24 Iceland 39 35 26 23 23 23 22 24 25 25 22 Ireland 17 18 17 17 16 16 16 18 19 20 19 Italy 8877 76 65...... Latvia 48 50 49 44 33 30 26 22 19 20 19 Lithuania 41 46 46 42 41 40 37 32 29 26 24 Luxembourg 12 13 12 13 11 10 10 9 9 10 13 Malta 11 12 12 13 11 10 17 17 17 17 18 Moldova 64 66 64 66 66 63 54 53 ...... Netherlands 8877 76 66677 Norway 17 16 15 14 14 13 13 13 12 12 12 Poland 33 34 31 28 26 22 21 20 19 18 17 Portugal 24 24 23 22 21 20 20 21 21 21 22 Romania 52 52 50 49 46 42 40 40 39 39 39 Russian Fed. 57 56 52 48 50 45 40 39 34 30 28 Slovak Rep. 49 53 49 46 39 33 30 29 27 25 24 Slovenia 25 22 20 17 15 13 11 9887 Spain 12 11 10 9 8 8 7 888.. Sweden 14 13 11 11 9 8 8 7677 Switzerland 6876 66 66666 Macedonia 44 43 42 47 46 44 39 37 34 .. .. Turkey 57 56 55 54 53 52 51 50 49 57 56 Ukraine 57 59 60 58 56 54 51 46 41 .. .. United Kingdom 31 31 30 30 29 29 31 31 31 30 29 Yugoslavia 43 41 37 36 34 33 30 28 26 25 ..

Source: Recent demographic developments in Europe 2001, Council of Europe.

93 Reproductive health behaviour of young Europeans

Figure 10 – Live births per 1000 women aged 15-19

100 Bulgaria

90 Finland

80 France Germany 70 Hungary

60 Moldova

50 Netherlands

Poland 40 Russia 30 Slovenia

20 Spain

10 Ukraine

United Kingdom 0 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

Years

Figure 11 – Live births per 1000 women aged 15-19

60 Czech Rep. Russia

50 Poland Ukraine

Hungary Slovenia 40

Bulgaria Moldova 30 Romania

0 1989 1991 1993 1995 1997 1999 1990 1992 1994 1996 1998

Years

94 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

Through the 1980s, teenage pregnancy rates tended to remain stable or decreased in western Europe. In the early 1990s, teenage fertility rates decreased considerably in most western European countries. The United Kingdom and Iceland had the highest rate, with round 30 per 1000. In the second category were Austria, Portugal, Greece and Ireland, where the rate was around 20 per 1000. In other EU countries the rate was round 10 per 1000 or even lower (in the Netherlands and Switzerland it was 6-7 per 1000). The percentage of 20 year-old women who have already given birth ranged from 2% (Switzerland) to 13% (UK). The teenage birth-rate has fallen in many western European countries, but has remained stable (at a high rate) in the UK, which has the highest rate for the continent. Every year about 90,000 teenagers in England become pregnant. Of these, more than 7000 are under the age of 16 (Scally, 1999). In the 1990s, the rate of teenage pregnancies generally decreased in the EU (the actual rate was between 12 and 25 per 1000 girls aged 15-19 years), with the lowest rates (5-7) to be found in Italy, Switzerland, Netherlands, Sweden and Slovenia, and the second lowest rates (8) in Spain and Denmark. The highest rates were found in the United Kingdom (30), Iceland (25), and Portugal (21). The second highest rates (13-16) were in Austria, Ireland, Germany, Norway and Greece. The differences in teenage pregnancies are striking: for example, 30 per 1000 girls aged 15-19 years in the UK and 5-6 per 1000 in Italy and Switzerland. Teen pregnancy rates are still high in most transitional countries relative to western countries. The fertility rate is currently close to 50 per 1000 for women aged 15-19 in Ukraine, the Republic of Moldova, Georgia, Turkey, and Bulgaria. Rates are round 40 per 1000 for women in Armenia, Azerbaijan, “the former Yugoslav Republic of Macedonia”, and Romania. Rates are close to 30 in Belarus, Estonia, Hungary, Lithuania, the Slovak Republic and the Russian Federation. The highest decreases took place in the 1990s in some central European countries. In Greece, 80% of teenage mothers are married when they have their fi rst child. More than half of teenage mothers were married in Switzerland, Poland Italy, Luxembourg, and the Slovak Republic. In the UK, Norway, Ireland, and Iceland a maximum of 10 per cent of teenage mothers were married then they had their fi rst child (Unicef, 2001a). Between the years 1984 and 1994, in some Russian cities the number of pregnancies among adolescents increased 20 times, from 0.5% to 10%. Romania and Russia had the highest rates of teenage pregnancies among the seven countries, with 16% of all pregnancies. In Hungary 14% of women were pregnant before the age of 18 in 1998. Adolescent women tended to hide their pregnancies, and terminated them either at a very early stage or in an unoffi cial way.

95 Reproductive health behaviour of young Europeans

Birth rates were higher in 1995 than in 1970 in only eight of the countries with data for both years, all of which are in eastern Europe: Armenia, Belarus, Estonia, Georgia, Lithuania, “the former Yugoslav Republic of Macedonia”, the Russian Federation and Ukraine (Singh and Darroch, 2000). In nineteen of the twenty-eight nations under Unicef review, births to teenagers have more than halved in thirty years. Giving birth while still a teenager is strongly associated with disadvantage in later life (Unicef, 2001b). In all developed nations in Europe except Ireland, teenage birth-rates were in lower in 1998 than in 1970. Other countries with a low decrease in teenage birth-rates during those thirty years (less than 50%) were the UK, the Slovak Republic, Poland and Portugal. The decrease was at least four times in the Netherlands, Switzerland, Italy, Denmark, Sweden, France, Norway, Germany, and Austria. Actual teenage birth-rates were higher than expected on the basis of each country’s total fertility in the Czech Republic, Slovak Republic, Hungary, Poland, Portugal, and the UK. These countries had not actively promoted sexual health among their teenage population. Concerning teenage pregnancies, statistics seldom provide information on ethnic background. In the Netherlands, seven ethnic groups are distinguished in the Registry: - autochthonous (Dutch and ethnic west European); - Mediterranean (Turks and north Africans, mainly Moroccans); - Afro-alloctonous (Surinamese, Antillians, Africans of black origin); - Hindustanis (West Indians); - Asians (exclusive of Turks and Hindustanis); - other Europeans (inclusive of North Americans); - others. During the period between 1990 and 1993, of all women whose pregnancies were registered, 15% were alloctonous, whereas 55% of teenage pregnancies occurred in this group (van Enk et al., 1999). Furthermore, more than 40% of abortions in the Netherlands are performed on women who live elsewhere or are immigrants. In Britain, both sexual activity and childbearing before age 20 are less common among foreign-born adolescents and among non-white adolescents than among native-born and white adolescents (Singh et al., 2001.) In the UK, the birth-rate per 1000 teenagers in the 1980s was 76 for the Bangladeshi and 44 for the Caribbean communities, as opposed to 29 for whites and only 17 for the Indian community. However, this ethnic factor has no signiﬁ cant effect on national standing regarding teen births due to rather small ethnic communities.

96 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

3.2. Background for the great variance in European teenage fertility trends Statistics show a general transition towards lower teenage fertility rates in Europe. However, there are several countries where trends were stable or even in minor increase in late 1990s. In this sub-chapter some explanations will be provided both for the decreasing trends in teenage fertility as such, and for the outstanding country differences in these trends in the 1990s. Over the past two centuries, the age at which childbirth is biologically possible has declined, while the period of adolescents’ economic dependence has increased. One result of these changes has been a growing cultural confl ict over reproductive choices during the transition to adulthood (Rhode, 1993). A common view among world value study analysts of the fertility decline has been that it was the product of a loosening of the normative constraints (individualistic value system) that had previously sustained fertility levels (Simons, 1995). The pragmatic European approach to teenage sexual activity, expressed in the form of widespread provision of confi dential and accessible contraceptive services to adolescents, is viewed as a central factor in explaining the more rapid decline in teenage childbearing in northern and western European countries (Singh and Darroch, 2000). Shifts in value orientation, resulting from greater individual autonomy in all domains, are consistent with a lifestyle in which people make their own choices about marriage and cohabitation, in which they are free to have children within or outside marriage, to raise them alone or with a partner, and can have them early or late in life or not at all. The current research literature tells us that many factors, including socio- economic conditions, cultural receptivity, new technology, ideology, and organised family planning programs, can infl uence fertility levels and fertility decline in particular situations (Hirschman, 2001). Many unwanted teenage pregnancies are a consequence of the avoidance of sexual health services. Reasons for the non-use of these services include embarrassment, concern that parents may be informed, lack of anticipation of when intercourse will occur, and indifference to becoming pregnant. Young people, especially sexually-active adolescent women and men, do not seek reproductive health services for reasons that include inconvenient schedules and locations, lack of privacy and confi dentiality, fear of social stigma, judgmental attitudes of service providers, and unaffordable fees (World population, 2002). Fullerton (1997) has listed a number of factors that are linked to sexual relations at an early age, non-use of contraception and teenage pregnancy. These include: - social infl uences, peer, cultural and religious; sisters or mother pregnant at an early age; educational input;

97 Reproductive health behaviour of young Europeans

- access to health services: health and sex education, awareness of and availability of contraceptive services; - socio-economic factors: poor employment prospects, housing conditions and poverty; - individual characteristics: knowledge, maturity, skills, age at fi rst intercourse, self-esteem. Factors that play an important role in explaining recent trends include the greater importance ascribed to educational achievement, increased motivation among young people to delay pregnancy and childbearing in order to achieve higher education levels and to gain job skills before forming a family, as well as improvements in knowledge of and access to the means of preventing unplanned pregnancy (Singh and Darroch, 2000). There is less motivation to avoid pregnancy among teenagers who have lower educational and job aspirations and expectations, among those who are not doing well in school and among those in poor and single-parent families. The trend toward smaller families in Europe refl ects the increased importance of achieving higher levels of education and training, which is particularly signifi cant in determining the transition to motherhood among females (Singh and Darroch, 2000). This is related to the utilitarian signifi cance of childbearing: that is, the practical advantages and disadvantages. People will seek self-expression and will focus on their own well-being and on actions they perceive as giving meaning to their lives (Van de Kaa, 2001). In Russia the decrease in adolescent fertility was caused by rising social aspirations of young adults. This was observed in a series of surveys carried out in Moscow and the provinces (Magun, 1998). The “new home economics” approach (Becker, 1994) argues that rising costs of having children bring about a decrease in the birth-rate, and that is what was observed in this case. Disadvantage has been characterised by such factors as living in poverty, being poorly-educated, having poorly-educated parents, being raised in a single-parent family or in an economically struggling neighbourhood, and lacking educational and job opportunities. Belonging to a racial or ethnic minority group and being foreign-born also have strong links to socio- economic disadvantage (Singh et al., 2001). In-depth qualitative research has shown that many adolescents who have a baby are reacting to problems in their family, including poverty and abuse (LeVan, 1998). Disadvantage is associated with several factors that can infl uence teenage sexual and reproductive behaviour and outcomes, including lowered personal competence, skills and motivation, limited access to health care and social services, lack of successful role models and living in a dangerous environment (Singh et al., 2001).

