91292 Knowledge Brief Health, Nutrition and Population Global Practice CHALLENGES FOR ADOLESCENT’S SEXUAL AND REPRODUCTIVE HEALTH WITHIN THE CONTEXT OF UNIVERSAL HEALTH COVERAGE Rafael Cortez, Meaghen Quinlan-Davidson, and Seemeen Saadat October 2014 September 2014 KEY MESSAGES:  Adolescent sexual and reproductive health (ASRH) is inseparable from all aspects of adolescent health, providing an opportunity for health gain or loss, and is key to poverty alleviation and economic development.  Recent World Bank studies in Bangladesh, Burkina Faso, El Salvador, Ethiopia, Lao PDR, Nepal, Niger, and Nicaragua present findings on the multi-sectoral burden of ASRH: o 50 percent of adolescents (15-19 years of age) in most of the analyzed countries have given birth. o Less than 41 percent of adolescents use modern contraception in most countries.  There is a lack of access to, demand for, and knowledge about ASRH health services among sexually active married and unmarried adolescent girls. Given the importance of ASRH within the context of development as well as the paucity of data on the issue, the Introduction WBG conducted a global analysis and country case studies in order to: (i) gain a deeper understanding of the multi- Young people (10-24 years of age), around the world face sectoral determinants of ASRH outcomes; (ii) explore further tremendous challenges to meeting their sexual and the multi-sectoral supply and demand-side determinants of reproductive health (SRH) needs. Inadequate access to access, utilization, and provision of services relevant to health information and services, as well as inequitable identified ASRH outcomes; and (iii) identify multi-sectoral gender norms, contributes to a lack of knowledge and programmatic and policy options to address critical awareness about puberty, sexuality, and basic human rights. constraints to improving ASRH outcomes that can inform This can have serious implications on young people’s health WBG lending operations and policy dialogue. Activities were and welfare as well economic development and poverty generated to benefit cross-regional learning on ASRH by reduction. identifying both health sector and non-health sector factors and lessons learned, while strengthening the availability and Decisions made during adolescence, particularly regarding analysis of data on adolescents in a standardized way. The SRH, have a long-term impact on human development. With aim is to incorporate the main findings and recommendations the onset of puberty, young people face new challenges – from these studies into existing and new WBG lending initiating sexual activity, entering the age of risk-taking, operations while simultaneously informing ASRH policies and entering unions and making decisions on family formation interventions for inclusion in country strategies. (WDR, 2007; WDR 2012) – that affect future health and opportunities, such as mental health, injuries, and non- To describe the multi-sectoral factors that impact adolescent communicable diseases (NCDs). health, the WBG used the following conceptual framework (figure 1) tailored to each country context. Page 1 HNPGP Knowledge Brief  likely to initiate sex outside of marriage. Figure 1. ASRH within the context of FAMILY PLANNING development Use of modern contraception is most common among ever- married females in Bangladesh (41 percent), followed by Ethiopia (20 percent) and Nepal (14 percent). Less than 10 percent of ever-married women use modern contraception in Burkina Faso, Niger, and Nigeria. Among never-married women, almost none use modern contraception in Ethiopia, Nepal, and Niger. Use of modern contraception is higher in Non-Health: Other Health Education & Skills Issues urban areas, higher wealth quintiles, and with increased Development educational levels. Contraceptive prevalence among ever- married adolescent girls (15-19 years of age) in SA is the lowest in the world with 15 percent using contraception. Similar results are found in EAP (ranging from less than 10 percent in Kiribati, Timor-Leste, and Samoa to 48 percent in Health sector determinants Indonesia). SOURCES OF FAMILY PLANNING INFORMATION Adolescent females most often hear about family planning through radio in all countries, except Bangladesh where TV Source: World Bank Group. ASRH within the context of development. is most utilized. Never-married adolescent women learn Concept note: Paving the Path to Improved Adolescent Sexual and about family planning through media sources more often Reproductive Health. than ever-married women. This is associated with urban residence, more wealth and more education. Also, visits by Key ASRH issues analyzed included (but not limited to): family planning workers are relatively rare among adolescent sexual activity, family planning, sources of family planning women, regardless of marital history. In contrast, in El information, sexually transmitted infections (STIs), Salvador, adolescents are most likely to hear about family adolescent marriage, adolescent childbearing, gender norms planning in school. and standards, and gender-based violence. Nine countries (Bangladesh, Burkina Faso, El Salvador, Ethiopia, Lao PDR, SEXUALLY TRANSMITED INFECTIONS Nepal, Nicaragua, Niger, and Nigeria) with a high ASRH burden were selected to inform operations and policy Self-reported STIs and symptoms are low among adolescent dialogue at the country level. women, regardless of marital history. Less than one third of adolescent females have comprehensive HIV/AIDS knowledge in all countries, regardless of marital status. A global analysis using Demographic and Health Survey