Volume 1, No.1, October 2008

June 27, 2008 (RP/KLM) Photo: WHO/MPS Adolescent Pregnancy Adolescent girls who give birth each year have a much higher risk of dying from maternal causes compared to women in their 20s and 30s. These risks increase greatly as maternal age decreases, with adolescents under 16 facing four times the risk of maternal death as women over 20. Moreover, babies born to adolescents also face a significantly higher risk of death compared to babies born to older women.

These notes were prepared by Mangiaterra V., Pendse R., McClure K. and Rosen J. (Department of Making Pregnancy Safer, WHO/HQ). The authors wish to thank Chandra Mouli V., and Camacho V. (Department of Child and Adolescent Health, WHO/HQ) and Mathai M., Portela A., Zupan J. (Department of Making Pregnancy Safer, WHO/HQ) and Olukoya P. (Department of Gender, Women and Health, WHO/HQ) for their valuable comments. Edited by Heine M.A. and designed by Gyamerah D. How prevalent is adolescent • Adolescent fertility rates have fallen in the age between 15-19 years according to DHS surveys in 35 out of 40 pregnancy? countries since 2000. • The range varies from an average decline of 16% in About 16 million adolescent girls aged 15-19 give birth each Eastern and Southern Africa, to 50% in North Africa/ year, roughly 11% of all births worldwide West Asia /Europe. • Almost 95% of these births occur in developing countries. • They range from about 2% in China to 18% in Latin In what context do adolescents America and the Caribbean. become pregnant? • Half of all adolescent births occur in just seven countries: Bangladesh, Brazil, the Democratic Republic of Congo, In developing countries, about 90% of births to adolescents Ethiopia, Nigeria, India and the United States (Population occur within marriage. The proportion is close to 100% Division 2008). in Western Asia/Northern Africa, Central Asia, and South- Central and South-Eastern Asia, while between 70-80% in • The adolescent fertility rate worldwide was estimated to South America and in sub-Saharan Africa be 55.3 per thousand for the 2000-2005 period, meaning that on average about 5.5% of adolescents give birth each year. About 75% of adolescent pregnancies are intended, ranging from 42% in Colombia to 93% in Egypt. The pregnancies • Adolescent birth rates in the less developed countries may be “intended” due to social and cultural norms, or are more than twice as high compared to rates in more because unmarried young women see it as their only means developed countries and these range from less than 1% of establishing identity. Worldwide, births to unmarried per year in places like Japan and the Republic of Korea, adolescent mothers are far more likely to be unintended and to over 20% per year in the Democratic Republic of those outside marriage are more likely to end in abortion. Congo, Liberia and Niger. • A small but significant percentage of adolescent Births to Adolescents Within or Before Marriage, by Region pregnancies result from nonconsensual sex. Recent Percent of First Births that Occur Within or Before Marriage studies of coerced first sex report rates between 10%

Western Asia/Northern Africa and 45% of girls who first had sex before age 15. South America • Age at first marriage is increasing in many countries, Caribbean/Central America as are rates of contraceptive use among both married Central Asia and unmarried adolescents. South-central/South-eastern Asia • Educational levels for girls, which are closely Western/Middle Africa associated with early childbearing, have also risen in Eastern/Southern Africa most countries, and job opportunities have expanded. TOTAL—All DHS 0% 20% 40% 60% 80% 100% Is adolescent pregnancy a

Within Source: National Research Council & Institute of Medicine, 2005, from Demographic problem? and Health Surveys in 51 countries, late 1990s-mid-2000s. Before Despite the downward trend, adolescent pregnancy remains very prevalent, particularly in the poorest countries. Childbearing to mothers under 15, is a problem in certain Adolescent childbearing has a negative impact on these countries three dimensions: health of the adolescents and their • An analysis of survey data from 51 developing infants; individual social and economic effects; and societal countries from the mid-1990s to the early 2000s level impacts. showed that almost 10% of girls were mothers by age 16, with the highest rates in sub-Saharan Africa and Health impact on mother and newborn South-Central and South-Eastern Asia. A study in Latin America found that maternal death rates for • Because the health risks of early childbearing appear adolescents under 16 are 4 times greater than for women to be magnified for the youngest mothers, these very in their 20s. Although some of this risk can be attributed to early births are a major concern. factors other than young age – e.g. giving birth for the first time, lack of access to care, or socioeconomic status - there Rates of adolescent childbearing have dropped significantly appears to be an independent effect of young maternal age in most countries and regions in the past two to three on pregnancy risk to the mother. decades

