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Home , Family planning, Reproductive health

Adolescents and Planning: What the Evidence Shows

International Center for Research on Women ICRW where insight and action connect 1 This review was made possible by the Definitions generous support of the Bill and Melinda • For the purposes of this • Supply is defined as the pro- Gates Foundation and was conducted study, adolescents are vision of reproductive by Allison Glinski, Magnolia Sexton and defined as those ages 10-24 services, particularly family Suzanne Petroni, with technical and years old. planning, that are appropri- editorial guidance and input from Ellen • Demand is conceptualized ate for adolescents’ needs Weiss, Anjala Kanesathasan, Jeffrey with a nuanced understand- and are available in a way Edmeades, Jennifer McCleary-Sills, Ann ing of how gender dynam- that is accessible to them. Warner, Kirsten Stoebenau and Gwennan ics influence adolescents’ • Accessibility in this context Hollingworth, all of the International reproductive desires. These includes issues such as the Center for Research on Women (ICRW). include the number, timing availability of an appropri- and spacing of children, as ate mix of contraceptive well as whether they want to methods, infrastructure,

Photos by Jennifer Abrahamson, David Snyder, Robyne Hayes use various options to control health systems and provider

© 2014 International Center for Research on Women (ICRW). their and have the knowledge, attitudes and Portions of this report may be reproduced without express agency to do so effectively. competence.1 permission from but with acknowledgment to ICRW. Adolescents and : What the Evidence Shows

Introduction

The International Center for Research on Women (ICRW) conducted a review of the literature to identify barriers to adolescents’ access to and use of family planning services, programmatic approaches for increasing access and uptake of those services, gaps in the evidence that require further research, and areas that are ripe for future investment.

The Importance of Family Planning for Adolescents

Roughly one-quarter of the world’s adolescents, the need is significantly — 1.8 billion people — is greater among 15-19 year olds, as between 10 and 24 years of age.2 compared to those ages 20-24.4 Indeed, marital status is a factor Among the many sexually active that cannot be overlooked in a adolescents worldwide, large world where one-third of girls in numbers want to avoid, delay developing countries are wed before or limit but lack the age 18, and one in nine is married by knowledge, agency or resources the age of 15.5 While both married to make decisions regarding their and unmarried girls are sexually . On average, unmet active, some 90 percent of the need for contraception is greater births experienced by adolescent among unmarried adolescents than mothers occur within .6 those who are married, however married adolescents ages 15-19 Socio-cultural and structural barriers experience a higher percentage often prevent adolescents from of unmet need than all married achieving their reproductive desires, women.3 Among unmarried which can result in unintended

Methods ICRW’s literature review in- adolescent family planning in- their perspectives on what is and instead fall within a more cluded 24 systematic reviews formation and/or services. The needed to advance adolescent comprehensive framework of published since 2000 that analysis was supplemented sexual and sexual and reproductive health evaluated programs providing with reviews of more than 200 rights and family planning. and rights. Finally, limited family planning information additional peer-reviewed arti- Limitations of this re- evidence is available about and services. All of these cles and grey literature reports search: Adolescents may not which strategies and programs studies used experimental or that identified best practices, demonstrate measurable most effectively reach distinct quasi-experimental methods. recent findings and innovative behavioral results until well groups of adolescents, such While not every study focused solutions for different types after the end of the program as married and unmarried, specifically on adolescents of programmatic approaches. or evaluation, so successful rural and urban, and younger and family planning (i.e., some Finally, to corroborate and ex- interventions may be missed and older youth. Evidence included family planning for pand upon the gaps in the ev- in the literature. Also, few regarding effective strategies adults or primarily addressed idence that were identified in adolescent-focused initiatives for reaching very young ad- HIV prevention), all included the literature, we interviewed are specifically defined as olescents (10-14 years old) is 3 some level of attention to several donors to understand “family planning” programs particularly thin. Adolescents and Family Planning: What the Evidence Shows

