Adolescent Pregnancy Prevention

1. Adolescent Pregnancy Prevention Robert Blum, M.D., M.P.H., Ph.D. William H. Gates Sr. Professor and Chair Population, Family and Reproductive Health Johns Hopkins Bloomberg School Public Health Prepared for: RHI Johannesburg, South Africa 7 Feb 2014

2. Adolescent Pregnancy: at a glance • 7.8 million births to girls under age 18 annually; • 95% of all adolescent pregnancy occurs in low and middle income countries; • 90% of all adolescent pregnancy occurs within marriage; • 2 million girls under the age of 15 give birth annually; • 19% of girls from LMIC report becoming pregnant by age 18. • 70,000 adolescents die annually from pregnncy related causes.

3. Half of all Adolescent Pregnancy occurs in 7 countries • Bangladesh, • Brazil, • The Democratic Republic of the Congo, • Ethiopia, • India, • Nigeria, • United States.

4. Some Good news… some bad • In 1950 the adolescent birth rate in LMIC was 180 per 1000… today it is 106. • 106 per 1000 is 4 times the rate in high income countries. • In not every country has the trend been positive: in 1955 in Niger the rate was 181 per 1000 today it is 210.

5. Health Consequences of Adolescent Pregnancy • Between 40%-60% of girls from LMIC who become pregnant are anemic; • Between 50,000-100,000 new cases of obstetrical fistuala annually– a third of which occur in adolescents; • 15-19 y.o. account for an estimated 3.2 million unsafe abortions annually;

6. Estimated Unsafe Abortions among 15-19 y.o. in LMIC:2008 (Shah and Ahmen, 2012)

7. Sexual Violence For many girls their first sexual experience was forced Japan: 1% Azerbaijan: 2% Bangladesh: 30% Dem. Rep. Congo: 64% (UNFPA & Pop. Council 2008)

8. Child Marriage • Defined as marriage < age 18 years; • 39,000 child marriages every day; • 16 % of girls in LMIC (except China) marry before age 18 years • 11% marry before age 15 years • 146 countries allow girls to marry before age 18; 52 allow them to marry before age 15 years • 18 is the legal age of marriage for males in 180 countries

9. Adolescent Birth Rate, Contraceptive Prevalence Rate, and Proportion of 20-24 year old females married by age 18 by Region

10. Adolescent birth rates per thousand for 15-19 year olds by region (high and low country)

11. Very Young Adolescents • 41% of 10-14 year old girls in sub-Saharan Africa live with neither parent. • 30% of 10-14 yo girls in SSA are working; in Asia 27%, Latin America 17%. • 15% have engaged in sexual intercourse in Sub-Saharan Africa, 31% in Latin America, the Caribbean, Europe and North America

12. Evidence based Interventions

13. Key Stakeholders • Policy makers, • Programme managers, • Providers (including health providers and teachers), • Parents, • Peers • Partners.

14. INTERVENTION COMPONENTS ADOLESCENT PREGNANCY DETERMINANTS BY KEY STAKEHOLDER • POLICYMAKER ENGAGEMENT • Elimination of age and marital status requirements to access contraception • Elimination of gender unequal laws (e.g., age of marriage) • Enforce sexual violence laws • P1: NATIONAL POLICYMAKERS • Reduce barriers and increase contraceptive accessibility for youth • Prohibit and enforce laws on coerced sex, child marriage • Universal secondary education • P2: COMMUNITY PROGRAM MANAGERS • Increase youth attachment to one or more adults • Alter community norms that normalize early pregnancy, sexual violence • Engage schools, youth organizations, the faith community in adolescent pregnancy prevention • Increase adolescents’ access to SRH services • COMMUNITY ENGAGEMENT • Community service/service learning • Mentoring • Community dialogue on gender inequality and child marriage norms INTERVENTION GOALS • HEALTH SERVICE PROVISION • Partnerships with community and school-based ASRH providers • ADOLESCENTBEHAVIORS • Increase consistent use of contraception • Reduce marriage before age 18 • Delay sexual initiation • Reduce coerced sex REDUCEADOLESCENT PREGNANCY • P3 and P4: PEERS & PARTNERS • Change norms about sex and contraception • Increase knowledge about sexual and reproductive health and attitudes about adolescent pregnancy • Change perceptions that peer sexual engagement is normative • COMPREHENSIVE SEX EDUCATION • School or community based • Skill building components • Counseling components • Peer-led education components • Parent involvement • P5: PARENTS & FAMILY • Increase connectedness/communication between parents and adolescent • Change harmful family norms around sex, child marriage, and girls’ schooling • Increase economic resources for low-income families • Alter family norms that reinforce gender inequality • FAMILY SUPPORT • Counseling • Parent education • Conditional/Unconditional cash transfer programs • CONTRACEPTION PROMOTION • Education • Distribution • Skill building • ADOLESCENT GIRL • Improve self efficacy /negotiation skills • Reduce involvement in other risky health behaviors • Improve future aspirations and opportunities • Improve educational attainment (school enrollment) • Improve school connectedness • Increase knowledge about SRH, contraception, and attitudes about adolescent pregnancy • ADOLESCENT DEVELOPMENT • Life skills development • Academic skills • Social support/mentors/safe spaces • Career counseling/Link to livelihoods