98 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

Being disadvantaged is associated with an early age at ﬁ rst intercourse, less reliance on or poor use of contraceptives, and lower motivation to avoid having a child or ambivalence about doing so. Once pregnant, disadvantaged adolescents are less likely than other adolescents to have an abortion, and more likely to deliver a child and have a premarital birth (Singh et al., 2001). Many factors can mitigate the effects of socio-economic disadvantage on adolescent behaviours, including adolescents’ biological and developmental characteristics; the quality of their communication and relationship with their parents, peers and partners; family stability, availability of parental time and supervision, and level of parental authority and control; adolescents’ values, beliefs, attitudes, sense of control over their life, motivation and expectations; and their receipt of sex education and access to reproductive health services (Singh et al., 2001). The rate of teenage pregnancies was still as high as 60-70 per 1000 women in the early 1990s in many eastern European countries and in countries of the former Soviet Union. During the time of socialism, the centrally planned economy could easily be directed towards a restricted supply of market contraceptives, and the state imposed restrictions on the implementation of clinical contraceptive methods (sterilisation). There were also economic reasons for this: the regime could not afford the import of modern contraceptive devices (Philipov, 2002). One of the consequences was the high rate of teenage pregnancies. Many of the countries of central and eastern Europe and the Baltic states experienced a rapid decline in adolescent fertility during the 1990s. Family planning organisations grew up and developed large-scale activities for the spread of knowledge on modern contraceptive methods. Towards the end of the 1980s and during the 1990s, usage of modern contraceptive methods increased considerably. The right of parents to have the number of children that they desired was legally formulated. Higher education raised women’s human capital and hence their earnings. The costs of time spent with the family and bringing up children rose. Thus births decreased (Philipov, 2002). However, teenage pregnancy rates are still three to four times higher in eastern Europe than in most western European countries. One important reason is the low prevalence of contraceptive use. Although modern contraceptive methods are known, they are often considered dangerous for health reasons. In some cases the modern devices are much more expensive than abortion. There is also a lack of information on the availability of devices and services for their usage at family planning clinics (Philipov, 2002). In the former Soviet Union abortions are free, and so more affordable for women than contraceptives, and besides information about modern birth control methods was still scarce in Russia in the 1990s (Gadasina, 1997). In

99 Reproductive health behaviour of young Europeans

Russia the picture remains one of uneven access to family planning options, over-reliance on abortion, and consumer suspicion of the reproductive health-care system. Women expressed considerable distrust of medical personnel and resentment of the informal system of having to pay bribes for even routine care. Of all respondents, 80% (and 87% of those under the age of 25) said their most recent pregnancy was unplanned (Dorman, 1993).

3.3 Disadvantages related to teenage pregnancies and young motherhood Teenage motherhood has long been of concern to governments for both medical and socio-economic reasons. Teenage mothers and their families have been shown to experience social disadvantage concerning education, employment and family income (Berthoud and Robson, 2001). Adolescents are at increased risk of adverse pregnancy outcomes compared with an older control population (Eure et al., 2002). The current research literature tells us that early childbearing entails a risk of maternal death that is much greater than average, and the children of young mothers have higher levels of morbidity and mortality (World population, 2002). There have been concerns related to the number of conceptions, the links with deprivation and the range of adverse outcomes for both mother and child. Examples of these include an increased likelihood of having a low birth weight baby and an increased risk of sudden infant death syndrome compared to older mothers. Children of teenage mothers are also more likely to be admitted to hospital as a result of an accident than children of older mothers. The long-term outcomes also include poverty: teenage mothers appear to be generally poorer, with 41% of them having an episode of depression within one year of childbirth, which is higher than for teenage girls in general, and an increased likelihood of the daughters of teenage mothers becoming teenage mothers themselves (Griffi ths and Kirby, 2000). Berthoud and Robson (2001) analysed the current positions of women whose fi rst child was born when they were teenagers, across thirteen countries in the EU, based on the European Community Household Panel Survey. Age-specifi c fertility rates were based on national birth-registration statistics. The medical outcomes of teenage pregnancy were not included in analysis. Taking the EU as a whole, women whose fi rst child was born when they were teenagers were consistently worse off than women who started a family in their twenties. A substantially higher proportion of these mothers were not in employment. Twice as many teen-mothers as twenties-mothers had minimal educational achievements, and twice as many were living in poverty. One might say that a low level of education would be likely to increase the probability of lone parenthood and that lone parenthood might mean the

100 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe absence of family employment, which would lead to poverty. The age at which a woman gave birth to her fi rst child proved to be associated with all of these factors. Of the 18-year-old mothers, 40% are estimated to have been in poverty when their child was ten years old. Teenage motherhood may be seen as conceptually equivalent to poverty (Berthoud and Robson, 2001). Teenage motherhood is especially problematic in societies where most young women leave home early, adopt an independent lifestyle in their twenties, and then start a family some years later. Early parenting is more disadvanta- geous in northern or “Protestant” Europe, where the gap between leaving home and starting a family is widest. The Netherlands was clearly the country where young mothers were most disadvantaged. In countries where young people are closely tied to their families of origin, and where women quite often have children at a relatively young age, teenage mothers are less isolated. A similar study was conducted in Sweden. Compared with Swedish women who fi rst gave birth at ages 20-24, those who were teenage mothers had signifi cantly increased odds of each unfavourable socio-economic outcome in later life, even after the data had been adjusted to the family socio-economic situation and maternal birth cohort. Teenage motherhood was positively associated with low educational attainment, with undesirable living arrange- ments, with high parity, with collecting a disability pension and with welfare dependency. These trends were usually linear, with the highest odds ratios corresponding to women who had had their fi rst child at the youngest ages (Otterblad Olausson et al., 2001).

4. Sexually transmitted infections and HIV/AIDS among European teenagers The WHOs estimates that 340 million new cases of STIs occurred in 1999. The highest rates of STIs are generally found in urban men and women in their most sexually active years, that is, between the ages of 15 and 35. Women become infected at a younger age than men (World Population, 2002). In most countries, teenagers account for more than one-ﬁ fth (and in some cases even half) of reported STD cases. Globally, more than half of all new HIV infections are among the15-24 age group. Incidence among adolescents is generally higher for females than for males. This is partly due to the fact that they are screened more regularly than males. In the era of HIV/AIDs, little attention has been paid to other STDs. The missing surveillance system for STIs in Europe is an example of low interest in the issue.

101 Reproductive health behaviour of young Europeans

The data and information sources for STI prevalence and statistics are very heterogeneous, and often the data quality is questionable (World population, 2002). Governmental statistics on reported STD incidence among adolescents were obtained in Europe et al. from three types of sources (Panchaud et al., 2000): published offi cial documents, unpublished governmental data, and scientifi c journal articles. The variations in the completeness of reporting of diagnosed STD cases are: - National compulsory physician reporting (available in most western European countries). This reporting depends on the proportions of and the representativeness of the population using such services; - National laboratory reporting (Switzerland, Denmark); - Declaration from public specialised STD clinics (England, Wales); - Sentinel system, networks of laboratories or physicians (Belgium, France. Syphilis data is not available). This system does not provide national coverage. One of the data sources is prevalence of individuals attending STD clinics in seventeen European countries (Van der Heyden et al., 1997). There is also STD prevalence data based on self-reports from national surveys in eight countries (Warszawski, 1998). The proportion of infected people who are actually identifi ed as having an STD varies from country to country. This has to do with differences in ease of access to STD services. Another predictor of prevalence is whether the sexually-active population is universally screened, or whether there is only selective screening of high-risk groups. The other determinants are whether an STD has clearly recognisable symptoms (for instance in gonorrhoea and chlamydia, asymptomatic rates for females are up to 80%), which deter- mines whether care is sought and the STD reported. Variation in motivation to seek STD services include the cost of services, whether they are covered by insurance, the extent to which confi dentiality and anonymity are assured, and perceptions of risk and patterns of health-seeking behaviour. The states of the former Soviet Union, other eastern European countries and the four nordic countries have relatively more active and extensive screening and case-fi nding policies. In England and Wales, STD-screening covers a large proportion of people seen for general health care. In Belgium, France, West Germany, the Netherlands and Switzerland, STD case fi nding and screening policies are not active because STD care is less centralised, taking place mainly at private facilities. In some eastern European countries the private clinics do not report their STI fi gures. High reporting (70% or more of diagnosed STD cases) for syphilis and gonorrhoea was found (Panchaud et al., 2000) in the four nordic countries

102 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe and in the four selected eastern European countries (East Germany, Romania, the Slovak Republic and the Russian Federation). In England and Wales high reporting was found for syphilis, but not for gonorrhoea. Fewer than 50% of diagnosed cases were reﬂ ected in ofﬁ cial statistics in Belgium, France, the Netherlands and West Germany. Reporting on chlamydia, an STD that is now one of the most prevalent, was added to surveillance systems in the late 1980s or early 1990s in Denmark, England and Wales, Finland, Norway, the Russian Federation, Sweden and Switzerland. Resources for screening for chlamydia are not available in most countries. Altogether, information is scarce on trends in Europe for chlamydia, genital herpes and human papilloma virus infection. When information is available it covers only the 1990s. Although some increases in incidence have been documented, it is unclear how much of this upward trend is due to improvements in case ascertainment and surveillance or to actual increases in STD incidence (Panchaud et al., 2000).

4.1. The incidence of syphilis, gonorrhoea and chlamydia among young people in Europe The prevalence of gonorrhoea and syphilis has been increasing in many European countries since 1995. A high proportion of STIs are currently diagnosed among young people. In the UK, 90% of all STIs diagnosed are in the under-25s (Vanhegan and Wedggwood, 1999). The incidence of STIs has increased alarmingly in large parts of central and eastern Europe in the past decade. The incidence of syphilis, which is fairly well documented, is now extremely high in several countries: 262 cases per 100,000 inhabitants in the Russian Federation in 1997, and 245 in Kazakhstan (compared to 0,7 in western Europe:WHO Regional, 2001). Six countries with high-quality reporting (Panchaud et al., 2000) had in the 1990s an annual syphilis rate of less than three cases per 100,000 (Denmark, England and Wales, Finland, East Germany, Norway and Sweden). The Russian Federation, which has been experiencing an epidemic of STD infections since the early 1990s, had an extremely high syphilis rate among female adolescents (313 per 100,000). In Romania the overall adolescent rate (58 per 100,000) was much higher than in most other countries. In several countries the reported incidence of syphilis is two to three times as high among female adolescents as among male adolescents. In Denmark, Romania and the Russian Federation adolescent rates were higher than rates in the general population. However, adolescents tend to have a lower syphilis rate than young adults aged 20-24.