and unhealthy , Conceptual Framework among other outcomes. To help adolescents better access and The following conceptual framework traditional demand-side and supply- use family planning services, we was developed to guide ICRW’s side components to contraceptive must understand the barriers analysis, and is based on past use. For example, even if adolescents they encounter in defining their examinations of reproductive want to use family planning methods reproductive intentions, and health barriers and programmatic and there are high-quality, youth- in demanding, accessing and approaches, as well as ICRW’s friendly methods available, if they do using contraceptives. And we Women’s Demand for Reproductive not have the confidence to walk into a must understand what works in Control paper.7 It postulates that clinic and ask for contraception, they empowering them to overcome adolescents must achieve three will not be able to use it. these obstacles. demand-side objectives and two supply-side objectives, though not Objectives 4 and 5 represent the Effectively addressing these issues necessarily in sequencea, in order “supply-side” components. Achieving results in stronger and to sustainably and effectively use Objective 4 means that adolescents : When girls grow up family planning to fulfill their desired have access to family planning healthy, educated and empowered, reproductive outcomes throughout methods at a location, time and they become productive and their lifetimes. price that is feasible and convenient. effective leaders, earners, providers Objective 5 is attained when services and, if they so choose, mothers. This The first three objectives operate are not only available for adolescents, in turn has a ripple effect on children, primarily on the demand side. but they are high quality, youth- households, communities and Achieving Objective 1 signifies that friendly and offer a variety of methods nations. And when girls and boys are adolescents want to avoid, delay, that are appropriate for them. By provided with education, information limit or space their pregnancies. achieving all of these objectives, and services to protect and promote They understand the benefits of adolescents are able to effectively use their sexual and reproductive health, waiting to initiate sexual activity family planning methods in line with they are better equipped to engage or of having [more] children and their fertility intentions throughout in healthy decisions and behaviors want to control their reproduction. their lives. This is an important now and for decades to come. With Objective 2, adolescents distinction, as reproductive desires Such positive outcomes therefore have a desire to use family planning and appropriate methods will change make it critical for us to understand methods, which demands a basic over one’s reproductive lifetime. adolescents’ reproductive desires understanding of contraceptive and enable them to achieve these methods and how reproduction Accomplishing these objectives aspirations by providing them with occurs. However, wanting to use is dependent on the individual appropriate, high-quality information family planning methods is not adolescent. This is also strongly and services. sufficient to enable adolescents to influenced by — but not limited to — actually use them. Adolescents need the social norms of the environment to be able to achieve Objective 3 — in which adolescents live, as well as possess the agency to access and the local political atmosphere, health use contraceptives — which means sector and the legal frameworks. they must be empowered with the The young person’s partner, parents, knowledge and self-efficacy to make family, peers and community also and act on their decisions.8 While we play a role in how he/she forms and have categorized Objective 3 as a achieves his or her reproductive “demand-side” factor, it can also be desires. viewed as the bridge between the

4

The Conceptual Framework T Goal: Sustained, effective use of family planning EN M Adolescents are effectively able to use family N O planning methods to reach their reproductive desires IR V over their life course. N E L A Objective 5: Provision of quality, C I youth-friendly services T I Not only do adolescents have access to services, L t

n but the services are of high quality and are O S

e SUPPLY

P M m appropriate for their reproductive needs.

R n

O o

r

N i

Objective 4: Access to family planning services

v L

n Adolescents have access to services at a time, A

I E

location, and price point that are C

g t

convenient for them. O

n

n S K

i

l

e

R

b

O m

a Objective 3: Agency to use family planning

n

n W

Not only do adolescents wish to use family planning o E

E r i

methods to avoid, delay, space, or limit births, but M v

A they have the ability to act on their desires and n

R E

R DEMAND make decisions regarding their reproduction. F

g O

L n T A i

l C

G Objective 2: Desire to use family planning b E E S

a L Not only do adolescents wish to avoid, delay, space, n H or limit births, but they want to use family planning E T L methods to do so. A E H

Objective 1: Desire to avoid, delay, space or limit childbearing Adolescents wish to avoid, delay, space, or limit the number of children they have.

a While the framework is presented as a series of objectives, Additionally, as an adolescent’s reproductive desires shift, these are not necessarily sequential. Demand and supply the required agency and type of services needed will shift. objectives could be achieved simultaneously, or supply-side For example, while it may be acceptable for an unmarried facilitators, such as the provision of youth-friendly services, adolescent to want to avoid pregnancy, societal views may could be present before it is socially or culturally acceptable shift once the adolescent gets married, and then shift again for adolescents to use contraceptives in a particular context. after the first birth.

Adolescents and Family Planning: What the Evidence Shows

For each objective, we identified key In general, we found that media, interpersonal/peer-to-peer barriers adolescents face, as well as interventions were better able to communication and education, rigorously evaluated programmatic achieve measurable improvements conditional cash transfers (CCTs), approaches that, either directly or in knowledge and attitudes than and improvements to health services. indirectly, address these obstacles. in behavior. Such programs were While factors that influence most effective when they combined Meanwhile, programs that impacted adolescents’ family planning desires, individual education, improvement of behavior were more likely to decisions and actions may not services and community outreach/ change contraceptive behavior always be changed or influenced mobilization to inform communities than sexual behavior. Those that by programmatic approaches, they about available services and to involved adolescents in program must be considered when designing increase acceptability of adolescents’ design tended to be more successful and implementing programs. use of family planning. Some of and programs that increased 5 the most effective efforts included contraceptive use usually had a educational interventions, mass health services component. Adolescents and Family Planning: What the Evidence Shows