Comprehensive knowledge of STIs is more common among (DHS) data from 6 countries (Bangladesh 2011; Burkina never-married adolescents, higher wealth quintiles, and Faso 2010; Ethiopia 2011; Nepal 2011; Niger 2012; and higher education levels. The proportion of adolescent Nigeria 2008) examined socioeconomic differences in females who have tested for HIV is higher among ever- relation to most of the key ASRH issues mentioned above married women in all countries, except Nigeria, and in urban among adolescent female respondents (15-19 years of age). areas, wealthier households, and higher levels of education. Data from regional studies (Latin America and the Caribbean Similar global patterns related to comprehensive knowledge [LAC]; West and Central Africa [WCA]; South Asia [SA]; and are found in SA and EAP. East Asia and the Pacific [EAP]) conducted by the WBG is also presented. ADOLESCENT MARRIAGE Early marriage is prevalent in all countries studied. Over 25 Global Trends and Challenges percent of adolescent women are married in all countries. Rates of adolescent marriage (including marriage before 15 SEXUAL ACTIVITY years of age) are highest in Niger (64 percent). Marriage – at In all countries, nearly all ever-married adolescent females any age and before age 15 – is more common in rural areas have sexual intercourse while sexual activity outside of and among those with less wealth and education (figure 2). marriage is low. However, sexual activity among never- At the regional level, SA has the highest prevalence of married adolescents increases with level of education and adolescent marriage in the world (46 percent). wealth in Burkina Faso and Nigeria. Further, over one third of ADOLESCENT CHILDBEARING ever-married adolescent females had sex before age 15 in Bangladesh (37 percent), Niger (37 percent), and Nigeria (38 Adolescent childbearing, except in LAC, is closely tied to percent). This is associated with rural residence, less wealth marital status. In all countries, approximately half (from 42 and less education. Evidence from regional data indicates percent in Nepal to 55 percent in Nigeria) of ever-married that similar socioeconomic characteristics are found in LAC. adolescents gave birth, while non-marital childbearing is rare. However, adolescents in LAC, SA, and EAP are far more Less than 10 percent have given birth before age 15. In Page 2 HNPGP Knowledge Brief  Bangladesh and Burkina Faso, childbearing among ever- 66 percent higher risk of being discriminated against for their married adolescents is positively associated with rural sexual behavior and identity than boys. residence, less wealth, and less education. Figure 3. Adolescent (10-19 years old) frequency Figure 2. Percentage of women 15 through 19 of contraceptive use by sex (percent) in El years of age who have ever been married, by Salvador country and education level Source: World Bank Group. Adolescent sexual and reproductive health and rights Survey: El Salvador. Health Focus. 2012. Data collection commissioned by the World Bank 2012. Source: World Bank Group and University of California San Francisco. Accelerating Progress for Adolescent Sexual and Reproductive Health: Results from a Multi-Country Needs Assessment. Washington, DC: BARRIERS TO IMPROVED ASRH World Bank & UCSF; 2014. A study in Bangladesh (Cortez et al, 2014) noted a powerful West Central African countries face the highest adolescent association between adolescent marriage, poverty, and poor fertility rates (AFR) in the world. Niger has an AFR of 204.8 SRH outcomes in four Dhaka slums. The study included a births (per 1,000 females 15-19 years of age), followed by quantitative household survey, qualitative interviews, Mali at 175.6 births, and Chad at 152 births. Nigeria has an formative research, and donor interviews. Results indicate AFR of 119.6 births and Burkina Faso has an AFR of 115.4 that adolescent females marry on average at 15 years of births (per 1,000 females 15-19 years of age). age, although their ideal age at first marriage is 18 years. Further, 70 percent of adolescent women give birth by the time they turn 19 years of age. Country Case Studies and Findings Figure 4. Current Use of contraception among Quantitative and qualitative studies were conducted in El adolescents (15-19 years of age) by number of Salvador, Bangladesh, and Niger in order to highlight the living children and method (Percent) multi-sectoral ASRH burden, and to inform WBG lending operations and country strategies. IMPACT OF TRADITIONAL GENDER NORMS In El Salvador, a quantitative household survey on ASRH was conducted among 1,258 adolescents aged 10-19 years (Cortez et al., 2014). Results indicate that despite El Salvador’s history of trying to meet human rights principles, adolescents and youth continue to face SRH violations. In fact, half of adolescents know about their sexual and reproductive health rights (SRHR), reducing the risk of becoming a parent by 66 percent and the risk of being mistreated by 46 percent. Source: World Bank Group and the International Center for Research Over 40 percent of adolescents in El Salvador have sex by on Women. Household Survey 2013: Adolescent Sexual and Reproductive Health in Bangladesh. 2013. 