103 Reproductive health behaviour of young Europeans

Table 2 – Annual reported rates per 100,000 for sexually transmitted infections among 15-19 year olds, by gender, and in total population, by type of infection and by country

Infection and country Female Male Tota In total population Syphilis Denmark (1995) 1.3 0.0 0.6 0.4 England &Wales (1996) 0.2 0.2 0.2 0.2 Germany FRG (1995) 1.1 1.2 1.2 1.2 Finland (1996) 2.5 1.2 1.8 4.2 Germany GDR (1995) 2.6 1.8 2.2 2.3 Netherlands (1995) 1.1 0.9 1.0 1.3 Norway (1995) 0.0 0.0 0.0 0.1 Romania (1994) .. .. 57.5 25.9 Russia (1994) 313.4 112.3 211.4 85.7 Sweden (1995) 1.2 0.0 0.6 0.8 Switzerland (1996) 0.5 0.5 0.5 2.5

Gonorrhoea Belgium (1996) 1.0 0.3 0.6 1.0 Denmark (1995) 5.0 5.0 5.0 3.4 England &Wales (1996) 95.7 59.1 76.9 22.4 Germany FRG (1995) 9.3 7.9 8.6 5.0 Finland (1996) 3.8 3.6 3.7 4.3 Germany GDR (1995) 16.1 14.1 15.0 8.0 Netherlands (1995) 7.5 7.8 7.7 9.2 Norway (1995) 9.1 4.4 6.7 4.0 Romania (1994) .. .. 65.8 23.1 Russia (1994) 589.1 603.7 596.5 204.6 Sweden (1995) 2.0 1.5 1.8 2.8 Switzerland (1996) 2.1 1.5 1.8 3.7

Chlamydia Belgium (1996) 23.7 1.3 12.2 7.8 Denmark (1995) 1875.0 287.0 1081.0 255.0 England &Wales (1996) 389.0 85.1 232.8 75.9 Finland (1996) 1122.1 1198.7 650.8 184.2 France (1996) 110.9 1.6 55.1 60.2 Norway (1995) ...... 215.4 Russia (1994) ...... 106.1 Sweden (1995) 921.0 235.2 569.6 156.0 Switzerland (1996) 72.2 3.9 37.7 39.1

Source: Panchaud et al. (2000)

Between the mid-1980s and the mid-1990s, syphilis rates generally decreased, both in the total population and for adolescents. This was not the case in the Russian Federation, however, where an epidemic started shortly after 1990. During the 1990-1996 period, only Finland, the Slovak Republic and the Russian Federation experienced relatively large increases.

104 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

In the majority of countries, the reported incidence of gonorrhoea among adolescents is relatively low – less than 10 per 100,000. In England and Wales, Romania, and the Russian Federation, the reported incidence of gonorrhoea is distinctly higher, with the Russian Federation approaching 600 per 100,000. In low-incidence countries, female adolescent gonorrhoea rates are equal to or only slightly higher than those of adolescent males. In these countries, the rates for adolescents are much lower than those for young adults, while in the higher incidence countries, rates are more similar. In the Russian Federation, male and female adolescents have a rate three times as great as the general incidence. The trend in the incidence of gonorrhoea from 1985-1996 is similar to that of syphilis, with a steady decrease in almost all countries. The Russian Fed- eration is the important exception, with an average increase of 15% in the incidence of the total population in the 1990s. Gonorrhoea increased sharply among adolescents (more so for males than for females) in the Russian Fed- eration throughout the period from 1985 to 1996. The most recently published national data from western European countries is consistent with increasing rates of gonorrhoea. Reports of gonorrhoea have increased in France, the Netherlands, Sweden, Switzerland, and the United Kingdom (Nicoll and Hamers, 2002). The rises have been widespread and have been highest among older teenagers (16-19 years), at 178% for male patients and 133% for female patients. According to the statistics collected by Unicef (2001b), newly-registered cases of syphilis and gonorrhoea were usually highest among teenagers in eastern Europe in 1994-1996. After that era rates decreased in most cases. In 1999 they were only a half (Moldova, Ukraine, Kyrgyzstan) or a third (Estonia, Latvia, Lithuania, Czech Republic), compared to the rates found in 1995. In Russia and Belarus there was also a major decrease in the rate of syphilis and gonorrhoea among teenagers. These countries had the highest rates of STI infections (611 and 480 per 1000 respectively). In many eastern European countries these rates were 20 or less. In 1996, there were 2,272 cases of gonorrhoea diagnosed and reported among teenagers aged 16-19 years and attending STD clinics in England and Wales. The numbers increased by 34% in women and 30% in men from those of 1995. Older female teenagers (age 16-19) had the highest rate of gonorrhoea, genital chlamydial infection and warts, and the second highest rate of genital herpes simplex (after 20-24-year-old women). Overall attendance at sexually transmitted disease clinics has gradually risen since 1988, and increased use of services may account for some of the 1994-1996 rises, which continued into 1997 (Nicoll et al., 1999).

105 Reproductive health behaviour of young Europeans ...... 408.4 302.3 546.1 185.4 590.5 300.8 691.0 412.2 732.7 ...... 330.5 200.0 .. 461.9 151.2 514.3 188.5 201.7 563.4 301.4 474.0 .. 120.7 81.2 46.6 39.3 47.2 31.9 .. .. 36.4 63.1 68.5 63.2 53.5 84.8 23.4 .. 33.1 29.2 ...... 74.6 .. 70.0 67.7 .. 50.6 28.0 .. 34.7 39.5 .. 70.5 80.9 80.8 33.7 82.2 76.8 70.9 9.8 14.1 10.1 9.4 2.5 1.8 1.8 1.2 3.0 .. .. 36.6 38.9 12.7 27.1 11.6 16.6 8.3 14.6 6.6 8.3 6.3 7.7 3.8 5.6 9.5 2.2 5.3 15.0 19.3 33.1 15.1 19.2 14.0 15.1 21.1 136.8 22.3 26.4 215.6 2.6 253.9 3.8 266.0 1.6 162.3 3.6 105.2 54.4 50.6 70.8 93.8 91.0 2.6 27.6 28.2 75.2 63.6 60.1 19.9 .. 23.9 28.0 41.7 28.1 39.1 .. .. 1.9 30.3 34.7 32.3 35.9 23.9 31.1 26.9 21.3 1989 1997 1998 1999 1990 1994 1995 1996 1991 1992 1993 102.6 110.5 110.9 137.7 84.8 133.3 118.3 61.8 59.1 42.2 37.5 30.7 21.2 20.9 .. 442.0 359.1 461.7 200.9 609.7 424.2 424.1 510.4 711.4 595.0 707.0 .. 631.2 510.8 722.6 480.5 759.7 334.1 300.9 298.3 668.4 414.3 559.4 533.0 470.5 602.2 320.0 624.4 317.0 269.7 247.4 585.9 390.4 499.8 851.1 699.5 953.6 611.4 878.2 474.0 422.3 421.2 807.9 570.7 806.4 458.8 409.9 577.2 290.3 540.2 259.8 229.2 215.4 489.9 298.5 372.6 .. .. 189.8 .. 200.8 227.5 242.2 ......

urkmenistan ajikistan Czech Republic Slovakia Poland Hungary Croatia Macedonia Estonia Latvia Lithuania Belarus Moldova Russia Ukraine Armenia Azerbaijan Georgia Kazakhstan Kyrgyzstan T T Uzbekistan Source: Unicef (2001b). Source: per thousand in the relevant population 1989-1999 CEE/CIS/Baltic States Sexually transmitted infections among individuals at age 15-19; newly registered cases of syphilis and gonorrhoea able 3 – T

106 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

The incidence of chlamydia, the most prevalent of the STDs, is especially high among young women. This is at least partly due to higher likelihood that young women will be screened and diagnosed. Males generally have less frequent contact with physicians for reproductive health care. In the case of chlamydia, screening strategies are aimed primarily at women. Expansion of screening beyond high-risk groups may improve prevention of chlamydia and its serious consequences. Chlamydia incidence ranges from 500 cases to 1000 cases per 100,000. The incidence of chlamydia is 4-6 times higher among female adolescents than among male adolescents. Reported chlamydia incidence is 1.6 to 6.0 times higher among adolescents than in the total population, except in France and Switzerland. However, adolescents have lower reported chlamydia rates than do young adults in all countries. In seven of the ten countries with trend information in 1991-1996, the reported chlamydia rate in the total population declined. The Russian Federation experienced an annual increase of 62%, which may be partly due to better reporting. Decline was observed in Sweden, while increases were recorded in Denmark, England and Wales and Finland. It remains possible that changes in screening policies and inadequacies of reported statistics may have inﬂ uenced the trends observed in some of the countries. Active screening programmes may have increased treatment of chlamydia. In NEM surveys, prevalence of STIs has been very low in the under-25 age group. The issue has been studied in France, Spain, Italy, the UK and Switzerland. Among respondents there were only single cases of herpes, and, in the UK one respondent with gonorrhoea. In the older age groups there was a much higher prevalence of STI infections.

4.2. HIV infection among young Europeans No surveillance for sexually transmitted diseases other than HIV is routinely undertaken in Europe. For HIV monitoring there is the European Centre for the Epidemiological Monitoring of AIDS (EuroHIV), which is situated in Saint-Maurice, France. Trends of HIV diagnoses are difﬁ cult to interpret, as they rely on people seeking or being offered HIV testing, and on accurate reporting. New diagnoses may represent transmissions that took place years previously. Furthermore, the countries most affected by HIV (France, Italy, and Spain) do not have national reporting data on HIV(Nicoll and Hamers, 2002). The rate of newly diagnosed HIV infections reported in 2001 was 55.1 in western Europe, 7.9 in central Europe and 365.2 per million populations in

107 Reproductive health behaviour of young Europeans eastern Europe. Of these, the percentage of under 30-year-olds was 31% in western Europe, 53% in central Europe and 83% in eastern Europe (EuroHIV). Trend data show that the numbers of new diagnoses of sexually acquired HIV infections increased by 20% in western Europe between 1995 and 2000. Of the 43,866 new diagnoses of HIV reported by the ten collaborating countries for the entire 1995-2000 period, 37% were attributed to sex between men, 35% to sex between men and women, 8% to sharing drug- injection material, and for 18% no risk group was reported. In 1997-2000, 64% of heterosexual infections reported were diagnosed in people originating from countries outside Europe that had a high prevalence of HIV (Nicoll and Hamers, 2002). In 2001, in the UK 4,163 people were found to be HIV-positive, of whom 1,338 were homosexuals, and more than 1,500 heterosexuals from Africa. Fewer than 200 cases were attributed to heterosexual sex in Britain. In 2001, there were 2,225 new cases among heterosexuals in Britain. Of those, 80% were infected in Africa, 10% in Britain and 10% elsewhere (The Times, 15 July 2002). Until the mid-1990s, the problem was much less widespread in transition countries than in western Europe, but the situation has since reversed. In eastern Europe, annual numbers of reported new HIV infections have increased dramatically since 1995, reaching a level of 124 cases per 1,000,000 populations in 1999 in the Russian Federation, and 115 in Ukraine. The HIV virus has been spread largely by intravenous drug users through their sharing of syringes and needles (WHO regional, 2001). Where the HIV epidemic is widespread among injecting drug users, as in Europe, most cases occur among young men, because young men are more likely than young women to use drugs. AIDS is now largely a disease of speople living on the outskirts of society. In some countries, including Italy, Portugal, and Spain, over half of all AIDS cases involve drug use. Also, in Latvia, Moldova, Russia, and Ukraine, more than half of all new infections in 1998-1999 were among intravenous drug users. In Poland, 86% of HIV- positive individuals are drug addicts (Kiragu, 2001). Women with AIDS were younger than their male counterparts, both in IDU and heterosexual contact cases. Heterosexual transmission also affected relatively young women, because a large proportion of female cases was among partners of IDUs, who tend to be infected with HIV at a relatively young age compared with homo- or heterosexual men and women who did not inject drugs (Houweling et al., 1998).