Demand Side

OBJECTIVE 1: How to Increase missing school and getting pregnant. cultural acceptability of adolescents’ Desire to Avoid, Delay, Space or While there is not as much evidence contraceptive use, can enable youth Limit Childbearing of their effect on reproductive to overcome barriers to wanting to desires, youth development use family planning methods. Programs that aim to increase the programs are able to build value of girls and promote the adolescents’ self-confidence and Programs that have been most benefits and cultural acceptability provide them with a greater sense of successful in achieving Objective of delaying sexual activity and first opportunities throughout the course 2 provide information and change pregnancy, and ultimately, of having of their life other than parenthood, social norms through education and smaller families, directly address which can indirectly discourage early media campaigns. In order to be barriers that inhibit girls from marriage and pregnancy. successful, such programs need to wanting to avoid, delay, space or be sure to provide both adolescent limit their childbearing. OBJECTIVE 2: How to Increase boys and girls with reproductive the Desire to Use Family Planning health information that is culturally Some of the interventions that Methods appropriate and relevant to them. have been most successful in For school-based educational achieving Objective 1 are indirect Programs that disseminate programs to achieve Objective approaches that increase school information about sexual and 2, they must be appropriately enrollment, which contributes to reproductive health and about designed and teachers need delayed marriage and pregnancy. In family planning methods are to be suitably trained and feel particular, programs that offer CCTs, essential to increasing adolescents’ comfortable with the material. incentives or support in the form of understanding of how fertility and Some communication programs school uniforms and supplies lower pregnancy prevention work. This that target specific contraceptive barriers to attending school and information, along with programs method use and deliver messages increase the opportunity cost of that change social norms around the through the Internet, mobile phones,

Demand-Side Barriers

(1) Desire to avoid, delay, Objective (2) Desire to use family planning (3) Agency to use family planning space or limit childbearing Barriers • Gendered roles/expectations • Stigma around accessing and • Limited decision-making for Girls o Wife/mother using methods and adolescent autonomy and power o Remain chaste sexuality • Early marriage • Need to prove fertility • Taboos around communication • Family pressure to have • Low value of childbearing • Lack of understanding of: children/not use a method alternatives o Reproductive health • Poor partner communication o Family planning methods, • Religious values including • Sexual coercion and other forms • Son preference of violence • Cultural taboos in providing • Desire to secure a relationship information about reproductive • Transactional sex health and family planning • Limited self-efficacy Barriers • Gendered roles/expectations • Stigma around accessing • Limited self-efficacy for Boys o Father and using o Sexually active • Taboos around communication • Need to prove sexual prowess • Lack of understanding of: and fertility o Reproductive health • Religious values o Family planning methods 6 • Son preference • Lack of perceived responsibility in family planning use their own path for the future, but also effectively pursue it. Programs that promote multiple, positive roles that girls can play in reinforce the fact that girls have the power to choose what they want and that they need not be limited by traditional norms. Increasingly, evidence suggests that working directly with married adolescent girls and their families can improve their agency within relationships as well. Informational programs, specifically peer-to-peer education interventions, have been most successful at enabling adolescents social media and other sources, OBJECTIVE 3: How to Increase to achieve Objective 3, by have been shown to be effective. Agency to Use Family Planning increasing their communication and These programs were most negotiation skills related to their successful when they addressed Agency-building programs can reproductive desires. Indirectly, gender norms that shape boys’ increase adolescent girls’ capacity youth development programs have notions of masculinity and limit girls’ to negotiate sexual behaviors, also effectively built adolescents’ control over sex. comfort with discussing issues self-confidence and empowered related to reproductive health, and them to advocate for their rights self-confidence to not only choose and beliefs.