October 2008 2 • Adolescent fertility rates have fallen in the age between • Conditions associating adolescent childbearing and Perinatal Mortality by Age of Mother 15-19 years according to DHS surveys in 35 out of 40 maternal health problems include obesity, anemia, countries since 2000. malaria, STIs, mental illness, unsafe abortion Perinatal Mortality by Mother’s Age at Birth, Adolescent vs. Women 20-29

• The range varies from an average decline of 16% in complications, and obstetric fistula. Philippines 2003 Eastern and Southern Africa, to 50% in North Africa/ • Accounting for about 11% of all births worldwide, Ethiopia 2005 West Asia /Europe. maternal conditions in adolescents cause 13% of all Burkina Faso 2003 deaths and 23% of all disability adjusted life years. Mozambique 2003 Malawi 2004

In what context do adolescents India 2005/06 Too-early childbearing also negatively impacts the survival become pregnant? Senegal 2005 of newborns Bangladesh 2004 (2) In developing countries, about 90% of births to adolescents • Studies have shown rates of newborn death to average Indonesia 2002/2003 occur within marriage. The proportion is close to 100% about 50% higher to adolescent mothers versus the United Republic of Tanzania 2004 Ghana 2003 in Western Asia/Northern Africa, Central Asia, and South- mothers in their 20s (Macro International 2008). Central and South-Eastern Asia, while between 70-80% in Guinea 2005 • As with health risks to the mothers, a combination of Morocco 2003-2004 (1) South America and in sub-Saharan Africa physical and socioeconomic factors place babies of Dominican Republic 2002

youngest mothers at higher risk of dying. Rwanda 2005 About 75% of adolescent pregnancies are intended, ranging • Studies have shown an independent adverse effect Moldova 2005 from 42% in Colombia to 93% in Egypt. The pregnancies of early pregnancy on newborn health, even after Madagascar 2003/2004 may be “intended” due to social and cultural norms, or controlling for a range of other factors (Conde-Agudelo Egypt 2005 because unmarried young women see it as their only means et al 2005; WHO 2007). Colombia 2005 of establishing identity. Worldwide, births to unmarried Kenya 2003 20-29 • A large U.S. study found a 55% higher risk of neonatal < 20 adolescent mothers are far more likely to be unintended and Bolivia 2003 death to babies of mothers aged 10-15, a 19% higher those outside marriage are more likely to end in abortion. Armenia 2005 risk in babies of 16-17 year-olds, and a 6% higher risk Jordan 2002 in babies of 18-19 year-olds. • A small but significant percentage of adolescent 0 10 20 30 40 50 60 70 80 90 pregnancies result from nonconsensual sex. Recent • The adverse impact of poor newborn health due to Perinatal mortality rate studies of coerced first sex report rates between 10% adolescent pregnancies can have inter-generational Source: (Macro International, 2008), IIPS and Macro International 2007 and 45% of girls who first had sex before age 15. effects and also long term effects leading to adulthood disease (Fetal Origins of Adulthood Diseases). • Age at first marriage is increasing in many countries, Societal impact as are rates of contraceptive use among both married Studies have shown that delaying adolescent births could and unmarried adolescents. Relative Risk of Adverse Outcomes by Maternal Age, Latin America significantly lower population growth rates, potentially

• Educational levels for girls, which are closely Reference Group: 20-24 year-olds generating broad economic and social benefits. associated with early childbearing, have also risen in 4.5 <=15 16-17 18-19 most countries, and job opportunities have expanded. 4 k 3.5 s How can adolescent pregnancy i r

3 e

v 2.5 i be made safer? t 2 a Is adolescent pregnancy a l e 1.5 R 1 Mothers and babies need care in pregnancy, for childbirth problem? 0.5 and after birth. It must be delivered as a continuum of care 0 I s ia ia s T g ia n ry y e ti th s s te M in io e m g ri a p p e U O d m t iv o a t e b R e e ec l t rh e that starts in the household and community and extends into m m a P e n s e io r m l d Despite the downward trend, adolescent pregnancy remains la la i l A - d is o o a c c D b C l p m d e E l r a E n rn re a te in m e te P n s g e l a the healthcare system, including care for complications. io e a h a very prevalent, particularly in the poorest countries. t im v m er M ta r e p s -t iv rtu r e d t a e G ir ra p u h e - P Adolescent childbearing has a negative impact on these T p P O three dimensions: health of the adolescents and their Source: Conde-Agudelo et al 2005 Individual, Family, and Community Care infants; individual social and economic effects; and societal Adolescent mothers often lack knowledge, education, level impacts. Socioeconomic impact experience, income, and power relative to older mothers. Thus, programs should emphasize several approaches to Health impact on mother and newborn Numerous studies have shown an association between overcome these relative disadvantages. adolescent pregnancy, and negative social and economic A study in Latin America found that maternal death rates for effects on both the mother and her child. However, recent • Improving the involvement of boys and men and the adolescents under 16 are 4 times greater than for women reviews have found the evidence inconclusive about whether community at large, and including “mothers-in-law” in their 20s. Although some of this risk can be attributed to adolescent pregnancy is the cause or consequence of in societies where they are the main decision-makers factors other than young age – e.g. giving birth for the first adverse socioeconomic factors. both at household and community level, would ensure time, lack of access to care, or socioeconomic status - there their support and acceptance in utilization of services. appears to be an independent effect of young maternal age • Ensuring good pregnancy outcomes start with home- on pregnancy risk to the mother. based care practices that support the mother and her newborn before, during, and after the pregnancy.