108 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

Almost half of all new HIV infections and at least one-third of all new sexually transmitted infections occur in people younger than 25. AIDS incidence among young people is of special interest, since several studies have reported that high-risk sexual and needle-sharing risk behaviours for HIV infection are associated with young age. The unplanned or secretive nature of many of their sexual encounters makes it difﬁ cult for young people to protect themselves even when they are aware of the risks involved (Greene et al., 2002; Houweling et al., 1998). During the early 1990s, Romania was confronted with a boom in HIV- infected children, most of whom were living in institutions and were probably infected before 1990. Most AIDS case in Romania – 2,340 – affect children between the ages of 5 and 9 years. In 1997, more than half of all European cases of children with HIV/AIDS were in Romania. These children had mainly been living in institutions and were infected with HIV by the use of contaminated medical equipment (Antoniu, 2000). Newly diagnosed HIV infections among European teenagers have been concentrated heavily in eastern Europe. In 2001 in the under-20 age group, 13,751 males and 6,864 females were diagnosed with the HIV infection. In central Europe these numbers were 156 and 125, and in western Europe 171 and 197 respectively. To put it simply, there were a hundred times more teenage HIV infections in eastern Europe than in central or western Europe. In western Europe these numbers were stable from 1997 to 2001, and in central Europe there had been some decrease. At the same time, in eastern Europe the number of cases went up by ten times. In the period from 1990 to 2001, teenage HIV infections focused very much on the Russian Federation, where the epidemic started after 1995. There were heavy increases in 1999 and 2000. In 2000, epidemics also started in Estonia, Latvia, and Romania. Contrary to this, in Belarus the epidemic was in 2001 under more effective control than in 1996 and 1997. This was also true of Moldova. In Ukraine, Germany, the United Kingdom, Poland and Switzerland, teenage HIV infections were prevalent but annual numbers were stable. Among forty-three countries there were twenty-nine where cumulative numbers of HIV infections were less than one hundred in the period from 1990 to 2001. In addition, there were sixteen countries where cumulatively there were less than ten cases during these years. These countries had been very successful in preventing HIV infections among their teenage population. In ﬁ ve countries (Albania, Bosnia-Herzegovina, Kazakhstan, San Marino and Yugoslavia) there was not been a single case of teenage HIV infection.

109 Reproductive health behaviour of young Europeans

Table 4 – Number of HIV infections among teenagers in the age group 13-19 in Europe in 1990-2001

HIV infections 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Total Albania 0 0 0 0 0 0 0 0 0 0 0 0 0 Armenia 0 0 0 0 0 0 0 1 1 0 2 1 5 Azerbaijan 0 0 0 0 0 0 0 1 2 3 2 1 9 Belarus 0 0 0 0 0 0 252 124 81 61 51 63 632 Belgium 0 0 0 0 0 0 0 16 16 14 30 25 101 Bosnia & H. 0 0 0 0 0 0 0 0 0 0 0 0 0 Bulgaria 0 1 0 0 0 2 5 1 1 1 2 2 15 Croatia 0 0 0 0 0 0 0 1 0 0 1 0 2 Czech Rep. 0 0 1 1 8 6 1 8 4 3 3 2 37 Denmark 0 0 2 2 2 4 3 2 0 3 2 0 20 Estonia 1 0 2 0 0 0 1 0 0 1 184 559 748 Finland 0 0 1 1 1 0 0 0 1 4 6 4 18 Georgia 0 0 0 0 0 0 0 0 1 0 2 2 5 Germany 0 0 0 43 64 47 51 62 45 52 42 32 438 Greece 13 9 10 6 4 9 6 5 4 13 3 1 83 Hungary 0 0 0 1 0 0 1 1 2 2 6 10 23 Iceland 0 0 0 0 0 0 0 0 1 0 1 0 2 Ireland 0 0 0 0 0 0 0 0 2 10 10 15 37 Israel 3 21 7 6 2 1 5 10 10 13 5 17 101 Kazakhstan 0 0 0 0 0 0 0 0 0 0 0 0 0 Kyrgyzstan 0 0 0 0 0 0 0 0 0 0 1 10 11 Latvia 0 0 0 0 0 0 0 3 11 26 90 210 340 Lithuania 0 0 1 0 0 0 1 3 8 2 5 0 20 Luxembourg 0 1 3 1 0 0 2 0 2 0 2 0 11 Malta 0 0 0 0 0 0 0 0 0 1 0 0 1 Moldova 0 0 0 0 1 0 5 67 54 25 15 23 190 Norway 2 2 1 2 3 0 1 2 6 2 6 6 33 Poland 99 66 56 25 40 49 52 32 51 46 50 29 595 Portugal 0 0 0 0 0 0 0 0 0 0 106 55 161 Romania 0 0 0 6 7 18 10 13 20 18 16 97 205 Russian Fed. 4 4 3 3 7 13 317 809 609 5174 14858 17321 39122 San Marino 0 0 0 0 0 0 0 0 0 0 0 0 0 Slovak Rep. 0 1 0 0 1 0 1 0 0 0 0 0 3 Slovenia 0 0 1 0 0 0 1 0 0 1 0 0 3 Sweden 6 5 11 16 4 4 3 5 2 5 3 4 68 Switzerland 22 27 21 16 9 11 10 14 12 18 19 27 206 Tajikistan 0 0 0 0 0 0 0 0 0 0 2 4 6 Macedonia 0 0 0 0 1 1 0 0 0 0 0 0 2 Turkey 1 0 1 1 2 3 3 4 5 6 5 5 36 Ukraine 0 2 1 1 1 269 423 468 648 341 330 430 2914 United Kingdom 56 44 37 39 35 44 44 34 39 36 39 74 521 Uzbekistan 0 0 0 0 0 0 0 1 0 1 5 0 7 Yugoslavia 0 0 0 0 0 0 0 0 0 0 0 0 0 Total 207 183 159 170 192 481 1159 1687 1638 5882 15904 19029 46731

Source: EuroHIV, Saint-Maurice, France.

110 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

Eastern European and central Asian countries represent a vast geographical zone where the situation with STIs and HIV/Aids remains heterogeneous. While the Russian Federation, Belarus and Ukraine are confronted with explosive epidemics of syphilis and HIV infection, other countries, such as Tajikistan and Turkmenistan, have registered only a few cases of HIV infection to date, and Azerbaijan, Armenia and Tajikistan have registered a moderate level of syphilis (Eramova and Toskin, 2001). In a birth cohort analysis of AIDS in Europe, Houweling et al. (1998) found increasing incidence between the 1950-1954 and 1960-1964 cohorts of IDU, which may have been caused by the increasing prevalence of injecting drug use. Among the youngest three cohorts, incidence at age 20-24 and 25-29 years appeared to be stabilising. On the other hand, AIDS incidence increased amongst all birth cohorts of heterosexual contact cases. Among heterosexual cases there was a sharp increase between the 1960-1964 and 1965-1969 cohorts, and to a lesser extent between the 1965-1969 and the 1970-1974 cohorts.

4.3. Background information on trends in sexually transmitted infections and HIV infections Trends in teenage STIs are fairly stable in western Europe, but have been decreasing since 1995 in eastern Europe. However, in Russia STIs were still increasing in the late 1990s. HIV infections have been stable in western and central Europe, but have seen a rapid increase in Russia and in some other countries of eastern Europe. In this sub-chapter some background information and explanations for these trends will be provided. Young people are more vulnerable to HIV/AIDS than older people are. Because their social, emotional and psychological development is incomplete, they tend to experiment with risky behaviour, often with little awareness of the danger. In fact, risky sexual behaviour is often a part of a larger pattern of adolescent behaviour, including alcohol and drug use, delinquency and challenging authority. Many adolescents believe that they are invulnerable themselves. Even young people who know how to protect themselves from HIV/AIDS often lack the social skills to do so. Some young people, especially women, are at risk of HIV/AIDS because they have a poor self-image or are uncomfortable with their sexuality (Kiragu, 2001). Adolescents are at particular risk of exposure to STIs and HIV because they are less likely to be married and more likely to have multiple and high-risk partners, as their sexual relations are often unplanned, sporadic and sometimes come about as a result of pressure or force. Their sexual relations typically occur before they have the experience and skill to protect themselves, and before they have adequate information about STI and adequate access to STI

111 Reproductive health behaviour of young Europeans services and condom supplies. From a social perspective, many adolescents do not use a barrier contraceptive either through ignorance or because access is limited for social and/or economic reasons (World Population, 2002). A high prevalence of teenage HIV infection is partly explained by active HIV testing. In 2001 in Russia, 12% of the population had an HIV test. HIV testing activity has been higher in Russia than anywhere else in Europe over the past ten years: for example, in Finland HIV testing has been fi ve times less prevalent than in Russia. While assessing the fi gures and trends in different countries, we need to bear in mind that the states of the former Soviet Union, other eastern European countries and the four nordic countries have relatively more active and extensive screening and case-fi nding policies for STIs and HIV infections. Among young people, barriers to voluntary testing include lack of information, perception of low risk, lack of confi dentiality, costs, transportation problems and laws that require parental consent. Due to high costs of diagnosis of chlamydia infection, more consistent and complete trend data on chlamydia is available only from seven countries. Decreasing trends in STIs and HIV/AIDS infections in western Europe are partly a consequence of AIDS prevention campaigns in the late 1980s and the early 1990s. After that the numbers of new reported diagnoses of gonorrhoea, infectious syphilis and other sexually transmitted infections fell in several countries in western Europe (Nicoll and Hamers, 2002). These campaigns proved to be successful. Some fundamental changes have probably contributed to bringing syphilis and gonorrhoea rates down in recent years and to keeping them at low levels: more widespread and better-quality sex education, improved access to contraceptive and STD services, and increased condom use. Improved treatment of STDs has probably helped shorten the duration of infections, while better education and improved preventive behaviour may have reduced the likelihood of transmission. Young people who are socially and economically the most disadvantaged are at the highest risk of HIV infection. Lack of education, poor general health, untreated STIs, sex-for-survival interaction, economically driven migration, labour and sexual exploitation all exacerbate the vulnerabilities of young people who live in poverty (World Population, 2002.) In eastern Europe, several countries have experienced rising unemployment, increases in poverty, the disintegration of social networks and severe budget cuts for the health and social sectors, all of which are having a devastating impact on the health of their populations (WHO regional, 2001).