Demand-Side Programmatic Approaches

(1) Desire to avoid, delay, Objective (2) Desire to use family planning (3) Agency to use family planning space or limit childbearing Direct • Information • Information (School/curricu- • Information (School/curricu- Programmatic o Alternative roles/options for lum-based education, work- lum-based education, interpersonal/ Approaches girls place-based education, interper- peer-to-peer education) sonal/peer-to-peer education, o Alternative roles/options o Benefits of delaying, spacing new media) for girls and limiting o Sexual and reproductive o Sexual activity negotiation skills • Mass media health o Acceptability of avoiding, o Family planning methods delaying, spacing, or limiting • Mass media small families o Acceptability of method use

Indirect Pro- • Youth development • Youth development grammatic • CCTs/incentives Approaches

7 Adolescents and Family Planning: What the Evidence Shows

Supply Side

OBJECTIVE 4: How to Increase approaches that boost adolescents’ Access to Family Planning Services knowledge and awareness of family planning (demand-side), frequently While there is some evidence also result in them better knowing around the use of community-based where and how to use services. distribution/outreach, vouchers and social franchises to achieve Similarly, supply-side efforts to Objective 4, more research is improve the quality of services needed. What the evidence does often include components designed demonstrate is that lack of access to to improve access and vice-versa. family planning services is another Indeed, the evidence shows that significant hurdle for adolescents efforts to increase young people’s seeking reproductive control. Their access to services are most effective ability to use services requires four when linked to interventions that basic components: a convenient target young people’s knowledge, and secure location, an affordable skills, attitudes and behaviors. cost, convenient operating hours and knowledge of the services and Specifically, creating links or referral how to access them. These are all systems between schools and supply-side challenges. However, reproductive health services can

Supply-Side Barriers

Objective (4) Access to family planning services (5) Provision of quality, youth-friendly services

Barriers for Girls • Lack of awareness of services • Lack of provider quality/ competence • Inaccessible location /limited mobility • Provider reluctance to provide contraceptives to adolescents • Inconvenient operating hours • Unavailability of appropriate methods • Long wait times • Stock-outs Barriers for Boys • Costs • Restrictions on use • Lack of access to financial resources • Gender biases in service provision • Lack of / confidentiality • Lack of perceived responsibility in family planning use

Supply-Side Programmatic Approaches

Objective (4) Access to family planning services (5) Provision of quality, youth-friendly services

Programmatic • Information • Information (new media) Approaches o Where/how to access services o How methods work o What methods are best for each adolescent’s needs • Mass media o Where/how to access services • Community-based distribution o Youth centers • Community-based distribution o Youth centers • Vouchers o Links/referral with schools • Social franchises • Vouchers • Youth-friendly services • Social franchises 8 • Youth-friendly services UNFPA: Essential and Supportive Elements of Youth-Friendly Services — Addressing Objectives 4 & 5 increase adolescents’ knowledge of Essential Supportive and access to reproductive health services, as can community-based Access Access outreach and distribution through • Convenient hours •Outreach services available innovative models such as vouchers • Reasonable waiting time •Accessible location and social franchises. • Affordable fees • Male and youth welcomed and served • Separate space and/or hours for youth, where needed •Publicity that informs and reassures young people OBJECTIVE 5: How to Increase

Provision of Quality, Youth-friendly Quality Quality Services • Specially trained staff •Comfortable setting • Respect for youth • Adequate space For family planning services to • Adequate time for client-provider •Youth input/feedback to operations effectively meet adolescents’ unique interaction needs, providers must be trained to •Educational materials available • Privacy and confidentiality understand the nuances of young • Provision of additional educational • Package of essential services available opportunities people’s sex lives and to deliver both counseling and appropriate • Referrals available • Peer providers/counselors available methods to meet their reproductive • Sufficient supply of drugs and commodities desires. A comprehensive, consistent method mix should be available, and • Range of contraceptives offered providers should be able to explain • Emphasis on dual protection/ (male and female) how different methods work and their associated side effects. Services (Adapted from UNFPA, Expanding Access to Youth Services: http://web.unfpa.org/adolescents/ should be private, confidential and youthfriendly.htm) linked with other health services. In addition to these key characteristics of youth-friendly service provision, programs Specifically, vouchers have shown should be tailored to meet the specific needs and barriers of underserved youth in various settings. (Gay, 2010) some success in increasing the privacy and confidentiality of services as well as increasing providers’ competence in providing needed services and counseling.

For Objective 5, evidence suggests that programs delivering all of these components increase the general quality and “youth-friendliness” of reproductive health services.