15 years of age. Use of contraceptive method at first sex is quite low (54 percent), while adolescent girls are less likely to use contraception (29 percent) in comparison to boys (10 Use of modern contraception is low among adolescent percent) (figure 3). Also, adolescent girls in El Salvador have females: 61 percent of adolescent females use poorer SRH outcomes. An adolescent female is 8 times more contraception, 31.9 percent do not use contraception, and likely to become a parent in comparison to her male 6.6 percent use traditional methods. Use of contraception counterpart, and more likely to experience abuse in increases among women of higher parity (figure 4) and comparison to boys (13.2 percent and 9.3 percent among adolescent girls employed in non - garment sectors. respectively), with older adolescents more likely to be The study found that 70 percent of adolescent females abused than younger adolescents. Adolescent girls are at a deliver at home; although adolescent females with some Page 3 HNPGP Knowledge Brief  level of education are 4 to 7 times more likely to seek SRH Conclusions services from a formal health care facility in comparison to those with no education. Despite international support to improve ASRH and SRHR, pervasive challenges remain. These studies highlight the Moreover, traditional gender norms continue to dictate a importance of investing in young people’s SRH. Investment female’s access to health care in Dhaka as 55 percent of in the health, education, and rights of young people, and the young women report that their husbands make decisions alignment of policies, is important, as it will enable regarding their own health care. productivity and economic growth. Meanwhile, empowering HIGH AFR AND MATERNAL MORTALITY young people in their healthy development, including SRH practices and rights, provides the right conditions so that they In Addressing Adolescent Sexual and Reproductive Health in can enter adulthood with strong capabilities to ensure better Niger, a recent analysis (Barroy et al., 2014) was conducted productivity as well as the protection of their health and their using DHS and Multiple Indicator Cluster Survey (MICs) data family’s wellbeing. among female and male adolescents 10-19 years of age. In addition, a policy review, stakeholder interviews, and focus group discussions were held. Young women in Niger are References more likely to initiate sex before age 15 than their male counterparts (24.5 percent and 1.1 percent respectively). Brindis, C., et al. 2014. Technical notes on Adolescent health commissioned by the World Bank. Although 73 percent of female adolescents have fair Patton, G.C., and S.M. Sawyer. 2013. A Global Perspective on knowledge about contraceptive methods, most do not use Adolescent Sexual and Reproductive Health. Centre for Adolescent contraception. Coverage of SRH remains limited for Health University of Melbourne. Australia. Background report adolescents and they face financial and geographic commissioned by the World Bank. obstacles; although the proportion of pregnant women Barroy, H., N. Le Jean, and H. Wang. 2014. Addressing Adolescent attending prenatal care has increased from 50.8 percent Sexual and Reproductive Health in Niger. (Forthcoming) in 2006 to 90.6 percent in 2010. Cortez, R., L. Hinson, and S. Petroni. 2014. Adolescent Sexual and Reproductive Health in Dhaka, Bangladesh. Health, Nutrition and Population Discussion Paper. Washington, DC: The World Bank. (Forthcoming). Policy Challenges Cortez, R., K. Revuelta, Y. Guirola and A. Gordillo Tobar. 2014. Adolescent Sexual and Reproductive Health in El Salvador. Health, Nutrition and Population Discussion Paper. Washington, DC: The World ASRH is inseparable from all aspects of adolescent health, Bank. (Forthcoming) providing an opportunity for health gain or loss. It is at this Sawyer S.M, R.A. Afifi, L.H. Bearinger, et al. 2012. Adolescence: A time that the risk of injury and mental disorders are greatest, Foundation for Future Health. Lancet; 370: 1630-40. while behaviors associated with later-life NCDs, such as World Bank Group. Adolescent Sexual and Reproductive Health in tobacco use, obesity and physical inactivity, are established. Selected Countries of West and Central Africa. (Background Report) This affects the future health, social adjustment, and ______. Adolescent Sexual and Reproductive Health in Latin America economic prospects of today’s adolescents as well as their and the Caribbean: Adolescent Pregnancy and Motherhood. capacity as parents and the health of their children. Within (Background Report) this context, ASRH investments are required and should be ______. Adolescent Sexual and Reproductive Health in East Asia and adapted to a country’s unique needs, by doing the following: Pacific (Background Report). ______. Adolescent Sexual and Reproductive Health in South Asia (Background Report).  Investing in universal access to integrated SRH; World Health Organization. 1986. Young People’s Health – A  Investing in high-impact adolescent interventions in other Challenge for Society. Geneva: WHO. sectors, and ensuring sustainability;  Investing in poor and vulnerable young populations;  Gaining policy and political will at the country level; This HNP Knowledge Brief highlights the key findings from a series of  Harmonizing technical and investment efforts among background reports produced under the World Bank Economic Sector partners at the country level; Work “Paving the Path to Adolescent Sexual and Reproductive Health”  Establishing country data systems to drive adolescent (P130031) led by Rafael Cortez (Task Team Leader, Health, Nutrition health policy and programming; and Population Global Practice) and funded by the Bank-Netherlands Partnership Program (BNPP).  Fully involving adolescents in the development of adolescent health programs; and  Strengthening health systems to scale up access to quality adolescent user-friendly health services. The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4