112 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

The Russian Federation now has the highest rates on gonorrhoea and syphilis, and HIV incidence among teenagers is the highest in Europe. Even in the early 1990s the threat of HIV seemed distant in Soviet-era Russia, given the context of limited personal freedoms, tight governmental and police controls related to drug use and prostitution, ofﬁ cially conservative values related to sexuality, and an authoritarian but effective approach to public-sector STD surveillance, treatment and contact tracing (Amirkhanian et al., 2001.) In the 1990s, Russia experienced sustained and severe economic upheaval, including the failure of its banking system, currency devaluation, corruption and the emergence of widespread joblessness and poverty. Many young people became fatalistic and held out little hope for the future. To make matters worse, large increases were observed in the prevalence of illicit drug use, including opiate injection, among teenagers and young adult Russians. Almost one-third of intravenous drug-users in St. Petersburg are younger than nineteen. Many young people believe that AIDS is a threat only to members of particular “risk groups”. A large proportion of adolescents do not associate safer sex with condom use (Amirkhanian et al., 2001). One of the determinants for the increasing trends is the fact that awareness of STIs and HIV infections is rather low in many eastern European countries. In Georgia only 81% of men and 60% of women reported having heard of syphilis and gonorrhoea. In Georgia only 15% of women knew of chlamydia and the same proportion recognised herpes. In the youth population aged 15-19 in Tajikistan and Albania, only slightly over half reported having heard of HIV/AIDS. In Tajikistan, over half did not know how to protect themselves from getting HIV/AIDS. Almost half of the youth in Kazakhstan reported no knowledge of STI symptoms (Eramova and Toskin, 2001). The reasons behind increasing infection rates in the 1990s also include increased opportunities for travel and migration, the replacement of the traditional state- funded health care system with a regional system, and uneven delivery, accessibility and use of health services. The resources available in Russia for STD control declined from 1990 to 1995, perhaps by as much as 50%. The traditional pattern of women’s sexual behaviour in Armenia, Georgia and Uzbekistan (sexual initiation after marriage, rare extra-marital sexual relationships and high rate of condom use in risky sex in Armenia) corresponds to the moderate level of STIs in these countries. The traditional patterns of women’s sexual behaviour in Kyrgyzstan and high incidence of syphilis in this country require additional research (Eramova and Toskin, 2001). Findings from in-depth interviews among young adults (Papp, Kontula and Kosunen, 2000; Lear, 1995) have shown that young women who look for more personal approval than sexual enjoyment in their sexual intercourse are prone to taking sexual risks. At weekends partying, intoxication, dance

113 Reproductive health behaviour of young Europeans and high sexual desire go together. Many young people do not want to miss the chances that they have during these evenings even though they are not prepared for the event, for example by carrying a condom with them. Female adolescents who lack conﬁ dence in their own abilities and future prospects often see little to lose in case of early pregnancy and childbearing (Rhode, 1993).

5. European policies for preventing unwanted pregnancies, sexually transmitted infections and HIV infections European sexual health policies have not been studied or reviewed com- prehensively. Knowledge concerning these policies would be an asset to understand and to compare variations in sexual and reproductive health in different parts of Europe. In this chapter examples of European national sexual health policies and activities will be provided as well as some reviews of the outcomes and evaluations of sex education trials and national sexual health policies.

5.1. Sexual values and evaluation of sexual policy outcomes in Europe Some of the differences in the sexual health patterns and policies in Europe can be understood by varying sexual values in each country and society. In the latest wave of the European values study (Halman, 2001) conducted in 1999-2000, some values related to sexual relationships were measured. These include importance of faithfulness in a successful marriage, importance of a happy sexual relationship in a successful marriage, approval of abortion for a married woman, approval of married men and women having a affair, approval of homosexuality and abortion, approval of having casual sex, and sex under the legal age of consent, and approval of prostitution. Approval of sex under the legal age of consent was measured in ﬁ fteen countries. It met most often with approval in Slovenia, Greece and Finland, and was viewed with least approval in Ireland, the Czech Republic and Lithuania. Attitudes to casual sex were studied in thirty-two countries. The highest rates of approval for casual sex were found in Sweden, Slovenia, Iceland, Spain and France, and the lowest in Malta, Romania, Poland, Latvia and Lithuania. Many eastern European countries were somewhat disapproving of casual sex. On the other hand, having affairs was most often felt to be justiﬁ ed in France, Slovenia, Estonia, Bulgaria and Belarus. The least tolerant attitudes to unfaithfulness were in Malta, Iceland, Ireland, Poland and Romania. Interestingly, prostitution was most approved in Germany, Austria and Great Britain. The counties where it was looked on with the least tolerance were Croatia, Ukraine, Northern Ireland and Romania.

114 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

All in all, western countries had more tolerant attitudes regarding sexual issues than eastern European countries. The exception was the attitude towards male unfaithfulness, which was tolerated to a greater extent in eastern Europe than in western Europe (France was an exception). The strongly Catholic countries had less tolerant attitudes on sexual issues both in the east and west. The results of the European values study prove that high teenage pregnancy rates and also high rates of teenage STIs and HIV infections in eastern Europe are not due to their liberal sexual attitudes on the contrary. Jones et al. (1985) used a thirty-seven –country comparison of patterns of adolescent pregnancy to examine the impact of (inter alia) government education policy, fi nancial support for abortion and single parents, religios- ity, openness about sexuality, ethnicity, and marriage laws on adolescent pregnancy and sexual activity. Findings from that study indicated that those countries that rated higher on openness about sex were also those that experienced the lowest birth-rates. Teaching of birth control in schools was associated with low adolescent fertility, and low birth-rates were associated with low abortion rates. In Europe, governments, primarily through grants to agencies that provide family planning and STD and HIV/AIDS prevention, provide funds for sex education (Moore, 2000). The comparison studies have indicated that when and where there was open and liberal policy as well the provision of sex education and related services (for example, family planning), there were lower pregnancy, birth, abortion, and STD rates (Grunseit and Kippax, 1997). Of forty-seven studies which evaluated interventions, twenty-fi ve reported that HIV/AIDS and sex education neither increased nor decreased sexual activity and attendant rates of pregnancy and STDs. Seventeen reported that HIV and/or sex education delayed the onset of sexual activity, reduced the number of sexual partners, or reduced unplanned pregnancy and STD rates. Only three studies found increases in sexual behaviour associated with sex education (Grunseit and Kippax, 1997). Kirby et al. (1994) have found that effective instruction was grounded in social learning theory along with focused curricula giving clear statements about behavioural values and norms. More specifi cally, successful programmes fea- tured clear delineation of the risks of unprotected sex, and methods to avoid those risks, focusing on activities that address social or media infl uences and modelling and practice in communication and negotiation skills. There is evidence also that providing clinical services, encouraging openness about sex and initiating sex education prior to the onset of sexual activity may further enhance these outcomes of later initiation and safer practices.

115 Reproductive health behaviour of young Europeans

5.2. National sexual health policies The Netherlands has been seen internationally as an inspiring example for successful sexual policy approach. The 1980s witnessed a “second sexual revolution” in Dutch attitudes, with the appearance of AIDS fostering public acceptance of all prevention activities, especially condom use. Improved funding of research produced a number of thoughtful publications. The media played an important role, and “Double Dutch” – using condoms and the Pill – became the primary message, especially for young people. National media campaigns, particularly during the weeks before holidays, stressed “Safer sex or no sex”, and condom use was promoted as a way for young men to share responsibility (Greene et al., 2002). In the Netherlands decisions regarding sexual behaviour belong to the sphere of individual responsibility. Respect for people’s wishes and boundaries are central to Dutch values concerning sexuality. Sex education is part of the school curriculum. Oral contraceptives are available primarily from general practitioners, and no charge is incurred for a visit to obtain them. A prescription for oral contraceptives requires only a screening for blood pressure. Conﬁ dentiality with respect to practitioners informing the parents of teenage clients is a concern (Moore, 2000). The department of Health, Welfare and Sport largely funds the Netherlands Institute of Social Sexological Research (NISSO), an independent research institute which addresses sexuality, intimate relationships and gender issues. Its youth incentives division, staffed by a team of researchers, educational specialists, trainers, and medical and non-medical consultants, promotes and disseminates sexual and reproductive health programmes for young people (Greene et al., 2002.) Throughout West Germany, education about sexuality has been a part of the school experience since the 1970s, but this was not the case in East Germany until reuniﬁ cation. In addition to sex education in schools, a variety of media educate adolescents, such as magazines, brochures, videos, counselling hotlines, and an interactive computer programme, Love Line. Boys are more likely to respond to computer games, while girls use the counselling hotline more frequently. Oral contraceptives, intra-uterine devices, barrier methods and sterilisation are covered by insurance and are free to women aged twenty and under. Germans need not visit a physician for contraceptives; they are available at family planning clinics (Moore, 2000). In France and Sweden, there appears to be a strong and universal perception that having a child during adolescence is undesirable (Singh et al., 2001). In France, however, for adolescents under the age of eighteen, parental consent is required for abortion. Before the HIV/AIDS epidemic, sex education in schools was thought to be unnecessary (Moore, 2000).