October 2008 3 • Knowledge about pregnancy complications and • Discussion of the “Plan for Birth and Complications,” recognizing the signs of complications should be widely including the place of birth, availability of disseminated to pregnant adolescents, their families transportation, companion of choice, and costs and the community at large. It may provide the route involved, is essential, particularly for adolescents in for ensuring that pregnant adolescents deliver with the light of the higher incidence of complications both for assistance of a skilled health-care provider and have the mother and her newborn. access to support and services for routine as well as • Health workers should prioritize adolescents’ access to emergency care throughout pregnancy, childbirth and services to prevent mother-to-child transmission of HIV, during the postpartum period. given the high concentration of infection rates in young • Adolescent mothers should be provided with life skills women. (including vocational training) and sexuality education • It is important that adolescent mothers be counseled to increase their autonomy, mobility, self-esteem, and and provided with post partum family planning methods decision-making abilities. of their choice to avoid future adolescent pregnancy. • Programs should be put in place to retain adolescent girls in school. Health Systems Features • Because adolescents are relatively more susceptible to violence from intimate partners than are older women, In addition to the special interventions that would enhance it is important to implement programs to empower the continuum of care for adolescents and their babies, adolescents to deal with domestic violence. countries can incorporate features into their health systems that can improve adolescents’ access to quality care • Programs should also find ways to reduce the cost including that for contraception and, ultimately, health of pregnancy care for adolescents, who tend to have outcomes. fewer financial resources. • A crucial area of focus is in human resources, where Outpatient and Clinical Care evidence shows the importance of developing health worker competencies in dealing with the special Skilled health workers provide a range of services in information and psychosocial needs of adolescent outpatient or clinical settings that help save the lives of mothers. pregnant mothers and their newborns. With a few important • A more conducive legal and policy environment that exceptions, the content of such clinical and outreach enhances access to care for adolescents including interventions should be the same for adolescent mothers as contraceptive services is needed. for other women. • It is important to provide adolescents with an early Conclusion start to antenatal care and to options for continuing or terminating pregnancy, particularly because Making pregnancy safer for the youngest mothers and adolescents tend to delay seeking abortion, resort to their babies is a priority for countries as they strive to the use of less skilled providers, use more dangerous meet targets for improving basic health care. Maternal methods, and delay seeking care for complications. and newborn health programs have a clear role in better They are, therefore, more likely to suffer serious serving the needs of the youngest mothers. However, more complications and even death. and better research is needed to expand the evidence base on effective interventions for pregnant adolescents and • Since adolescents are especially susceptible to anemia to translate knowledge into action at the country level. As in pregnancy, it is important for programs to make a part of a broader effort being undertaken by various WHO special effort to diagnose and treat for anemia. Departments, WHO’s MPS Department hopes to contribute • Adverse outcomes such as low birth weight can to this effort by publishing a Position Paper on Adolescent be reduced by improving the nutritional status of Pregnancy later in 2008. The position paper will lay out an adolescents before pregnancy and preventing sexually action plan for WHO and partners to address adolescent transmitted infections before and during pregnancy. pregnancy using the framework of the Making Pregnancy • Pregnant adolescents especially first time mothers Safer Approach to Improving Maternal and Newborn are particularly susceptible to malaria, a major factor Survival. in maternal deaths in some countries. Priority should

be given in treatment and management of malaria in © World Health Organization 2008 pregnancy. All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland • Special attention should be given to adolescents under (tel: +41 22 791 3264; fax: +41 22 791 4857; email: [email protected]). Requests for permission to reproduce or translate WHO publications – whether for sale or for 16 during obstetric care because they and their infants noncommercial distribution – should be addressed to WHO Press, at the above address are at especially high risk of complications and death. (fax: +41 22 791 4806; email: [email protected]). All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. This publication does not necessarily represent the decisions or the stated policy of the October 2008 4 World Health Organization.