9 Adolescents and Family Planning: What the Evidence Shows

Conclusions and Recommendations

This analysis provides a synthesis To further advance the field and of the evidence base in regard to the evidence base, we offer several interventions that have worked, recommendations. directly or indirectly, to impact the family planning knowledge, attitudes 1) Donors should invest in long-term and practices of adolescents in studies that capture the results of the developing world. While we interventions with adolescents over have only scratched the surface in time, as their needs and fertility terms of understanding the various desires change. Where longitudinal advantages and limitations of the studies may be challenging and unique and diverse interventions resource-intensive, donors can implemented over the years, we leverage existing or past program feel confident that there is a path data about program participants to forward. This path leads toward understand the long-term creating a more supportive effects of an intervention. environment that enables youth to overcome the “demand-side” 2) Implementation research that and “supply-side” barriers to more elucidates how and why certain 5) Advocacy is needed in both effectively and sustainably use programs are successful in certain donor and developing countries family planning to reach their fertility places can help the field better to improve the relationship desires over the course of their lives. understand whether particular between articulated policies and interventions or program their implementation in practice. There is a great deal of evidence elements can be replicated and/ Two examples follow: about what works to empower or scaled up. This could apply adolescents to reach their fertility to interventions that aim to a. Comprehensive sexuality desires over the course of their lives. influence both the “demand-side” education (CSE) with certain However, many gaps and unknowns and “supply-side” factors. key characteristics can have still remain. Much of the existing positive impacts on reproductive evidence is not sufficiently rigorous, 3) Future research should consider health knowledge, attitudes and various evaluation findings multi-component interventions, and practices, including family present nuanced contradictions. such as combining mass media planning; and school-based As with many other issues in programming and capacity CSE has the potential to reach , there is no singular building for local organizations a significant proportion of programmatic approach or solution with youth-friendly health services. adolescents, including very that is guaranteed to work; with This approach would enable young adolescents. However, so much depending on contextual analysis of programs that work on while many governments note factors, various approaches and both demand and supply sides. the importance of CSE and have combinations of approaches are policies on the books pertaining necessary in different circumstances. 4) All programmatic interventions to it, very few are investing Despite this challenge, several aimed at influencing adolescent adequately in it, and fewer yet conclusions can be drawn from the sexual and reproductive health utilize evidence-based curricula evidence regarding which types outcomes should strive to and/or training programs to of approaches and what specific include a substantial monitoring build teacher capacity. components or characteristics of and evaluation framework and each work best to tackle the barriers strategy from the beginning, so b. In many countries, to achieving various objectives of that the field can better capture governments’ statements, adolescent family planning demand, and learn from the differential policies and plans regarding 10 access and use. We have tried to impacts of the various elements adolescents’ access to present those conclusions in this brief. of interventions. contraception are forward- thinking, but in practice, Endnotes many government-supported service providers are reluctant 1 McCleary-Sills, J., McGonagle, A., & 3 Presler-Marshall, E., & Jones, N. (2012). to provide contraception to Malhotra, A. (2012). Women’s demand Charting the future - Empowering girls for reproductive control: Understanding to prevent early pregnancy. Overseas unmarried youth. Research and addressing gender barriers. Development Institute: London in select countries on these Washington, DC: ICRW. 4 MacQuarrie, K. (Forthcoming - 2013). inconsistencies can build Malhotra, A., & Shuler, S. (2005). Tailored to fit: Programming for the evidence to inform country- Women’s empowerment as a variable in sexual and reproductive health of young level advocacy and policy international development. In Measuring women in Africa. Measure DHS Report. change that has the potential Empowerment: Cross-Disciplinary Calverton, MD: Measure DHS. Perspectives. 71–88. Narayan, D. ed. to foster large-scale change in 5 UNFPA. (2012). Marrying too young: Washington D.C.: , Gender the short-term. End Marriage. New York: UNFPA. and Development Group. 6 UNFPA, 2012 6) There are 70 million girls under Bongaarts, J. (2008). Fertility transitions in developing countries: Progress or 7 McCleary-Sills, McGonagle & Malhotra, the age of 18 who are currently stagnation? Studies in Family Planning, 2012 married, and 14.2 million more are 39, 105-10. 8 Golla, A.M., Malhotra, A., Nanda, P. married each year. Addressing 2 , Department of and Mehra, R. (2011). Understanding therefore has the Economic and Social Affairs, Population and measuring women’s economic potential to significantly impact Division (2013). empowerment: Definition, framework family planning and other Prospects: The 2012 Revision, Key and indicators. Washington, DC: ICRW. reproductive health outcomes. Findings and Advance Tables (Working Within the context of addressing Paper No. ESA/P/WP.227). New York: UN Department of Economic and Social the social norms needed to Affairs, Population Division. improve all of the demand- side factors addressed in this paper, donors and implementers should work to prevent early marriage, and better understand how delaying marriage impacts first birth. At the same time, understanding how best to support married girls, including helping them to delay and/or space first, second and third pregnancies, would serve as a critical contribution to the field.

7) Finally, this study has demon- strated the tremendous need for sharing data, information and resources regarding adolescent reproductive health amongst a wide range of donors, researchers and implementing agencies. We hope that this report is but one contribution toward that goal.

A more comprehensive version of this paper, with a complete list of citations, is available at 11 www.icrw.org. International Center for Research on Women (ICRW)

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