116 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

Concerning the Swedish population policy, the whole system has been based on the high degree of co-ordination of the individual parts of the system. Another important aspect of the Swedish situation is a certain pragmatism. Demand for teenage sexual abstinence came gradually to be viewed as unrealistic. This being the case, teenagers’ use of contraceptives is viewed as highly desirable because it will prevent both childbearing and abortion. Teenage abortion is seen as desirable only in so far as it prevents teenage parenthood (Santow and Bracher, 1999.). In Sweden explanations for the decrease in teenage pregnancies and in teenage STDs could include repeated STD information to the public, compulsory sex education in schools, increased resources to adolescent clinics, and subsidised oral contraceptives to women younger than 20 years of age, thus refl ecting the tolerant Swedish attitude toward sexual activity among adolescents (Týden et al., 2001). Regardless of the excellence of contraceptive and sex education, the provision of contraceptives takes the primary role in reducing rates of teenage pregnancy. For teenagers, this means provision of the Pill. Teenage abortion rates fall when the cost of the Pill is subsidised (Santow and Bracher, 1999). In eastern Europe, pro-natalist policies have been adopted for example in Bulgaria, Hungary and Romania since the end of the 1960s, in Czechoslovakia, GDR and Hungary since the fi rst half of the 1970s, and in the USSR since the early 1980s, with the aim of reaching a temperate and steady population increase. These policies were carried out with instruments such as child allow- ances, maternity leave, preferential loans, and preferential housing. In some countries the regime made use of other restrictive instruments, such as a ban on abortion, introduction of a bachelor’s tax, and restriction of the supply of modern contraceptives (Philipov, 2002). Of former Soviet citizens, 87% never had discussions about sexuality with their parents. Before the 1980s, most Soviet youths failed to receive any sex education in school. The curriculum promoted virginity until marriage, and life fulfi lment solely in the context of marriage, often through the production of children. Information on contraceptives was relatively meaningless in the face of limited contraceptive supplies (Friedman, 1992). Texts on sexual moral education devoted minimal attention to birth control methods. Oral contraceptives were banned in 1974 by the Soviet ministry of health, and until quite recently many in the medical profession and lay community considered the Pill more dangerous than abortion. Citizens were obliged to assume responsibility for resolving the demographic crisis by responding to s the collective and personal need for more children (Rivkin-Fish, 1999).

117 Reproductive health behaviour of young Europeans

In the 1990s, sexuality in Russia quickly began to be polarised and politicised due to sexually-explicit language and erotic scenes on prime time television and pornography that became readily available in street kiosks. The very concept of sex education became maligned by conservatives as leading to the import of “western cultural evils” – including homosexuality, governmental failures, and depopulation. The Russian Orthodox Church called for a return to Orthodox morality and the need to protect Russian traditions and values from the onslaught of a “western” takeover (Rivkin-Fish, 1999). In Russia there is no requirement that sex education be taught in schools, and courses on biology and hygiene do not cover the subject. However, in 1999, the ministry of health ordered that sex education be provided in health clinics for children below the age of seventeen. The Russian Family Planning Asso- ciation has faced resistance from certain organizations infl uenced by “pro- life” ideology. They have launched a fi erce mass-media campaign against all state and non-governmental initiatives dealing with sexual health issues. In Russia conservative political and religious voices have labelled sexual health education as an inappropriate western concept. Research on sexual health problems such as syphilis and HIV has also been met with similar resistance (Hilber, 2001). At the same time, the Communist wing of the State Duma succeeded in reducing the state family planning budget from 25 billion roubles to 11 billion (Gadasina, 1997). All the countries featuring in the “Women of the World” report (2000), that is, Albania, Croatia, Hungary, Lithuania, Poland, Romania and Russia, have governmental organisations or bodies working on AIDS prevention. In all seven countries, national AIDS commissions or c have been established to manage and enforce either directly or with the ministry of health policies and public education strategies. Only in Albania and Lithuania are HIV/AIDS and STI services integrated within reproductive health and family planning programs. Most of the eastern countries long ago approved sex education offi cially, but have not yet managed to implement it adequately. In Czechoslovakia, under communist rule, people held puritanical beliefs about sexuality and sex education in schools was practically non-existent, being often limited to one or two biology classes that discussed anatomy without referring to the genitals. Teachers traditionally emphasised the negative consequences of sexual behaviour and installed shame in their students. With the end of communism came the increased infl uence of the Catholic Church, now waging strong campaigns against sex education. The Church also actively opposes family planning, which it sees as part of a “communist conspiracy”. Those who do provide sex education are accused of being immoral, of promoting premature sexual behaviour and favouring abortion. According to them, the goal of sex education should be to prevent teenage sexual expression (Friedman, 1992).

118 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

In Poland, family planning services are generally not provided in the public health care system. In Romania there are no separate family planning services for adolescents. In Russia there are special units for youths within health clinics in cities with populations of between 300,000 and 500,000. In Russia, Romania, Lithuania, Hungary and Albania the main strategy to reduce unwanted pregnancies and abortions has been to initiate activities to provide family planning information (Women of the World, 2000). In Croatia, elementary and secondary school curricula do not include sex education. In a survey among secondary school students, only 20% were familiar with the functioning of the human reproductive system. In Hungary there is neither a general overall policy nor a unifi ed practice regarding sex education for adolescents. Civic organisations and individual programmes of some institutions conduct work in this fi eld. In Lithuania, only a few schools offer organised sex education programmes. In 1998 the Lithuanian Peda- gogical University created an elective programme for health teachers which will qualify them to teach sexual health classes. In Poland, all curricula and manuals present the Catholic Church’s views on human sexuality, gender roles and contraception. The government has made no attempt to provide secular, neutral information. In Romania, the few efforts that have been made to introduce sex and contraceptive education into secondary school curricula have been hindered by the resistance of both teachers and parents and the lack of adequate teacher training (Women of the World, 2000). In Russian cities there are selected groups of gynaecologists and psycho- therapists which have taken it upon themselves to initiate new sex education efforts. With no set curriculum or offi cial guidelines (and no budget for supplies), educators create patchworks of material gathered from personal libraries and donated by western humanitarian organisations, missionaries and commercial fi rms (Rivkin-Fish, 1999). There have also been programmes for condom distribution targeted at teenagers. Unfortunately, there has not been any budget targeted specifi cally for HIV/AIDS prevention activities (Popova, 1996)

6. Conclusions The programme of action adopted at the International Conference on Popu- lation and Development in 1994 produced expansive deﬁ nitions of sexual and reproductive health and reproductive rights. It also focused attention on gender equality, equity and empowerment of women. The ICPD Programme of action called on world leaders to acknowledge the centrality of sexual and reproductive health to health in general, and to respect the rights of young people to lead healthy reproductive lives. The ICPD Programme of Action

119 Reproductive health behaviour of young Europeans made specifi c promises regarding funding of reproductive health activities overall. At the ICPD, 179 countries met to construct this international agreement (World Population, 2002; Greene et al., 2002). The concept of reproductive rights is an inclusive one, encompassing not only decisions about childbearing and access to contraceptives, but also implying a larger commitment to the social progress that leads to equitable gender relations. Women who have choices in other areas of their lives are more likely to exercise control over their reproductive and sexual health (World Population, 2002). The following year, the fourth world conference on women in Beijing affi rmed the principle of women’s human rights and called on governments to promote and protect women’s rights, including their reproductive rights, and to remove obstacles that prevent the achievement of these rights (World Population, 2002). Many international organisations defi ned a list of sexual rights in the 1990s. These include the International Planned Parenthood Federation (IPPF), World Association for Sexology (WAS), and the United Nations Population Fund (UNFPA) (Lottes and Kontula, 2000; UNFPA, 1995). Fundamental rights are the right to information and education, the right to choose whether or not to marry and have and plan a family, the right to decide whether or when to have children, and the right to health care and health protection (IPPF). Looking at trends and other information in this report these rights are not properly met in Europe, especially in eastern Europe. The central ethical issue is justice. The procreative rights of patients and populations seem illusory, given the poverty and lack of power and competence which impair individual freedom of choice and informed consent for most people. Reproductive justice does not appear possible in a society characterised by pervasive socio-economic injustice (Brody, 1976).

6.1. Summary of the European trends on teenage sexual behaviour, teenage pregnancies and teenage sexually transmitted infections and HIV/AIDS in Europe Information on teenage sexual initiation in Europe is based on national surveys conducted in twenty-three countries in the 1990s. According to these surveys, teenage sexual initiation has been in transition in Europe during recent decades. Decreasing trends in the age of teenage girls at ﬁ rst sexual intercourse started in northern Europe in the 1960s, and was followed in the 1970s in many western European countries. The mean age of women at ﬁ rst sexual intercourse decreased in all western European countries and also in some central European countries by two to three years after the 1960s. The mean age of men has also decreased, but less than the mean age of women.

120 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

This has narrowed the gap between the male and female mean ages at sexual initiation. The mean age of men was long signifi cantly lower than the mean age of women. There was a double sexual standard that allowed males to have more sexual experience before the marriage. This double standard was particularly strong in southern and eastern Europe. In the 1980s, the age at fi rst sexual intercourse remained fairly stable around Europe. In different countries there were both slight decreases and increases in the mean age at fi rst intercourse. All in all, there is not much evidence that HIV infection and HIV prevention campaigns had any impact on teenage sexual initiation in Europe in the second part of the 1980s. In the fi rst part of the 1990s there is some evidence that the mean age at fi rst sexual intercourse decreased in western Europe, on average, by months. The mean age varied typically from 17 to 18 years. At the same time, there are eastern European countries where the mean age is close to 20 years. The lowest mean age for sexual initiation among women was found in the UK, at 16.2 years. The transition in sexual initiation has taken place one generation later in eastern Europe compared to the similar transition in western Europe. The decrease in age at fi rst sexual intercourse started 20-30 years later than in western European countries in most eastern European, and also in some southern European, countries. In the most traditional eastern European countries, such as Romania and Moldova, the transition has not yet truly started at all. The mean age of men at fi rst sexual intercourse is fairly homogeneous in Europe; the variation is typically one year from country to country. The mean age of women varies much more: in western Europe it is around two years, and in Europe as a whole three to four years. This is related to the sexual double standard in which women have been allowed fewer premarital sexual experiences. In the countries where the double standard operates, the mean age of women at fi rst sexual intercourse is much higher than the comparable age of men. In older generations this age gap was as great as six years. In the youngest generation the gap was only one to two years. In nordic countries women have sexual initiation even younger than men do. Gender equality has progressed in sexual issues in Europe among the generation that has lived its teenage years in the era of AIDS even though it is still very inadequate in most European countries. The time from fi rst sexual intercourse to cohabitation or marriage has increased. As a consequence, young people have more casual sexual relationships than in previous decades. The age gap from fi rst sexual intercourse to cohabitation is fi ve to six years for European males, but around four years for western European females, and only one to two years for eastern European females.