15. Policy Maker Interventions • Improve literacy • Eliminate Child marriage • Eliminate the age differential when males and females can marry • Implement and enforce gender based violence laws • Make adolescence a notional priority • Support conditional cash transfer programs

16. Community level interventions • Multi-sectorial/ Comprehensive approaches Geraceo Biz (Mozambique) Berhane Herwan (Ethiopia) DISHA (India) Carerra/ Children’s Home Society (USA)

17. Community level interventions (cont.) • Mentorship programs Big Brothers/ Big Sisters • Access to family planning services • Reduce barriers to health service utilization Competitive voucher scheme (Nicuagua) • Provide access to Long acting reversible contraception and emergency contraception

18. School level Interventions • Conditional Cash Transfer Programs Bola Escuala (Brazil) Food for Education (Bangladesh) Opportunitades (Mexico) Zoma Cash Transfer Program (Malawi)

19. School level Interventions (cont.) • Comprehensive School based sex education • Life Skills Education •Cognitive – critical thinking and problem-solving skills for responsible decision-making; • Personal – skills for awareness and drive and for self-management; • Interpersonal – skills for communication, negotiation, cooperation and teamwork, and for inclusion, empathy and advocacy.

20. Family level Interventions • Economic Supports Opportunitades Bola Escula Parent communication programs Family Matter! Strengthening Family program

21. Partner/Peer Interventions • Violence Prevention Programs Safe Dates (USA) • Safer Sex Stepping Stones (South Africa) • Comprehensive Sex Education PEAS (Brazil) • Promoting Gender equitable norms Programa H (Brazil)

22. Adolescent Girl Initiatives • Reduction of Child Marriage Ishraq (Egypt) • School enrollment and attendance Food for Education (Bangladesh) • Sexual victimization Safe Dates (USA) • Contraceptive technologies Long Acting Reversible Contraception • Health services access Competitive Voucher Scheme (Nicaragua)

23. Lessons Learned from Effective Programs: Policy Makers • Engagement of policy makers is key. • Laws have impact only to the extent to which they are enforced. • National strategies to eliminate child marriage and pregnancy under the age of 18 needs to be priority. • Multi-sectorial programs that work at the policy, community, parent school and individual levels are promising approaches.

24. Lessons Learned from Effective Programs: Program Managers • Use evidence-based programs • Use theory-based programs • Scare tactics are very unlikely to be effective. • Engaging adolescents in program planning and implementation improves programming and contributes to adolescent development. • Information-based programs alone are unlikely to be effective • Relationships are key.

25. Lessons Learned from Effective Programs: Parents • Adolescents need and want parents in their lives. • Addressing parental expectations is critical to delaying marriage. • Gender inequality starts at home. • Parent expectations behaviorally and educationally have a substantial impact on child marriage and adolescent pregnancy. • Parental poverty and adolescent pregnancy are closely related.

26. Lessons Learned from Effective Programs: Providers (teachers) • Schooling is strongly associated with adolescent pregnancy prevention. • Conditional cash transfer programs directly impact school enrollment and attainment. • Evidence-based Life Skills Training programs impact child marriage and adolescent pregnancy.

27. Lessons Learned from Effective Programs: Providers (Health professionals) • Youth friendly services alone are insufficient to increase clinic utilization. • There are insufficient programs reaching young married couples to delay first and reduce second pregnancies. • Barriers for adolescents to access family planning services (age, parental/spousal approval) contribute to adolescent pregnancy • Technologies such as long acting reversible contraception and emergency contraception hold significant promise to reduce pregnancy.

28. Lessons Learned from Effective Programs: Peers and Partners • There is evidence that programs can address gender norms and partner violence though the behavioral outcome data is less strong than attitudinal change. • Comprehensive sex education curriculae have been evaluated and there is good evidence that they impact both knowledge and behavior.