121 Reproductive health behaviour of young Europeans

Previously, age at fi rst marriage was a strong determinant of sexual initiation and age at birth of fi rst child, especially for women. This is still true in the developing world (Kontula, 2000). The time from fi rst sexual intercourse to age at fi rst marriage is much shorter in eastern Europe. Currently, sexual initiation is very seldom related to marriage in western Europe. On the other hand, in Armenia marriage and fi rst sexual intercourse are still strongly interlinked. During the latest generation the mean age of women at fi rst marriage has increased by four to fi ve years in western Europe, varying from twenty- seven to thirty years. In eastern European countries the mean age has been stable or has increased only by one to two years, varying from twenty-two to twenty-four years. The mean age of women at birth of fi rst child is much lower in eastern Europe compared to western Europe. It varies from twenty-two to twenty- four years, whereas in western Europe it is twenty-seven to twenty-nine years. In western Europe young people have sexual relationships for a much longer time before they start a family. In northern Europe young people cohabit younger than in southern Europe. This implies that they have regular sexual activities younger. Of the single young women in the 20-24 age group, from 3-55% have annually multiple partners. These include both short-term steady relationships and casual relationships. Among males this proportion varied from 10-63%. The lowest fi gures are from Italy where young people seem to have casual partners less often than young people in other western European countries. In some eastern European countries women report almost only single partners whereas a high proportion of men report multiple partners. Based on survey data, almost all teenage pregnancies are unwanted. In the 20-24 age group, around half of pregnancies are unwanted. These pregnancies are basically due to missing or unreliable contraceptives. Teenage pregnancy rates were stable or decreasing in western Europe in the 1980s. In the 1990s they decreased heavily. Contrary to this trend, the rates of teenage pregnancies (30 per 1000) were stable in the UK. In more religious western European countries the teenage pregnancy rate is around 20 per 1000. The lowest rates (5-7 per 1000) are found in Italy, Switzerland, the Netherlands and Sweden. In eastern Europe teenage pregnancy rates are much higher than in western Europe. In the early 1990s, rates in some countries were as high as 60-70 per 1000. At the end of the 1990s, pregnancy rates were still close to 50 per 1000 in Ukraine, Moldova, Georgia, Turkey, and Bulgaria. In Russia and central Europe they were equal to the UK: 30 per 1000. The highest decrease in teenage pregnancy rates took place in the 1990s in central Europe.

122 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

During the last thirty years teenage pregnancy rates have more than halved in two thirds of European countries. In nine countries decreases were at least fourfold. However, there were eight eastern European countries where teenage pregnancy rates were higher in 1995 than in 1970. These countries are Armenia, Belarus, Estonia, Georgia, Lithuania, “the former Yugoslav Republic of Macedonia”, the Russian Federation and Ukraine. Teenage pregnancy rates are on average three to four times higher in eastern Europe compared to western Europe. Reasons for high teenage pregnancy rates in eastern Europe are strongly related to poverty and to the non-use of contraceptives. Before the transition eastern European countries strongly restricted the supply of market contraceptives, and on the other hand, they could not afford the import of modern contraceptive devices. These devices were said to be dangerous to health and the prices were kept so high that modern contraceptives did not gain true popularity among the eastern European population. Studies of the consequences of teenage motherhood indicate that it involves a high risk of poverty. This report could not be successful in reviewing teenage trends in STIs in Europe because of the lack of co-ordinated surveillance systems in Europe for sexually transmitted infections apart from HIV. High reporting of STIs was found in nordic countries, in some central European countries and in Russia. Countries where the most sexually transmitted infections are dealt with by primary care or private doctors ﬁ nd it especially difﬁ cult to establish reporting. In many western European countries the available statistics cover less than 50% of the actual infections. Chlamydia has been included in statistics only in some countries and only since the 1990s. Information on genital herpes and human papilloma virus is very scarce in Europe. There is an urgent need to build up the European surveillance system on STI infections. The best available statistics for teenage STIs are found for syphilis and gonorrhoea. Syphilis generally decreased in Europe in the 1980s and 1990s. In the 1990s, syphilis rates were only 1-2 per 100,000 in many western European countries, whereas these rates were in Romania 58 and in Russia and Kazakhstan over 200 per 100,000. In Russia the incidence of syphilis was 100 times higher than in the nordic countries. Young adults had higher rates than adolescents. There was a steady decrease in gonorrhoea rates in almost all western European countries in 1985-1996. The rates were usually less than 10 per 100,000. Much higher rates were found in Romania (66 per 100,000), England and Wales (77 per 100,000), and Russia (round 600 per 100,000). In Russia the rates were also high among teenagers and they were still increasing in the second part of the 1990s. In most eastern European countries, syphilis and gonorrhoea rates were highest in 1995-1996 and have decreased since. In 1999

123 Reproductive health behaviour of young Europeans the rates were a half or a third of that of 1995 in eastern Europe. However, in some western European countries gonorrhoea rates were incvreasing at the end of the 1990s. Most troubling is the pattern in countries where an initial wave of gonorrhoea infection is succeeded by a surge in the more destructive syphilis, and, more recently, the incidence rates for HIV have started to move up (Unicef, 2000). For HIV monitoring there is the European centre for the epidemiological monitoring of AIDS (EuroHIV). This centre has information on HIV infections and AIDS from most European countries. Unfortunately, there is no national reporting in France, Italy and Spain where HIV prevalence has been known to be the highest in western Europe. In 1995, HIV infection rates were still much lower in transition countries compared to western European countries. Since then HIV rates have increased very much in many eastern European countries. High increases in some eastern European countries have been largely due to increasing numbers of intravenous drug users among young men. More than half of HIV infected persons are drug addicts. The most disadvantaged young people are at the highest risk of HIV infection. One important reason for high rates for HIV infection in eastern European countries is poor awareness of STIS and HIV infection and the means to prevent them. HIV rates are 100 times higher in eastern Europe than in the countries of central and western Europe. In 1997-2001, teenage HIV rates were stable in western Europe, and in central Europe they decreased somewhat, but in eastern Europe they have multiplied by ten times. In eastern Europe there was a heavy increase in HIV infections in 1999 and 2000. HIV rates were in 1999 124 per 1,000,000 in Russia, and 115 per 1,000,000 in Ukraine. In Russia a major increase took place in 2000; high increases were also found in Estonia, Latvia and Romania. In Belarus and Moldova HIV rates were decreasing. In Romania most AIDS cases (23–0)are children aged between 5 and 9 years. They have been infected by the use of contaminated medical equipment. Some experts are forecasting that in Ukraine and in the other transition countries, the swift, drug-related expansion of HIV will follow the Polish model, eventually stabilising, but at higher levels. The Polish pattern is similar to the patterns in other central European nations and in the countries of the former Yugoslavia. However, Bulgaria and Romania have signiﬁ cantly higher incidence rates, and the number of registered cases has risen in the population in recent years (Unicef, 2000).

124 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

Declines in STDs in some countries, in particular the nordic countries, offer hope that it is possible to reduce the burden of STDs through a combination of information and education programmes, partner notifi cation and active screening strategies, better access to STD health care, and programmes promoting behavioural change. In conclusion, transition in sexual initiation started fi rst in the 1960s in the nordic countries, then spread to many western European and central European countries and fi nally, one generation later, to southern and eastern Europe. In this transition sexual initiation broke with marriage and age of women at fi rst sexual intercourse decreased several years almost everywhere in Europe. From the viewpoint of sexual and reproductive health, this transition did not cause increasing sexual health hazards. On the contrary, teenage pregnancies and STIs (syphilis and gonorrhoea) decreased in countries that faced this sexual transition. In eastern Europe sexual abstinence before marriage protected young people from STIs but young age at fi rst marriage caused a high rate of teenage pregnancies. In western Europe, decreasing trends in teenage pregnancies and STIs are due to secularisation of sex and liberalisation of attitudes. They made possible the distribution of relevant information on sexual issues, sex education and related public health services. HIV prevention campaigns in the 1980s were very important in providing to the young generation with the sexual knowledge and skills that they needed in order to protect themselves from sexual health hazards. Unfortunately similar knowledge was not available in eastern Europe. After the transition in eastern Europe in the early 1990s, the new generation was freer to make personal choices but usually without the knowledge and means to protect themselves. At the same time public health resources were cut down. One of the consequences was the increasing trends in teenage STIs in eastern Europe. The rate of teenage pregnancies also remained high. In late 1990s, European teenagers and young adults were sexually somewhat more active than before. Thanks to reliable contraceptives, teenage pregnancies were at the same time decreasing. In eastern Europe, syphilis and gonorrhoea were also better in control than before. Some countries have lately seen an increase in teenage pregnancies and STIs, which is related to decreasing use of condoms. In the late 1990s, public sex education and HIV prevention campaigns were less active than ten years previously. Attitudes to condoms were less favourable than some years before. This transition had dramatic consequences, especially in Russia, where the rates of teenage STIs and HIV infections were 100 times higher than in western Europe, and were signifi cantly increasing even in the late 1990s. Public opinion has not been supportive of proper sex education, and poverty

125 Reproductive health behaviour of young Europeans has brought an increasing number of drug addicts to the streets. Due to insufﬁ cient investments in sex education and the public health sector, teenagers and young adults have not been equipped to face risky situations. That has led to serious disorders in sexual and reproductive health among teenagers and young adults in Russia.

6.2. Need for sexual health surveillance and a data bank in Europe The review in this report into teenage sexual and reproductive health in Europe reveals the incompleteness of readily available statistics on sexual and reproductive health indicators at European level. Availability of statistics for teenage pregnancies and HIV infections is satisfactory, but information related to teenage sexual behaviour, contraceptive use and STIs is scarce and unsystematic. In addition, abortion statistics are insuffi cient. There is an urgent need to activate a European surveillance system on STI infections. We also need funds and co-ordination for sexual health surveys in Europe that will cover information related to sexual initiation, sexual knowledge, use of contraceptives, and sexual patterns among young adults. Creation of the EU co-ordinating centre for sexual behaviour research, in collaboration with existing European research centres, would be an asset. Such a centr could co-ordinate and provide technical assistance in organising and implementing studies of sexual behaviour for various population groups in the European countries. The EU should play a leading role in promoting the creation of networks, research and information exchange facilities concerning sexual and reproductive health care. Frequency of intercourse and the type and duration of sexual relationships may infl uence exposure to pregnancy and STD risk. STD rates may refl ect greater exposure to infected partners (both by having sex with more partners over a given period of time and by greater prevalence of STDs in the country as a whole). Unfortunately, such information is mostly not available (Darroch et al., 2001.) This information should be included in the surveillance system. It would be useful to continue to monitor and compare countries, as conditions keep changing (Singh and Darroch, 2000). Lottes and Kontula (2000) created the sexual health evaluation model that they applied to Finnish sexual health. It would be useful in describing and evaluating sexual health also in the other European countries. The model covers the following sexual health components/indicators: - planned and unwanted pregnancies; - reproductive health; - risk of contracting a sexually transmitted disease or HIV infection; - sexual knowledge and education;

126 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe

- sexual enjoyment and pleasure; - sexual coercion, abuse, harassment, assault, rape, or mutilation; - discrimination. These are the indicators that should be included in the European surveillance system on sexual health. In the European Parliament report on sexual and reproductive health and rights, Van Lancker (2002) recommends that the European Commission develop a database concerning sexual and reproductive rights, based on harmonised reproductive health indicators. The research currently supported by the Commission in this ﬁ eld should be continued under the new Community health action programme, for example, the Reprostat project that aims to develop indicators and determinants of reproductive health for monitoring and evaluating reproductive health in the EU, and the ECHI project that posits sexual behaviour as a health determination the EU health strategy. A concept of sexual and reproductive health that is strongly focused on fertility has limited relevance to the lives of young people. Why measure the success of sex education only in terms of pregnancy prevention? Why not measure numbers of cases of HIV/AIDS and other sexually transmitted diseases, or the incidences of sexual abuse and assault? To shift away from the a focus on danger, why not mark success by increased intimacy, sexual competence, satisfaction, number of orgasms, or other measures of sexual pleasure? (Friedman, 1992).

6.3. Sexual health policy implications in Europe Van Lancker (2002) maintains in the European Parliament report on sexual and reproductive health and rights that European countries should provide relevant data and information on policies to the Commission in order to compile a Europe-wide database on sexual and reproductive health statistics and to compose a vademecum on best practices and positive experiences in the fi eld of sexual and reproductive health. Promoting multidisciplinary scientifi c research in sexology is a key factor in providing up-dated information on European sexual and reproductive health. This research approach needs to be properly fi nanced. Due to missing information, there are serious diffi culties in comparing sexual and reproductive health policies, both within the EU and between the EU and the accession countries, and even more so in eastern Europe. In many cases such a policy is completely absent. Van Lancker (2002) recommends that the governments of the member states and the accession countries develop a high quality national policy on sexual and reproductive health, in co-operation with plural civil society organisations.

127 Reproductive health behaviour of young Europeans

Prevention in sexual health is cost-effective in the long run. The prevention of STIs, particularly, is a cost-effective option for countries to invest in. Preventing HIV infection among youths would also help reduce the mounting cost of treatment, providing resources that could help meet other needs of young people. Prevention of teenage pregnancies would give young people a chance to educate themselves and get a proper profession. Prevention of teenage pregnancies also prevents poverty. Lottes and Kontula (2000) argue that we should work to promote equality of sexual standards, and in particular to promote policies that do not dis- criminate on the basis of class, race or ethnicity, religion, age, marital status, disability, gender and gender identity, or sexual preference or orientation. Policies should be directed toward increasing sexual skills and knowledge and providing quality sexual health services for all. Countries should ensure the provision of unbiased, scientiﬁ c and clearly understandable information and counselling on sexual and reproductive health, including the prevention of unwanted pregnancies and the risks involved in unsafe abortions carried out under unsuitable conditions. Advice and counselling must be conﬁ dential and non-judgmental (Lancker Van, 2002). Counselling will be needed also for preventing and treating sexual abuse as well as to help people gaining control of their sexuality. Young people often also need help to attain the acceptance and enjoyment of the full potential of their sexuality. No national governments in the EU have a clear and separate policy on sexual and reproductive health, but the majority of countries support family planning services. These services, including contraceptives, are free of charge in the UK and Portugal. In other countries clients pay, but in most cases are partially or fully reimbursed. Family planning is not integrated into the health system in Spain and Greece, and in Ireland state funding is only available to centres providing “natural methods” (Lancker Van, 2002). Berne and Huberman (1999) have studied sexual health policies in the Netherlands, Germany, and France. They found that in these countries a major public health goal is to ensure that everyone, including adolescents, has the necessary skills to behave responsibly when sexually active. Major effort goes into developing and delivering effective mass media campaigns. The mass media promote more open and frank discussions about sexuality than previously existed. Western European experts believe such discussions contribute to the acceptance of sexuality as a normal and healthy component of life for everyone. They present images and concepts that relate to sexuality in a sensual, amusing, or attractive way. Great value is placed on individual ethical behaviour in choosing sexual health and responsibility. National health care in each country covers the costs of most forms of contraception,

128 Trends in teenage sexual behaviour: pregnancies, sexually transmitted infections and HIV infections in Europe emergency contraception, abortion, counselling services, physical examinations, screening and treatments. In Europe a top priority is to encourage and fund high-quality sexuality and lifeskills education nationwide from the earliest age. Teachers and health care providers must be given the knowledge and the skills to communicate com- fortably about sexual and reproductive health with young people (Greene et al., 2002). High quality sex and relationship education, begun early, tailored to young people’s needs, linked to sexual health services and well delivered by trained staff remains of vital importance in enabling young people to make informed choices about their sexual health. Through education, young people learn negotiation and decision-making skills that they can apply to prevent unwanted sexual relationships, protect themselves from exploitation and violence, and negotiate condom use when sexually active. The provision of sex education in schools, which has increased in many countries (as part of societal efforts to counter the epidemic of HIV and AIDS), is likely to have made a cumulative contribution to improved knowledge of contraception, ability to negotiate contraceptive use and effectiveness of contraceptive use among adolescents (Singh and Darroch, 2000). Unfor- tunately, this kind of education is still almost completely absent from most eastern European countries. Sex education must be considered in a holistic and positive way, paying attention to psycho-social as well as bio-medical aspects, and must be based on mutual respect and responsibility. Young people can be reached through formal and informal education, publicity campaigns, social marketing for condom use and projects such as conﬁ dential telephone helplines (Lancker Van, 2002). Responding to the needs of young people is not the responsibility of the government alone: communities, parents, churches and civil society need to join in efforts to reach young people. NGOs, including women’s rights groups, have an important role to play in advocating with the government and with the public, and in shaping the implementation of youth sexual and reproductive health policies (Greene et al., 2002). Teaching sex education should be a collaborative effort between school personnel, community youth workers, reproductive health clinicians, parents and communities. Reproductive health interventions for adults generally focus on supplying services, but for young people even more than adults, social constraints affect their ability to access services and other means of supports (Greene et al., 2002). Prevention programmes must be delivered in the environments where adolescents socialise, communicate, and meet new friends and potential sexual partners. Adolescents are often sceptical of advice given by adults and authority ﬁ gures, and may trust their peers more than the authorities (Amirkhanian et al., 2001).

129 Reproductive health behaviour of young Europeans

Adolescents would like to have sexual health services which are free, are anonymous and do not require an appointment (urban youth), are close at hand and allow equal access to services (rural youth). Young women value close proximity to services, access to a comfortable environment, a friendly staff, absolute conﬁ dentiality, and being able to come with a friend and have enough time for discussion (Bender, 1999). Social exclusion, poverty, low educational attainment and access are also key factors in this complex public health issue. Governments should provide contraceptives and sexual and reproductive health services free of charge, or at low cost, for under-served groups, such as young people, ethnic minorities and the socially excluded. People living in poverty should get better access to reproductive and sexual health services, and they should be offered the choice of contraception and the prevention or diagnosis of sexually transmitted diseases. Emergency contraception should be promoted as standard practice within sexual and reproductive healthcare. Walk-in clinics outside school hours in accessible locations might improve uptake of services and effective use of contraceptives. At the local level aims are, through improved sex education and sexual health services, to ensure that pregnant teenagers and teenage mothers complete their education and, if they are under eighteen, are not housed in isolated and unsupported accommodation. As a part of a national campaign, parents should be encouraged to talk with their children about sex, and young men should be encouraged to be more responsible in their sexual behaviour (Scally, 1999). Moreau-Gruet et al. (1996) suggest that prevention programmes should emphasise, among boys, responsibility in contraception and the need for protection in situations where there are multiple partners, and among girls, a positive attitude towards condom use and an increased familiarity with condoms presented both in a perspective of contraception and prevention of STDs. Girls with lower levels of education should receive particular attention. It might be best to begin with the training of health and education professionals to address the issue appropriately with their clients and students. There is also the need to support national NGOs and professional associations.

130 References

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137 The authors

Dr Nathalie Bajos is a researcher at INSERM (Institut National de la Santé et de la Recherche Médicale) Address: INSERM –INED - U 569 Hôpital de Bicêtre 94276 Le Kremlin Bicêtre Cedex Tel: +33.1.45.21.22.73 E-mail: [email protected]

Mme Agnès Guillaume is a researcher at IRD (Institut de recherche pour le Développement) Address: IRD- CEPED Campus du Jardin Tropical 45 bis Avenue de la Belle Gabrielle 94736 Nogent sur Marne Tel: + 33 1 43 94 72 93 E-mail: [email protected]

Dr Osmo Kontula is a senior researcher at the Population Research Institute, Family Federation of Finland Address: Population Research Institute, P.O. Box 849, FIN-00101 Helsinki Tel. +358-9-22805123 E-mail: Osmo.Kontula@vaestoliitto.ﬁ

138 Titles in the same collection

24. Information and education in demography Rossella Palomba, Alessandra Righi (1993) (ISBN 92-871-2111-7)

25. Political and demographic aspects of migration ﬂ ows to Europe Raimondo Cagiano de Azevedo (editor) (1993) (ISBN 92-871-2360-8)

26. The future of Europe’s population Robert Cliquet (editor) (1993) (ISBN 92-871-2369-1)

27. The demographic situation of Hungary in Europe Andras Klinger (1993) (ISBN 92-871-2352-7)

28. Migration and development cooperation Raimondo Cagiano de Azevedo (editor) (1994) (ISBN 92-871-2611-9)

29. Ageing and its consequences for the socio-medical system Jenny De Jong-Gierveld, Hanna Van Solinge (1995) (ISBN 92-871-2685-2)

30. The demographic characteristics of national minorities in certain European states (Volume 1) Werner Haug, Youssef Courbage, Paul Compton (1998) (ISBN 92-871-3769-2)

31. The demographic characteristics of national minorities in certain European states (Volume 2) Various authors (2000) (ISBN 92-871-4159-2)

32. International migration and regional population dynamics in Europe: a synthesis Philip Rees, Marek Kupiszewski (1999) (ISBN 92-871-3923-7)

139 Reproductive health behaviour of young Europeans

33. Europe’s population and labour market beyond 2000 (Volume 1: An assessment of trends and policy issues) Aidan Punch, David L. Pearce (editors) (2000) (ISBN 92-871-4273-4)

34. Europe’s population and labour market beyond 2000 (Volume 2: Country case studies) Aidan Punch, David L. Pearce (editors) (2000) (ISBN 92-871-4399-4)

35. Fertility and new types of households and family formation in Europe Antonella Pinnelli, Hans Joachim Hoffmann-Nowotny and Beat Fux (2001) (ISBN 92-871-4698-5)

36. Trends in mortality and differential mortality Jacques Vallin and France Mesle, Tapani Valkonen (2001) (ISBN 92-871-4725-6)

37. People, demography and social exclusion Dragana Avramov (2002) (ISBN 92-871-5095-8)

38. The demographic characteristics of immigrant populations Werner Haug, Paul Compton, Youssef Courbage (editors) (2002) (ISBN 92-871-4974-7)

39. Demographic consequences of economic transition in countries of central and eastern Europe Dimiter Philipov and Jürgen Dorbritz (2003) (ISBN 92-871-5172-5)

40. The economically active population in Europe Rossella Palomba and Irena E. Kotowska (2003) (ISBN 92-871-5183-0)

41. Active ageing in Europe (Volume 1) Dragana Avramov and Miroslava Maskova (2003) (ISBN 92-871-5240-3)

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